Peyronie's disease response to intralesional collagenase clostridium histolyticum therapy is independent of baseline testosterone

BACKGROUND

Testosterone plays an important role in collagen metabolism, transforming growth factor-β1 expression, and wound healing, which are all critical factors in pathogenesis of Peyronie's disease. Some clinical studies have suggested an association between Peyronie's disease and hypogonadism.

OBJECTIVE

We sought to investigate whether baseline total testosterone levels influence response to intralesional collagenase clostridium histolyticum in Peyronie's disease.

METHODS

A retrospective review of patients receiving collagenase clostridium histolyticum injections with available total testosterone levels within 1 year of initial injection was conducted at a single institution. Baseline demographics, hypogonadal status, total testosterone, number of collagenase clostridium histolyticum cycles, and pre- and post-treatment degrees of curvature were collected. Hypogonadism was defined as total testosterone <300 ng/dL.

RESULTS AND DISCUSSION

Thirty-six men were included with mean age of 58.2 years (SD 10.4) and mean body mass index 26.8 (SD 3.2). The mean total testosterone was 459.2 ng/dL (SD 144.0), and four (11.1%) were hypogonadal. Mean pre-treatment curvature was 47.6°, and mean post-treatment curvature was 27.8°, with mean improvement of 19.9° (40.1%). Hypogonadal status was not significantly associated with more severe curvature, 46.4° among hypogonadal men as to 57.5° among eugonadal men (p = 0.32). On linear regression analysis, total testosterone did not significantly predict improvement in degrees (β = -0.02; R2 = 0.06; p = 0.14) or percent (β = 0.0; R2 = 0.05; p = 0.18). Improvement in neither degrees nor percent differed significantly by hypogonadal status (p = 0.41 and 0.82, respectively). The cycle number did significantly predict greater improvement in curvature on both univariate and multivariate analyses (β = 5.7; R2 = 0.34; p < 0.01).

CONCLUSION

Neither total testosterone nor hypogonadism is associated with a degree of improvement after collagenase clostridium histolyticum treatment.

Does climate impact inflatable penile prosthesis infection (IPP) risk? Assessment of temperature and dew point on IPP infections

BACKGROUND

Variations in climate have been associated with a greater risk of surgical site infections, urinary tract infections, and changes in the skin microbiome; however, limited data exist on the impact of climate on inflatable penile prosthesis (IPP) infections.

AIM

We sought to evaluate the impact of climate on the risk of IPP infections in a large international, multicenter cohort.

METHODS

We performed a multi-institutional, retrospective study of patients undergoing IPP surgery. We then evaluated whether the month or season, during which surgery was performed, affected device infections. Implant infections were defined as infections requiring device explantation. A univariate logistic regression analysis was undertaken.

OUTCOMES

Our primary outcome was implant infection.

RESULTS

A total of 5289 patients with a mean age of 62.2 ± 10.8 years received IPP placement. There was a fairly even distribution of implants performed in each season. A total of 103 (1.9%) infections were recorded. There were 32 (31.1%) IPP infections in patients who underwent surgery in the summer, followed by 28 (27.2%) in the winter, 26 (25.2%) in the spring, and 17 (16.5%) in the fall. No statistically significant differences were recorded in terms of season (P = .19) and month (P = .29). The mean daily temperature (P = .43), dew point (P = .43), and humidity (P = .92) at the time of IPP placement was not associated with infection.

CLINICAL IMPLICATIONS

These findings provide reassurance to prosthetic urologists that infection reduction strategies do not need to be tailored to local climate.

STRENGTHS AND LIMITATIONS

Climate data were not directly recorded for each hospital, but rather based on the monthly averages in the city where the surgery was performed.

CONCLUSION

The climate at time of IPP placement and time of year of surgery is not associated with IPP infection risk.

Trends, safety, and efficacy of wearable male sexual devices

INTRODUCTION

The prevalence of male sexual dysfunction (MSD) increases with age, with >50% of men aged >40 years reporting erectile dysfunction (ED). In recent years, wearable male sex devices (WMSDs) have been increasingly utilized by patients and recommended by sexual medicine clinicians.

OBJECTIVES

This study seeks to investigate the safety and efficacy of products currently marketed for the treatment of MSD.

METHODS

Available products for WMSDs were reviewed by analyzing product websites, forums, advertisements, and clinical recommendations. Qualitative comparisons were based on patient reviews, cost, and specific features. Investigatory evidence and Food and Drug Administration status were also reviewed. Additionally, Google Trends was used to determine the popularity of devices over time.

RESULTS

Eight WMSDs for the treatment of MSD and enhancement of sexual pleasure were reviewed. Constriction bands, such as the Maintain Ring Loop, Eddie by Giddy, and Xialla, have shown significant benefits in clinical trials and were the most popular devices among patients. Smart devices can provide real-time feedback on erectile quality and/or sexual performance. Similar to the RigiScan, the Adam sensor provides feedback on erectile quality while monitoring changes in penile tumescence during sleep with additional analysis available through a mobile application. Neuromodulation devices such as the Morari Patch and vPatch/in2 Patch use electrical stimulation to delay ejaculation and improve sexual function. The FirmTech Performance Ring uses sensors to track the vital signs of erectile fitness with clinical trials ongoing.

CONCLUSIONS

Overall, this review describes the available investigatory evidence for a range of WMSDs and highlights the potential benefits and limitations of these devices in treating MSD and enhancing sexual pleasure. Further research is needed to evaluate the effectiveness of these devices and to determine which ones may be the most suitable for individual patients.

Cosmetic penile enhancement procedures: an SMSNA position statement

BACKGROUND

Penile cosmetic enhancement procedures have been performed for many years with varying success. However, they have historically been relegated to niche areas of sexual medicine, with limited data, and have not achieved mainstream adoption. More recently, the topic has been increasingly discussed within academic congresses due to availability of novel techniques, therapies, and procedures. Given their distinctive nature, the Sexual Medicine Society of North America (SMSNA) felt that it was pertinent to develop formal position statements to help guide both patients and sexual medicine providers on the current state of the scientific literature and to give recommendations for future research.

AIM

The study sought to provide an evidence-based set of recommendations for injection and surgical procedures designed to lengthen, augment, or otherwise cosmetically enhance the penis.

METHODS

A review was performed of all scientific literature listed in PubMed from inception through December 2023 relating to penile cosmetic enhancement procedures. Only invasive (injection/surgery) therapies were included due to their distinct risk-benefit profile compared with more conservative treatments (eg, vacuum erection devices, penile traction devices). Similar therapies were categorized, with pertinent data summarized and used to help create relevant position statements. All statements were expert opinion only and were based on analyses of the potential risks and benefits of the specific therapies.

OUTCOMES

A total of 6 position statements were issued relating to 5 distinct sexual medicine cosmetic enhancement procedures.

RESULTS

A consensus opinion was reached by SMSNA leadership on the state of injection/surgical penile cosmetic enhancement procedures as of 2024. Key topic areas addressed included injectable soft tissue fillers, suspensory ligament division, graft-and-flap procedures, silicone sleeve implants, and sliding/slicing techniques. Distinct recommendations were tailored to each therapy and were based solely on the current state of the literature. It is anticipated that future studies will further inform position statements and will lead to ongoing modifications.

CLINICAL IMPLICATIONS

The current position statements provide both patients and clinicians evidence-based, expert recommendations on best practices relating to penile cosmetic enhancement procedures.

STRENGTHS AND LIMITATIONS

Strengths include the use of an expert panel of sexual medicine clinicians, consensus design, and summary of existing literature. Limitations include expert opinion and limited research on the topic.

CONCLUSION

The current SMSNA position statements provide evidence-based, consensus opinions on the appropriate role for penile augmentation and cosmetic procedures in 2024.

Multiple sclerosis and hypogonadism: is there a relationship?

INTRODUCTION

Multiple sclerosis (MS) is a chronic autoimmune disease that affects the central nervous system and is widely recognized as a disease primarily affecting women. The relationship between MS and hypogonadism is complex and not fully understood, with recent evidence showing that hypogonadism may have a significant impact on the quality of life and disease progression of patients with MS.

OBJECTIVES

This review aims to provide an overview of the current knowledge regarding the relationship between MS and hypogonadism, including the mechanisms underlying this relationship; the effects of hypogonadism on patients with MS; and the potential benefits and drawbacks of testosterone replacement therapy for patients with MS and hypogonadism.

METHODS

This scientific review analyzed 19 articles that investigated the potential relationship among MS, testosterone levels, and hypogonadism. The articles were published between November 2008 and March 2022 and were identified through a comprehensive search of the PubMed database. The search terms used included "multiple sclerosis," "testosterone," "hypogonadism," and "MS and testosterone levels."

RESULTS

Of the 19 articles reviewed, 11 described a positive correlation between low testosterone levels and dysfunction within the hypothalamic-pituitary-gonadal axis in individuals with MS. These findings suggest that low testosterone levels may contribute to dysfunction within the hypothalamus-pituitary-gonadal axis, which plays a crucial role in regulating testosterone production. The results also showed a relationship between sexual dysfunction and low testosterone levels, as well as a positive correlative relationship between these factors.

CONCLUSION

The reviewed articles indicate a complex relationship among MS, testosterone levels, and the hypothalamic-pituitary-gonadal axis, with low testosterone levels potentially contributing to dysfunction in this axis and to sexual dysfunction. Further research is needed to better understand the effects of testosterone therapy on MS and sexual dysfunction in patients with MS.

The relationship between hematologic malignancies on male hypogonadism: a scoping review

INTRODUCTION

The associated symptoms of hypogonadism have been reported in patients with various types of cancer. However, the prevalence and significance of hypogonadism among certain hematologic malignancies have not been completely summarized in recent literature.

OBJECTIVE

In this review we aimed to examine the current literature on hypogonadism in patients with hematologic malignancies, with emphasis on leukemias, lymphomas, and multiple myeloma (MM).

METHODS

This review included relevant studies published before July 2023 that were retrieved through a search of PubMed using the keywords "hematologic cancer," "hematologic malignancy," blood cancer," "leukemia," "lymphoma," "hypogonadism," "multiple myeloma," and "testosterone."

RESULTS

The search yielded 214 studies, of which 21 met the inclusion criteria. Commonly reported findings were that patients who had received hematopoietic stem cell therapy for acute lymphoblastic leukemia and acute myelogenous leukemia as children had laboratory-confirmed hypogonadism as adults. However, the impact of these diseases on hypogonadal symptoms was variable in these studies.Studies reporting on lymphoma and hypogonadism had mixed results, with some studies finding that the degree of cytotoxic chemotherapy was associated with hypogonadism, while others showed no correlation. Regardless, multiple studies found that hypogonadism secondary to lymphoma treatment and symptoms of hypogonadism had no apparent association.The most comprehensive assessment of the frequency of hypogonadism in an MM cohort found that 74% of 561 MM patients were classified as hypogonadal compared to 33% of patients in a control population. Testosterone supplementation was found to lower interleukin-6 levels, which could potentially help manage some of the adverse effects of MM, including decreased bone mineral density.

CONCLUSION

There is a relationship between hematologic malignancies and hypogonadism, which is likely multifactorial. In this review we established that the most plausible factors are related to the secondary effects of gonadotoxic treatments and/or systemic inflammatory responses to the diseases.

Comparison of the gut microbiome composition between men with erectile dysfunction and a matched cohort: a pilot study

BACKGROUND

To-date there have been minimal studies to investigate an association between the gut microbiome and erectile dysfunction. There have been many inflammatory diseases linked to gut microbiome dysbiosis; such as cardiovascular disease and metabolic syndrome. These same inflammatory diseases have been heavily linked to erectile dysfunction. Given the correlations between both conditions and cardiovascular disease and the metabolic syndrome, we believe that it is worthwhile to investigate a link between the two.

OBJECTIVE

To investigate the potential association between the gut microbiome and erectile dysfunction.

METHODS

Stool samples were collected from 28 participants with erectile dysfunction and 32 age-matched controls. Metatranscriptome sequencing was used to analyze the samples.

RESULTS

No significant differences were found in the gut microbiome characteristics, including Kyoto Encyclopedia of Genes and Genomes richness (p = 0.117), Kyoto Encyclopedia of Genes and Genomes diversity (p = 0.323), species richness (p = 0.364), and species diversity (p = 0.300), between the erectile dysfunction and control groups.

DISCUSSION

The association of gut microbiome dysbiosis and pro-inflammatory conditions has been well studied and further literature continues to add to this evidence. Our main limitation for this study was our small-sample size due to recruitment issues. We believe that a study with a larger population size may find an association between the gut microbiome and erectile dysfunction.

CONCLUSIONS

The results of this study do not support a significant association between the gut microbiome and erectile dysfunction. Further research is needed to fully understand the relationship between these two conditions.

Current opinions on the management of prolonged ischemic priapism: does penoscrotal decompression outperform corporoglanular tunneling?

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.

Penetrative anal intercourse may require high axial loading forces

BACKGROUND

Despite increases in the lifetime prevalence of anal intercourse, little is known about the safety of inflatable penile prosthesis use during anal intercourse or the forces required for anal penetration.

AIM

We sought to determine the force required for anal penetration.

METHODS

A digital force gauge device was secured to a silicone phallus with a length and girth representative of the average male phallus in the United States and inserted into the anal canal of 6 male participants for a total of 5 measurements per participant. The maximum axial forces on insertion were recorded. Participants then completed a survey eliciting demographic information and past experience with receptive anal intercourse.

OUTCOMES

The outcome measure was the force recorded during insertion of a force gauge device into the anal canal.

RESULTS

The median maximal force recorded on anal penetration was 26.5 N (2.7 kg; range: 16.1-51.7 N or 1.64-5.27 kg). Participants who engaged in receptive anal intercourse more than once per month tended to use lesser median maximal forces (25.7 N or 2.62 kg) than participants who engaged less frequently in receptive anal intercourse (41.6 N or 4.24 kg).

CLINICAL IMPLICATIONS

Compared with the forces required for vaginal penetration, anal penetration forces may cause additional mechanical stress to the phallus.

STRENGTHS AND LIMITATIONS

While the study is limited primarily in its small sample size and in the use of a single device for anal penetration with a set size and rigidity, the resulting findings presented here are to our knowledge the first reported data pertaining the force required for anal penetration.

CONCLUSION

As the forces required for anal penetration exceeded those for vaginal penetration, clinicians may need to carefully counsel patients on the safe use of an inflatable penile prosthesis for anal intercourse.

Maximizing outcomes in penile prosthetic surgery: exploring strategies to prevent and manage infectious and non-infectious complications

Inflatable Penile Prostheses (IPP) implantation is a surgical treatment for patients desiring definitive treatment for erectile dysfunction. While this procedure has proven to be effective, it also carries its own set of unique risks that need to be carefully considered. The article reviews the current understanding of complications associated with penile prosthetic surgery and provides strategies to mitigate these adverse events. This article covers various aspects of IPP implantation, including the risks of infection, bleeding, injury to nearby structures, glans ischemia, and device malfunction. It also discusses the importance of careful preoperative screening to identify risk factors and the implementation of infection reduction strategies such as antimicrobial prophylaxis, skin prep, and operative techniques. In addition, it emphasizes the need for postoperative vigilance and prompt management of any complications that may arise. Overall, the article provides a comprehensive overview of the risks and strategies for mitigating complications associated with IPP implantation. Our recommendations are given based on the current consensus in the field and highlight the importance of careful planning, attention to detail, and effective communication between healthcare providers and patients. Despite the potential risks, this review underscores the fact that complications following penile prosthesis implantation are relatively rare.

Single Dilation in Primary Inflatable Penile Prosthesis Placement Is Associated With Fewer Corporal Complications Than Sequential Dilation

OBJECTIVE

To assess the difference in outcomes between single dilation (SingD) and sequential dilation (SeqD) in primary penile implantation, hypothesizing that patients who undergo SeqD had higher rates of noninfectious complications.

METHODS

We performed a multicenter, retrospective study of men undergoing primary inflatable penile prosthesis placement. Intraoperative complications and postoperative noninfectious outcomes were assessed between the two groups. Multivariable analysis was performed to identify predictors of complications.

RESULTS

A total of 3293 patients met inclusion criteria. After matching, there were 379 patients who underwent SingD and 379 patients who underwent SeqD. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length (20 cm with interquartile range [IQR] 18-21 cm vs 20 cm with IQR 18-20 cm respectively, P = .4). On multivariable analysis, SeqD (OR 5.23 with IQR 2.74-10, P < .001) and older age (OR 1.04 with IQR 1.01-1.06, P = .007) were predictive of postoperative noninfectious complications. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length. SeqD and older age were predictive of postoperative noninfectious complications.

CONCLUSION

During inflatable penile prosthesis placement in the uncomplicated patient without fibrosis, SingD is a safe technique to utilize during implantation that will minimize postoperative adverse events, and promote device longevity without loss of cylinder length.

Satisfaction rates of inflatable penile prosthesis in men who have sex with men are high

Men with erectile dysfunction (ED) have high patient satisfaction after placement of inflatable penile prostheses (IPP). The impact on satisfaction and quality of life has never been studied in men who have sex with men (MSM). This study sought to assess the satisfaction rates and quality of life of MSM after placement of IPP for ED. This study was a multi-institutional, retrospective study that enrolled adult men who self-identified as MSM and underwent IPP placement. Two questionnaires were administered at one time point post-operatively, the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS), and the Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire. Results of these questionnaires were analyzed with descriptive statistics. Forty-nine MSM were assessed retrospectively with median age of 62 years with average follow-up of 15.2 months. Median EDITS score was 93.2/100 (range, 70.5-100). Median overall QoLSPP score was 72/80 (58-79), with median scores of 22/25 (16-25), 19/20 (13-20), 18/20 (12-20), and 14/15 (9-15), for the functional, personal, relational, and social domains respectively. Overall, MSM report high satisfaction rates and quality of life after IPP placement. A better understanding of the needs and demands of this patient population may lead to improved patient satisfaction and quality of life.

Delayed placement of an inflatable penile prosthesis is associated with a high complication rate in men with a history of ischemic priapism

BACKGROUND

Corporal fibrosis is known to result from prolonged priapism; however, the impact of the timing of penile prosthesis placement after priapism on complication rates is poorly understood.

AIM

We sought to evaluate the impact of timing of inflatable penile prosthesis (IPP) placement on complications in men with a history of ischemic priapism.

METHODS

We performed a multicenter, retrospective cohort study of patients with a history of priapism undergoing IPP placement by 10 experienced implantation surgeons. We defined early placement as ≤6 months from priapism to IPP. We identified a 1:1 propensity-matched group of men without a history of priapism and compared complication rates between men who had early placement, late placement, and no history of priapism.

OUTCOMES

Our primary outcome was postoperative noninfectious complications, and secondary outcomes included intraoperative complications and postoperative infection.

RESULTS

A total of 124 men were included in the study with a mean age of 50.3 ± 12.7 years. A total of 62 had a history of priapism and 62 were matched control subjects. The median duration of priapism was 37 (range, 3-168) hours and the median time from ischemic priapism to IPP placement was 15 months (range, 3 days to 23 years). Fifteen (24%) men underwent early (≤6 months) IPP placement at a median time of 2 months (range, 3 days to 6 months) following the ischemic priapism event. The remaining 47 (76%) underwent placement >6 months following priapism at a median time of 31.5 months (range, 7 months to 23 years). The complication rate in the delayed placement group was 40.5% compared with 0% in the early placement group and control group. Cylinder-related complications such as migration or leak accounted for 8 (57%) of 14 of the postoperative noninfectious complications. Full-sized cylinders were used in all patients who had a cylinder related complication.

CLINICAL IMPLICATIONS

Priapism patients should be referred to prosthetic experts early to decrease complication rates in those needing an IPP.

STRENGTHS AND LIMITATIONS

This is a multicenter study from experienced prosthetic urologists but is limited by the retrospective nature and small number of patients in the early placement group.

CONCLUSION

IPP complication rates are high in men with a history of ischemic priapism, especially when implantation is delayed beyond 6 months.

Climacturia and Penile Length Shortening: Adverse Outcomes following Robot-Assisted Radical Prostatectomy

Purpose: While erectile dysfunction and urinary incontinence are commonly cited side effects following radical prostatectomy (RP), climacturia and penile length shortening are less explored. The present study seeks to explore the incidence, risk factors, and predictors of recovery associated with climacturia and penile length shortening following robot-assisted radical prostatectomy (RARP). Patients and Methods: From September 2018 to January 2020, 800 patients underwent RARP for primary treatment of localized prostate cancer. A survey was sent to patients following 1-year follow-up assessing outcomes of continence, erectile dysfunction, climacturia, and penile length shortening. Descriptive statistics were utilized to describe incidence and risk factors and logistic regression modeling was used to identify predictors associated with recovery. Results: Of the 800 patients surveyed, 339 (42%) and 369 (46%) patients responded, with 127/339 (37.5%) and 216/369 (58.5%) endorsing climacturia and penile length shortening. In univariate analysis, a lack of bilateral nerve sparing was associated with climacturia; high body mass index (BMI), high prostate weight, lack of nerve-sparing, and high pathologic stage was associated with penile length shortening. In logistic regression modeling, BMI, prostate weight, and p-stage were all significantly correlated with penile length shortening. Recovery from climacturia was associated with a preoperative International Index of Erectile Function-5 score >21. When patients were asked to rank the importance of these outcomes compared to erectile dysfunction and incontinence, <5% of patients ranked either climacturia or penile length shortening as a high priority following RP. Conclusion: While incidence of climacturia and penile length shortening following RP is significant, impact on patient- and partner-related quality of life are low in comparison to risks of erectile dysfunction and urinary incontinence.

The pandemic, telemedicine, and andrology: what have we learned?

BACKGROUND

Telemedicine gained wide acceptance during the COVID-19 pandemic, as it was deemed critical for patient care when lockdowns were implemented worldwide. While there is evidence to suggest that urology patients were receptive to telemedicine, no systematic review has been done to date on andrology patients and their perception of telemedicine.

METHODS

Three electronic databases, PubMed, Scopus, and Web of Science, were searched from their inception until June 2022 for relevant articles. Two independent teams reviewed abstracts and extracted data from the selected manuscripts. A meta-analysis was completed in line with PRISMA 2020 and AMSTAR Guidelines. For our study, we limited telemedicine to communication through videoconferencing or telephone encounters between patients and medical professionals. Positive response to telemedicine was defined as patients "wishing for telemedicine consultation", "preferring telemedicine over in person", "accepting the current telemedicine arrangement", "having needs addressed with teleconsultation", or "willingness to do a teleconsultation".

RESULTS

Of the 1128 retrieved abstracts, 56 underwent full-text review and 12 were included in the final analysis, comprising a total cohort of >4021 cases. Video visits were evaluated in 5 studies, telephone encounters were analyzed in 2 studies, and both methods were examined in 1 randomized control study. Three studies showed that andrology and sexual medicine are compatible with telemedicine, with few 30- and 90-day in-person revisit rates. Telemedicine was shown to save an average cost of US$149-$252 per patient, and 8 studies that directly assessed andrology patient perceptions of telemedicine showed that most patients had a "positive perception."Pooled analyses of the positive responses to telemedicine were 68.7% (95% CI, 49.4%-83.1%, P = 0.057), and those of patients who recommended telemedicine were 65.1% (95% CI, 18.4%-93.9%, P = 0.577). While the percentage of patients recommending telemedicine was high among studies using videoconferencing, the percentage dropped in studies using telephone visits only. The difference between recommending video and telephone practices was statistically significant, with 84.6% pooled proportion for recommending video practice compared to 38.9% pooled proportion for recommending telephone practice, P = 0.035. In the telephone-only encounters, up to 27.1% of patients preferred in-person visits, as security and privacy of any mode of telecommunication were of concern.

CONCLUSIONS

Most patients have a positive perception of telemedicine, particularly with videoconferencing and less so with telephone visits. These results suggest that telemedicine will likely continue to play a pivotal role in andrology and sexual medicine practices.

Does Medicaid cover artificial urinary sphincter and male urethral sling surgery?-a state-by-state analysis

Background

Information regarding the Medicaid coverage of artificial urinary sphincter (AUS) and male suburethral slings (MS) placement in the United States (US) is not readily available. In this manuscript, we seek to elucidate the state-by-state Medicaid coverage of these two procedures in the US.

Methods

State Medicaid websites were utilized to access publicly available physician fee schedules for the calendar year 2020. Fee schedules were searched for current procedural terminology (CPT) codes. CPT codes representing insertion of tandem cuff, insertion of AUS, removal of AUS, removal and replacement AUS, sling operation for correction of male stress urinary incontinence (SUI), and removal or revision of sling for male SUI were utilized. Data were recorded by the procedure for each device, including the coverage status and physician fees.

Results

Of the 50 US states analyzed, 49 publish publicly accessible physician fee schedules. All 49 of these states reported coverage for removal with and without revision of the AUS, and 48 states reported coverage for insertion of an AUS, and insertion of a tandem cuff. The median reimbursement for each AUS related procedure was $624.00 ($181.84-$10,960.90) for tandem cuff, $665.54 ($199.89-$11,949.86) for AUS insertion, $528.03 ($146.90-$1,893.12) for AUS removal, and $630.29 ($208.55-$11,586.74) for AUS revision. All 49 states reported coverage for placement of MS, and 48 states reported coverage for removal or revision of MS. The median reimbursement was $652.57 ($198.00-$5,237.35) for MS placement and $554.47 ($104.27-$2,288.93) for MS revision.

Conclusions

AUS and MS procedures in the Medicaid population are covered by nearly all states. Therefore, surgical treatment of SUI may be offered to Medicaid patients in most states without reimbursement concerns.

Oral testosterone therapy: past, present, and future

INTRODUCTION

Testosterone replacement therapy (TRT) remains a commonly utilized treatment for men with testosterone deficiency (TD). Despite the recent FDA approval of new oral TRT medications, concerns remain regarding their efficacy and safety, and prescription rates for these medications have decreased compared to those for TD medications with other routes of administration.

OBJECTIVE

In this study we sought to investigate the efficacy and safety of oral testosterone undecanoate (oTU), a new oral TRT medication.

METHODS

A comprehensive review of the literature was performed using the Medline, EMBASE, and Cochrane Library databases; 1269 articles were identified, with 44 articles included in the final review and 12 used to perform meta-analyses to investigate the change in serum total testosterone (TT) and risk of adverse effects following oral testosterone undecanoate (oTU) use. Articles were also reviewed to investigate the reported effects of oTU on body composition, liver function, hematologic assays, lipid profiles, hormone assays, prostate growth, hypertension, and symptoms of TD.

RESULTS

Across placebo-controlled randomized trials, there was no significant increase in TT for those receiving oTU vs placebo (mean difference, -0.26 [95% CI, -1.26 to 0.73]). On subanalysis, when eugonadal participants received oTU, a significant decrease in TT was demonstrated (mean difference -0.86 [95% CI, -1.28 to 0.43]). When participants who were hypogonadal at baseline received oTU, a significant increase in TT compared to placebo was seen (mean difference 1.25 [95% CI, 0.22-2.29]). There was no significant risk of adverse effects (RR, -0.03 [95% CI, -0.08 to 0.03]) or serious adverse effects (RR, 0.15 [95% CI, -0.66 to 0.96]) in the oTU groups compared to placebo.

CONCLUSION

oTU was found to be well tolerated in hypogonadal patients, resulting in improved testosterone levels, height velocity, and sexual symptoms, without significant hepatotoxicity, prostatic enlargement, or worsening hypertension. There was no consensus regarding the effect of oTU on lean and fat mass percentages, hematologic assays, lipid profiles, mood, and general well-being.

Partial Component Exchange of a Non-Infected Inflatable Penile Prosthesis is Associated With a Higher Complication Rate

OBJECTIVE

To describe the infectious and non-infectious complications in men undergoing Inflatable penile prosthesis (IPP) revision with partial and complete component exchange for mechanical malfunction.

METHODS

We performed a multicenter retrospective cohort study of patients who underwent IPP revision. Men undergoing procedures for implant infection were excluded. Patients were divided into those who had complete exchange of the entire device or partial exchange of only one or 2 components. Infectious and non-infectious complications were compared between groups.

RESULTS

Three hundred sixty-eight men had complete exchange of the entire device and 85 had partial component exchange. Men undergoing partial exchange had a significantly higher infection rate (7.1% vs 2.2%, P = .031). The partial exchange group also was more likely to receive antifungals (51.8 vs 16.6%, P < .001), have a modified salvage washout (77.4 vs 60.2%, P = .004), and less likely to receive vancomycin and gentamicin (63.5 vs 83.7%, P < .001). Time to revision was significantly shorter in the partial exchange group (44.9 vs 168.2 months, P < .001). Mean follow-up was slightly longer in the complete exchange group (18.3 vs 13.0 months). In multivariable analysis, partial exchange surgery, vancomycin and gentamicin prophylaxis, modified salvage washout, and antifungal prophylaxis were no longer associated with postoperative infections. The partial exchange group had greater rates of non-infectious complications (21.2% vs 9.5%, P = .005) such as pump malfunction and tubing breakage.

CONCLUSION

Patients undergoing partial component revision had more infectious and non-infectious complications. These findings suggest that partial component exchange increases complications in men undergoing IPP revision.

Update on Treatment Options for Stuttering Priapism

Purpose of Review

There is a paucity of peer-reviewed evidence to guide medical management of stuttering priapism. The purpose of this review is to summarize the current understanding regarding the pathophysiology of priapism and management options for stuttering priapism.

Recent Findings

Conducting large-scale, randomized, placebo-controlled trials that elucidate the optimal treatment of stuttering priapism is challenging. Therefore, recent treatment guidelines are based upon small case series, retrospective studies, and expert opinions. Nonetheless, multiple compounds from various drug classes have shown promise in treating stuttering priapism, and a few pharmacotherapies such as Crizanlizumab are currently under active investigation.

Summary

Stuttering priapism is an under-investigated disorder with a complex pathophysiology. Currently, there is no wildly adopted universal therapeutic strategy. Further research is warranted to identify the appropriate treatment of stuttering priapism and to determine the long-term side effects of current pharmacotherapies.

Synchronous Surgical Management of Erectile Dysfunction and Stress Urinary Incontinence: A Systematic Review and Meta-Analysis of Reoperation Rates

INTRODUCTION

The efficacy, safety, and postoperative outcomes of synchronous surgery for concomitant erectile dysfunction (ED) and stress urinary incontinence (SUI) remain unclear.

OBJECTIVES

We performed a systematic review and meta-analysis to evaluate the available synchronous surgical approaches for concomitant ED and SUI and to assess the reoperation rates compared to asynchronous surgery and surgery only for ED or SUI.

METHODS

We searched PubMed, Cochrane Library, and Embase databases until June 2022 for relevant studies. Based on data availability, we performed a meta-analysis of odds ratios (ORs) comparing reoperation rates after synchronous surgery in patients with concomitant ED and SUI versus asynchronous surgery, as well as surgery solely for ED or SUI (PROSPERO: CRD42022326941).

RESULTS

We included 18 studies in the systematic review (16,517 patients) and 5 in the meta-analysis. Comparing synchronous implantation of penile prosthesis and artificial urinary sphincter (AUS) versus asynchronous surgery, no statistically significant differences were observed in the reoperation rates [OR:0.98, 95% confidence interval (CI): 0.52-1.84, I²:0%). Comparing synchronous implantation of both penile prosthesis and AUS versus implantation of only a penile prosthesis or an AUS, combined surgery was associated with higher reoperation rates (OR:2.02, 95%CI: 1.29-3.16, I²:36% and OR:1.7, 95%CI: 1.25-2.32, I²:0%, respectively). Synchronous surgery led to high satisfaction rates and significant improvement in ED and SUI. Evidence for the combination of penile prosthesis with a male sling or the ProACT device is low, but data suggests it may be safe and effective. The synchronous placement of a Mini-Jupette sling and penile prosthesis represents a promising treatment modality for the correction of ED and mild SUI and/or climacturia.

CONCLUSIONS

Synchronous penile prosthesis and AUS implantation appears safe and effective in patients with severe ED and SUI. Further high-quality studies are mandatory to strengthen the current scarce evidence for synchronous surgery in patients with ED and SUI. Pyrgidis N, Barham DW, Hammad M, et al. Synchronous Surgical Management of Erectile Dysfunction and Stress Urinary Incontinence: A Systematic Review and Meta-Analysis of Reoperation Rates. Sex Med Rev 2022;XX:XXX-XXX.

Hypogonadism associated with higher rate of penile prosthesis infection: An Analysis of United States claims data

OBJECTIVE

To understand the relationship between hypogonadism and penile prosthesis infection risk.

METHODS

We performed a retrospective analysis using IBM MarketScan™ Commercial Claims and Encounters database. We identified men with ED diagnosis who underwent penile prosthesis placement from 1/1/2008 to 12/31/2017. Comorbidities and risk factors were identified along with a diagnosis of hypogonadism. After placement of penile prosthesis, men were followed until date of surgery of penile prosthesis explant due to infection. Cox proportional hazards models from time of penile prosthesis surgery to date of infection adjusting for various known confounding factors were run.

RESULTS

We identified 16,660 men who had received penile prosthesis during the study period. 4,832 (29.0%) men had a hypogonadism diagnosis at the time of their initial surgery date. There were 421 (2.5%) device infections requiring explanation. Descriptively, a higher percentage of infections were noted for removal and replacement surgeries compared to primary implants. Hypogonadism was independently associated with a 25.8% higher risk of penile prosthesis infection (HR: 1.258, 95% CI: 1.024-1.546). Among those men who received testosterone therapy for hypogonadism (prescription data within 0-30 days and within 0-90 days of their initial implant surgery), the effect of hypogonadism on infection risk was no longer significant.

CONCLUSIONS

Untreated hypogonadism was associated with a 26% higher risk of penile prosthesis infection. This association was most pronounced in men undergoing removal and replacement surgery, which likely drives this association. This suggests a possible benefit to testosterone therapy in testosterone deficient men prior to penile implant, specifically in men undergoing revision.

Pharmacotherapy in Peyronie's disease: a state-of-the-art review on established contemporary and emerging drugs

INTRODUCTION

Current clinical guidelines on Peyronie's disease (PD) advocate non-surgical treatment options as the first-line therapy despite inconsistent clinical outcomes when compared to definitive penile reconstructive surgery.

AREAS COVERED

This article examines the current understanding of established contemporary and emerging pharmacotherapies for PD. Emphasis has been placed on published clinical studies on drugs in the last 10 years.

EXPERT OPINION

Published studies have shown that combination therapy is likely more effective than monotherapy. Combined treatment modalities involving various oral and/or intralesional pharmacotherapies together with mechanical devices or clinical psychosexual therapy may provide additional or synergistic benefits for PD patients. A multidisciplinary approach coupled with more novel targets for pharmacological intervention could deliver a more effective treatment paradigm to prevent or at least delay the need for definitive penile reconstructive surgery. Drugs targeting the inhibition of TGF-β1 pathway and myofibroblast transformation are of great interest and studies into next-generation genetic sequencing and transcriptional biomarker regulatory pathways in PD will provide useful insights into the pathophysiology of PD, and assist the development of future regenerative technology including cellular-based therapies to target various anti-fibrotic molecular mechanisms and the potential to be integrated into existing treatment armamentarium for PD.

Evidence for the integration of total and free testosterone levels in the management of prostate cancer

OBJECTIVE

To comprehensively assess total and calculated free testosterone levels in a consecutive group of patients with prostate cancer (PCa) and any potential impact on disease aggressiveness and recurrence outcomes.

PARTICIPANTS AND METHODS

The study included a single-centre prospective cohort of 882 patients presenting for radical prostatectomy from 2009 to 2018. Data on total testosterone (TT), sex hormone-binding globulin (SHBG), and calculated free testosterone (cFT) were prospectively collected. Stepwise logistic regression models were used to assess correlations of TT and cFT with pathological Gleason Grade Group (GGG), extraprostatic extension (EPE), seminal vesicle invasion (SVI) and biochemical recurrence (BCR).

RESULTS

Total testosterone remained nearly constant across decades (40s-80s): 0.09 decrease/year (R = 0.02), while SHBG increased 0.87/year (R = 0.32) and cFT decreased 0.08/year (R = -0.02). Low cFT of <5.5 independently predicted: very-high-risk GGG (odds ratio [OR] 0.435, 95% confidence interval [CI] 0.846-0.994; P = 0.036), EPE (OR 0.557, 95% CI 0.810-0.987; P = 0.011), SVI (OR 0.396, 95% CI 0.798-1.038; P = 0.059), and BCR within 1 year after robot-assisted radical prostatectomy (OR 0.638, 95% CI 0.971-3.512, P = 0.046). TT was not a predictor.

CONCLUSION

In contrast to popular belief, testosterone remained stable in men aged 40-80 years, whereas free testosterone decreased by 2-3%/year. Low cFT was an independent predictor of very-high-risk PCa and BCR.

Canadian Urological Association guideline: Erectile dysfunction

Erectile dysfunction (ED) impacts the wellness and quality of life of millions of Canadians. An evaluation focused on the identification of reversible and irreversible underlying factors is recommended for patients presenting with ED. Through a shared decision-making model framework, the goal of ED treatment is to improve functional outcomes and enhance sexual satisfaction while minimizing adverse effects associated with treatment. Given that ED is assessed and treated by multiple different types of health practitioners, the purpose of this guideline is to provide the best available evidence to facilitate care delivery through a Canadian lens. After a narrative review of ED assessment and treatment for general readership, five key clinical questions relating to priority areas of ED are assessed using the GRADE and evidence-to-decision-making frameworks.

Peyronie's disease - outcomes of collagenase clostridium histolyticum injection: A systematic review

Objective

To review recent literature pertaining to collagenase clostridium histolyticum (CCh)and other intralesional (IL) therapies for the treatment of Peyronie’s disease (PD). 

Methods

A systematic search of literature was performed using MEDLINE and PubMed.‘Peyronie’s Disease Clostridium Histolyticum’, ‘Peyronie’s Disease Intralesional’, ‘Peyronie’sDisease Causes’, and ‘Atypical Peyronie’s Disease’ were used as query entries. Inclusion criteriarequired English text from 1980 onwards and have a full text available. Records were reviewed for study power, accuracy, and relevance to our research topic. The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.

Results

Recent literature supports the notion that CCh is the most effective IL treatment forpatients with typical and atypical PD. The capstone CCh study was the IMPRESS trial thatshowed a 34% reduction in curvature with a mean (SD) – 17.0 (14.8)° reduction with IL CCh,while men in the placebo saw an average 18.2% decrease in penile bend with a mean (SD) – 9.3 (13.6)° per person (P < 0.001). A shortened protocol for IL CCh treatment offered a 31.4%reduction in curvature, while decreasing cost and office visits, potentially increasing patientcompliance. Lastly, literature shows CCh is used most in atypical cases, with ~64.8% of patients being treated with CCh, probably because of the high efficacy and safetyprofile that it offers. Serious complications associated with CCh include urethralinjury, corporal rupture, and penile fracture.

Conclusion

Since the approval of CCh by the United States Food and Drug Administration in2013, it has been a staple in the treatment of PD, and here we report the continuedsuperiority of this therapy. CCh is an effective, minimally invasive option in most PDpopulations; however, recent changes have made CCh unavailable for commercial use outside the United States, impacting many patients who have previously benefited.

Development and Validation of the Satisfaction Survey for Inflatable Penile Implant (SSIPI)

BACKGROUND

No validated English language patient-reported outcome (PRO) currently exists that assesses satisfaction with inflatable penile prosthesis (IPP). Satisfaction data have been largely based primarily on surgeon assessment of patients or using questionnaires that have not been designed for this purpose.

AIM

To develop an English-language validated PRO that assesses patient satisfaction after IPP surgery.

METHODS

Initially, a literature review and discussions with experts defined domains important to IPP satisfaction (pain, appearance, function, overall satisfaction). The initial 35-item Satisfaction Survey for Inflatable Penile Implant (SSIPI) was developed. Cognitive interviews were then performed with IPP patients (n = 12) to gain feedback on the SSIPI domains and items. These data were used to modify SSIPI with the addition of 2 questions for a final item number of 37. Patients from 4 centers, who were between 6 months and 5 years after IPP, were administered the questionnaire through RedCap. Reliability statistics and content analysis were used to winnow questions to yield the final 16-item version of the SSIPI. Internal consistency was assessed via Cronbach's alpha and item-total correlation. Test-retest reliability was assessed via intraclass correlation coefficients using baseline and 2-week data. For convergent validity, the Erectile Dysfunction Inventory of Treatment Satisfaction and the Self-Esteem and Relationship (SEAR) questionnaire were used. For discriminant validity, the International Prostate Symptom Score (IPSS) was used. Confirmatory factor analysis was used to assess the factor structure of the SSIPI.

OUTCOMES

Internal consistency, test-retest reliability, convergent and discriminant validity, and confirmatory factor analysis were assessed.

RESULTS

118 men were surveyed. Mean age was 66.8 ± 9.5 years. The 16-item SSIPI showed high internal consistency with an overall Cronbach's Alpha of 0.97 (domains 0.85-0.89). Item-total correlations for individual items to subscales ranged from 0.60 to 0.91. The overall test-retest reliability was 0.94 (domains 0.87-0.93). Erectile Dysfunction Inventory of Treatment Satisfaction and Self-Esteem and Relationship had correlations of 0.84 overall (domains 0.57-0.79) and 0.47 overall (domains 0.34-0.44), respectively. International Prostate Symptom Score (discriminant validity) had correlations of -0.29 overall (domains -0.17 to -0.31).

CLINICAL IMPLICATIONS

SSIPI is the first English-language validated IPP satisfaction PRO. This will enable clinicians to collect satisfaction data in a standardized way.

STRENGTHS AND LIMITATIONS

As strengths we have used a rigorous psychometric process and have no industry sponsorship. Limitations include small numbers of specific subpopulations.

CONCLUSION

The SSIPI has demonstrated robust psychometric properties. Salter CA, Bach PV, Jenkins L, et al. Development and Validation of the Satisfaction Survey for Inflatable Penile Implant (SSIPI). J Sex Med 2021;18:1641-1651.

Does Medicaid Cover Penile Prosthesis Surgery? A State-by-State Analysis

BACKGROUND

Malleable [MPP] and inflatable [IPP] penile prosthesis surgery for the management of erectile dysfunction is a reliable treatment option with high success rates and excellent patient satisfaction; however, Medicaid coverage transparency is poor leaving a knowledge gap in this population.

AIM

The present study seeks to assess Medicaid coverage for MPP and IPP by state as evidenced by inclusion in publicly available physician fee schedules.

METHODS

State Medicaid websites were utilized to access public physician fee schedules. Individual search queries were performed for CPT codes 54400 and 54405 which represent insertion of MPP and IPP, respectively. Data were recorded for each device, including the coverage status, physician fees, and the presence of clear documentation of a prior authorization requirement.

OUTCOMES

Medicaid physician fee schedules were accessible for 49 out of 50 US states, and 28 states reported coverage for at least one type of penile prosthesis.

RESULTS

Two states reported coverage for MPP only, one state reported coverage for IPP only, and 24 states reported coverage for both devices. One state reported that it did not cover either device, but listed coverage for a self-contained IPP (CPT 54401) only. Mean physician reimbursement was $477.15 (290.82-$1175.50) for MPP placement and $691.76 (421.68-$1794.27) for IPP. Eleven states documented prior authorization requirements within their fee schedules, while the remaining 17 states did not. Criteria for approval for prior authorization were not clearly stated in any fee schedule.

CLINICAL IMPLICATIONS

Efforts to clearly document approval criteria and educate Men's Health providers on available coverage could result in a significant improvement in sexual satisfaction in the Medicaid population.

STRENGTHS AND LIMITATIONS

Graphical representation of states offering Medicaid penile prosthetic coverage and physician reimbursement ranges are provided with comparison to Medicare rates. Limitations include heterogeneity in fee schedules, lack of prior authorization requirement details, inability to correlate to successful claims data, and the evolving nature of Medicaid coverage for the given procedures.

CONCLUSIONS

Medicaid coverage exists for penile prosthetic surgery in 28 states, although often with significant, non-transparent prior authorization criteria. Barnard JT, Grimaud L, Yafi FA. Does Medicaid Cover Penile Prosthesis Surgery? A State-by-State Analysis. J Sex Med 2021;18:1455-1460.

Post-market safety and efficacy profile of subcutaneous testosterone enanthate-autoinjector: a cohort analysis

A subcutaneous testosterone enanthate-autoinjector (SCTE-AI) was recently approved by the Food and Drug Administration for patient-administered weekly testosterone replacement therapy (TRT). From January 2019 to October 2019, 110 hypogonadal men were treated with SCTE-AI at two institutions. Patients were assessed in a pretherapy visit prior to receiving SCTE-AI and re-assessed 6 weeks after treatment initiation. Patients with a history of prostate cancer were excluded. Trough serum total testosterone (TT), estradiol (E2), prostate-specific antigen (PSA), and hematocrit (HCT) levels were collected at clinic visits. Therapeutic phlebotomy was recommended for HCT > 54%, and treatment was discontinued for significant increases in PSA as well as for significant treatment-related adverse events. Values from each visit were compared with univariate analysis. 110 patients completed the 6 weeks of observation with a mean age of 40.3 (SD: 10.5). TT significantly rose from 246.6 ng/dL (SD:113.3) pretherapy to 538.4 ng/dL (SD: 209.3) at 6 weeks (p < 0.001). Post-therapy, 101/110 (91.8%) of patients had TT > 300 ng/dL. No patients had HCT > 54%. 74 patients (70.5%) had PSA increase with only 3 (2.9%) experiencing an increase >1.0 ng/dL. There was a significant increase in mean PSA from 1.07 ng/dL (SD: 0.8) pretherapy to 1.18 ng/dL (SD: 0.9) at 6 weeks (p = 0.01). One patient had immediate treatment cessation following diagnosis of prostate cancer. This is the largest non-industry sponsored safety and efficacy profile of SCTE-AI application in urology clinics. After 6 weeks of observation, TT levels increased significantly without any reports of adverse events. SCTE-AI is a safe and effective alternative delivery system of TRT.

Comparing and Contrasting Peyronie's Disease Guidelines: Points of Consensus and Deviation

BACKGROUND

Peyronie's disease (PD) is a challenging clinical entity. To assist clinicians with diagnosis and management, four separate organizations have published PD guidelines over the past five years, but there remains a lack of consensus and data-driven recommendations for many aspects of diagnosis and treatment.

AIM

To compare and contrast PD guidelines, highlighting key similarities and differences among the guideline panel recommendations and identify areas for further research.

METHODS

We performed an extensive review to compare and contrast diagnosis and treatment recommendations from publically available published PD guidelines from four different organizations: American Urological Association, European Association of Urology, Canadian Urologic Association, and the International Society of Sexual Medicine.

OUTCOMES

Key similarities and differences with regards to definition, evaluation, nonsurgical and surgical treatments were compared.

RESULTS

Points of general consensus among the guideline panels included: History is adequate for diagnosis of PD, and intracavernosal injection is a gold standard to evaluate penile deformity prior to invasive intervention. Careful counseling with shared decision-making is required prior to treatment. In general, plication and incision and/or grafting surgery is reserved for patients with preserved erectile function whereas penile prosthesis implantation is the only surgical option for PD patients with erectile dysfunction. Overall, nonsurgical treatments have inferior evidence of efficacy with these being the main area of controversy; however, all societies recognize that intralesional injections may be used. 0Further research into the pathophysiology of PD may direct novel treatments targeted towards early intervention and rigorous outcomes research may direct best practices for the surgical treatment of PD in the future.

CLINICAL IMPLICATIONS

PD is a challenging clinical entity. Direct comparison of the published PD guidelines highlights clear standards of care as well as areas where more research is needed to promote higher levels of evidence-based practice.

STRENGTHS & LIMITATIONS

To our knowledge this is the first report to directly compare and contrast published guidelines pertaining to the diagnosis and management of PD. Limitations include the lack of evidence-quality review pertaining to individual guideline recommendations, although this was not the aim of this review.

CONCLUSION

We highlight consensus of major urologic societies on many aspects of work up and management of PD with notable exceptions which may guide further research. Manka MG, White LA, Yafi FA, et al. Comparing and Contrasting Peyronie's Disease Guidelines: Points of Consensus and Deviation. J Sex Med 2021;18:363-375.

Hypogonadism and its treatment among prostate cancer survivors

Adult-onset hypogonadism (AOH) is associated with sexual dysfunction, poor bone mineralization, decreased muscle mass, metabolic syndrome disorder, and cognitive suppression. Historically, testosterone has been contraindicated in men with a history of prostate cancer. However, there has been a modern resurgence in re-evaluating this belief. Not only can testosterone be safely utilized to alleviate AOH symptoms in prostate cancer survivors, it has been also touted as a treatment option for aggressive prostatic cancer. While much work remains in understanding the relationship between testosterone and prostate cancer, those who survive this disease should not be automatically turned away from an opportunity to be treated and restored.

Review of Sexual Preservation After Novel Benign Prostatic Hyperplasia Surgical Treatment Modalities From Food and Drug Administration Clinical Trials

INTRODUCTION

Traditional benign prostatic hyperplasia treatment options, such as transurethral resection of the prostate and laser, have focused on addressing urinary symptoms for men; however, these options are associated with a high risk of sexual dysfunction.

OBJECTIVE

The objective of this study was to assess newer technologies (Aquablation therapy, UroLift, and Rezum) for the treatment of benign prostatic hyperplasia and the impact of preserving sexual function compared with transurethral resection of the prostate.

METHODS

A comprehensive review of Food and Drug Administration randomized studies from each of the technologies was carried out. A comparison of 3-year outcomes for International Index of Erectile Function-5 and Male Sexual Health Questionnaire Ejaculatory Function domain short form was analyzed.

RESULTS

Aquablation and prostatic urethral lift were the only therapies to show permanent sexual function preservation in both Male Sexual Health Questionnaire Ejaculatory Function domain short form (ejaculatory function) and International Index of Erectile Function-5 (erectile function) at 3 years after treatment.

CONCLUSION

For prostates less than 80 cc, Aquablation and prostatic urethral lift were able to demonstrate permanent sexual function preservation in both Male Sexual Health Questionnaire Ejaculatory Function domain short form (ejaculatory function) and International Index of Erectile Function-5 (erectile function) at 3 years after treatment. Bhojani N, Yafi FA, Misrai V, et al. Review of Sexual Preservation After Novel Benign Prostatic Hyperplasia Surgical Treatment Modalities From Food and Drug Administration Clinical Trials. Sex Med Rev 2021;9:169-173.

Risk profiling in patients undergoing penile prosthesis implantation

Penile prosthesis implantation is the gold standard of surgical therapy for patients with medication-refractory erectile dysfunction. However, this umbrella definition includes significant heterogeneity and associated risk profiles that should be candidly discussed and addressed perioperatively. Factors associated with operative success and patient satisfaction are often surgery specific; however, risk profiling via patient selection, preoperative optimization, proper device selection, and intraoperative consideration are highly correlated. Some examples of common risk profiles include comorbidity(ies) such as cardiovascular disease, diabetes mellitus, prior abdominal surgery, Peyronie's disease, and psychological risk factors. Similarly, integration of surgeon- and patient-amenable characteristics is key to decreasing risk of infection, complication, and need for revision. Finally, patient risk profiling provides a unique context for proper device selection and evidence-based intraoperative considerations.