Minimally invasive techniques in quest of Holy Grail of surgical management of enlarged prostates: a narrative review.

PURPOSE: Past decade has seen a renewed interest in minimally invasive surgical techniques (MISTs) for management of enlarged prostate. This narrative review aims to explore newer MIST for benign prostatic hyperplasia (BPH) which are not yet integrated into established societal guidelines. METHODS: We conducted a literature search across PubMed, Google Scholar, and FDA ClinicalTrials.gov databases on June 1st, 2023, to identify studies published within the past decade exploring various MISTs for BPH. Additionally, we gathered insights from abstracts presented in meetings of professional associations and corporate websites. We broadly classified these procedures into three distinct categories: energy-based, balloon dilation, and implant/stent treatments. We collected detail information about the device, procedure details, its inclusion and exclusion criteria, and outcome. RESULTS: Our review reveals that newer energy-based MISTs include Transperineal Laser Ablation, Transurethral Ultrasound Ablation, and High-Intensity Focused Ultrasound. In the sphere of balloon dilation, Transurethral Columnar Balloon Dilation and the Optilume BPH Catheter System were gaining momentum. The noteworthy implants/stents that are on horizon include Butterfly Prostatic Retraction Device, Urocross Expander System, Zenflow Spring System, and ProVee Urethral Expander System. CONCLUSION: The exploration of various MISTs reflects ongoing efforts to enhance patient care and address limitations of existing treatments. This review provides a bird-eye view and valuable insights for urologists and researchers seeking to navigate the dynamic landscape of MISTs in the quest for effective and minimally invasive solutions for enlarged prostates.

Complications associated with minimally invasive surgical therapies (MIST) for surgical management of benign prostatic hyperplasia: a Manufacturer and User Facility Device Experience (MAUDE) database review.

PURPOSE: MAUDE database houses medical device reports of suspected device-related complications received by Food and Drug Administration. In the present study we aim to evaluate the MAUDE database for reported complications of MIST procedures. METHODS: The database was queried using keywords: rezum, urolift, prostate embolization (PAE), transurethral needle ablation (TUNA), transurethral microwave therapy (TUMT), prostate stent and Temporarily Implanted Nitinol Device (iTIND) on 10/1/22 to extract information regarding device problems and procedure-related complications. Gupta classification system was used to stratify complications. Statistical analysis was performed to compare frequency of complications among MIST procedures. RESULTS: We found a total of 692 reports (Rezum-358, urolift-226, PAE-53, TUNA-31, TUMT-19, prostatic stent-4, and iTIND-1). Most complications related to device or users were minor (level 1 and 2) and there was no significant difference among various MIST procedures. The screen/system error was responsible for 93% and 83% aborted cases in Rezum and TUNA, respectively, and PAE showed 40% of device component detachment/fracture. Overall Urolift and TUMT were associated with statistically significant higher incidence of major (level 3 and 4) complications (23% and 21%, respectively) as compared with Rezum (7%). Most major complications needing hospitalization after Urolift included hematoma and hematuria with clots and those after Rezum included urinary tract infection and sepsis. Thirteen deaths were reported, mostly due to cardiovascular events, which were classified as not associated with the proposed treatment. CONCLUSION: MIST for BPH can occasionally cause significant morbidity. Our data should assist urologists and patients in shared decision-making process.

Histopathological assessment of depth of coagulation necrosis with Holmium, Moses, and Thulium fiber lasers in human prostate tissue.

PURPOSE: To evaluate coagulation necrosis depth (CND) of Holmium (HL), Moses (ML), and Thulium fiber laser (TFL) in ex vivo human prostate tissue at various energy settings. METHODS: After endoscopic HL enucleation, small prostate tissue fragments were removed from the bladder with graspers and used for study. Immediately after surgery, a single incision was made on the surface of the tissue kept under normal saline at room temperature using a hand-held 550-µm laser fiber. Variable energy settings were tested for all three lasers. Two pathologists measured the CND with light microscopy using ocular micrometer. Impact of various laser settings on CND was analyzed. The differences in CND of all three lasers at similar laser power were compared. RESULTS: Mean CND was 0.56 ± 0.53 mm for long-pulse HL, 0.54 ± 0.53 mm for ML, 0.67 ± 0.67 mm for low-pulse TFL, and 0.81 ± 0.78 mm for high-pulse TFL. There was no significant difference between mean CND of HL and ML at various laser settings ranging from 10 to 120 W and CND with long- and short-pulse settings of TFL at settings from 10 to 60 W. There was a trend of increasing CND in HL and ML with increasing laser power; however, it was not statistically significant. TFL had similar tissue effects as HL and ML. CONCLUSION: There is no significant difference in CND of HL, ML, and TFL in ex vivo human prostate tissue. Other factors besides laser type and settings need to be studied to explain clinical differences among various lasers used for prostate enucleation.

Is tadalafil associated with decreased risk of major adverse cardiac events or venous thromboembolism in men with lower urinary tract symptoms?

PURPOSE: To evaluate the association of tadalafil, a phosphodiesterase-5 inhibitor (PDE5I), with major adverse cardiac events (MACE) or venous thromboembolism (VTE) in men with lower urinary tract symptoms (LUTS). METHODS: Data was obtained from the TriNetX Research Network, ICD-10 codes were used to identify men with LUTS, MACE, and VTE. In addition, demographic characteristics and use of tadalafil or alpha-blocker was evaluated. Then, unbalanced and balanced association analyses was performed to assess the relation between tadalafil and/or alpha-blocker use with MACE/VTE. RESULTS: After participant selection, analysis included 821,592 men that did not use an alpha blocker or tadalafil, 5,004 men that used tadalafil but no alpha blocker, 327,482 men that used an alpha blocker but no tadalafil, and 6,603 men that used both an alpha blocker and tadalafil. On balanced analysis, tadalafil was independently associated with a decreased risk of MACE/VTE within a 3-year time period (OR = 0.59, 95%CI 0.49-0.70, p < 0.0001). Among men with a history of alpha blocker use, tadalafil use was also independently associated with a decreased risk of MACE or VTE, both before and after controlling for potentially confounding variables (OR = 0.57, 95%CI: 0.50-0.66; p < 0.0001). CONCLUSIONS: In our study, tadalafil was associated with a decreased risk of MACE/VTE in men with LUTS with and without a history of alpha blocker use. It is time to perform further long-term prospective randomized studies to further analyze the cardiovascular effects of PDE5Is as combination treatment with alpha blockers in the management of LUTS.

Are all procedures for benign prostatic hyperplasia created equal? A systematic review on post-procedural PSA dynamics and its correlation with relief of bladder outlet obstruction.

PURPOSE: To evaluate and provide a comprehensive literature review of Prostate specific antigen (PSA) dynamics after various surgical procedures for benign prostatic hyperplasia (BPH). METHODS: A thorough PubMed database search was performed over last 30 years including terms "PSA" and various surgical procedures for BPH. PSA nadir after various procedure was evaluated. The post-operative improvement in International Prostate Symptom Score, maximum void rates and post-void residue after surgeries were recorded. An indirect correlation was made between PSA nadir and outcome of various BPH surgical procedures. RESULTS: Enucleation procedures like simple prostatectomy and endoscopic enucleation of prostate (EEP) produced maximum drop in PSA level after surgery and were associated with the highest improvement in post-operative parameters. The PSA nadir following resection techniques like transurethral resection of prostate and Holmium laser resection of prostate and vaporization technique was variable and less robust when compared to EEP. Newer techniques like Aquablation, Rezum, Urolift, Prostate artery embolization and Temporary implantable nitinol devices (iTIND) produce relatively less reduction in PSA and lesser percentile improvement in post-operative parameters. CONCLUSIONS: Various surgical procedures for BPH result in varying PSA nadirs level. Enucleation procedures and simple prostatectomy produce the most drastic and sustained decrease in PSA. There is a possible indirect evidence suggesting that the level of PSA nadir corresponds closely with the degree of post-operative improvement and durability of the procedure. Establishing the new PSA nadir at 3-6 months after the procedure is recommended as a part of routine surveillance for prostate cancer in eligible patients.

Incidence and risk factors for postoperative urinary incontinence after various prostate enucleation procedures: systemic review and meta-analysis of PubMed literature from 2000 to 2021.

PURPOSE: To evaluate the risk of urinary incontinence (UI) after various prostate enucleation procedures (PEP). METHODS: PubMed was searched from January 2000 to July 2021 for studies investigating UI after PEP. The articles were divided into 5 subgroups: holmium, thulium, greenlight laser, electrocautery, and simple prostatectomy. Meta-analysis was performed to examine rate of stress (SUI), urge (UUI) or unspecified UI at short (< 3 months), intermediate (3-6 months), and long-term (> 6 months). The impact of age, prostate size, surgery time, laser time, postoperative nadir PSA level and technical modifications on UI was analyzed. RESULTS: Most (69.4%) of 49 articles included employed holmium laser. There was no significant difference in incidence of short-, intermediate-, and long-term UI, SUI and UUI between five sub-groups and within different technical modifications. Although not statistically significant, the incidence of UI was higher (15%) at short-term with green-light and simple prostatectomy (95% CI 9-23 and 1-84), and higher (4%) at intermediate-term with holmium laser (95% CI 2-8). SUI was more prevalent at short-term with holmium laser (4%; 95% CI 2-5%), and at intermediate term with simple prostatectomy (3%; 95% CI 1-14). UUI was higher in the thulium group (10%, 95% CI 7-16). Increased age, surgery time, laser time and prostate size up to 80 cc were associated with higher UI. There was no correlation between postoperative PSA and UI. CONCLUSIONS: There is no significant difference in incidence of UI, SUI and UUI after various PEP. Patients age, prostate size, surgery and laser time are linearly associated with UI.

Impact of COVID-19 pandemic on diagnosis and surgical management of common urological conditions: results from multi-institutional database analysis from the United States.

OBJECTIVE: To determine real life impact during the first pandemic year on diagnosis and surgical management of common urological diseases and 90-day postoperative mortality following common urological surgeries. METHODS: Cross-sectional study from 2016 to 2021. We used TriNetX to obtain the data. Patients with a diagnosis of six common non-oncologic and five oncologic urologic conditions were included. Twenty-four surgical interventions were also analyzed. The total number of diagnosis and surgical procedures were compared yearly from 2016 to 2021 and Chi-square test was used for statistical analysis. Additionally, monthly changes were evaluated during the first pandemic year and a z score period time was reported. The 90-day post-operative mortality rates during the first pandemic year were compared to the preceding year. RESULTS: Overall, a decrease in diagnosis and surgeries were observed during the first pandemic year, with maximum drop in April 2020. Among non-oncological conditions, the decrease in diagnosis of enlarged prostate (5.3%), nephrolithiasis (9.4%), urinary incontinence (18.7%), and evaluation for male sterilization (14.8%) reached statistical significance (P < 0.05 in all). Prostate cancer was the only cancer whose diagnosis showed statistically significant decrease (6.2%, P < 0.05). The surgical case load for benign conditions showed higher reduction (13.1-25%) than for malignant conditions (5.9-16.3%). There was no change in 90-day post-operative mortality in any of the analyzed surgeries. CONCLUSIONS: Our study showed that although healthcare delivery decreased in the first pandemic year, causing a decline in the diagnosis and surgical treatment of several diseases, surgical interventions did not increase the risk of death.

COVID-19 vaccination not associated with increased risk of erectile dysfunction.

Although mRNA COVID-19 vaccines have proven to be safe and effective against SARS-CoV-2, vaccination rates have slowed, with some individuals citing impotence as a concern. Therefore, we conducted a survey of the US males to evaluate the impact of COVID-19 vaccination on erectile function. We hypothesized that vaccinated men would not have a higher risk of ED compared to unvaccinated men. Amazon Mechanical Turk (MTurk) was utilized to survey the US adult male population between August 26 and September 2, 2021. Survey participation was open to 1000 males over the age of 18 and currently living in the United States regardless of vaccination status or the past medical history of COVID-19. Selection criteria included respondents ≥45 years old, no history of physician-diagnosed ED, biologically born, and identify as male. Participants completed an anonymous 16-question survey that included a multidimensional scale used to evaluate ED, the International Index of Erectile Function (IIEF-5). Among vaccinated men, the median IIEF-5 score was 20 [16-24] compared to 22 [17.5-25] in the unvaccinated group (p = 0.195). The multivariable-adjusted analysis demonstrated that vaccination against COVID-19 was not associated with increased risk of ED. Overall, this cross-sectional survey showed that COVID-19 vaccination was not associated with an increased risk of erectile dysfunction in males 45 years and older.

Socioeconomic differences associated with consumption of a plant-based diet: Results from the national health and nutrition examination survey.

BACKGROUND: A plant-based diet (PBD) has been associated with potential health benefits, but factors that may affect access to and consumption of a PBD are not well defined. AIM: To determine the association between socioeconomic status and plant-based dietary consumption among participants enrolled in the National Health and Nutrition Examination Survey (NHANES). METHODS: This was a cross-sectional study using data obtained from the NHANES database. The following covariates were assessed: age, sex, race/ethnicity, educational level, marital status, smoking status, physical activity, alcohol use, history of diabetes, and hypertension. Socioeconomic status was categorized according to poverty-income ratio (PIR). Food frequency questionnaires were used to calculate previously validated plant-based diet index (PDI) and healthful plant-based diet index (hPDI). Multivariable-adjusted logistic regression was performed to determine the association between PIR, clinical, demographic, and plant-based diet indices. RESULTS: A total of 5037 participants were in the final analytic sample. Median age of participants was 51 ± 18.5 years. Overall PDI and hPDI were 50 [46-54] and 52 [47-57], respectively. Median PDI index was significantly different among PIR groups (PDI, p = 0.018; hPDI, p < 0.001). On multivariable analysis, participants in the poorest socioeconomic group (PIR ≤ 130%) were more likely to have lower consumption of a healthful PBD (hPDI). CONCLUSION: Lower socioeconomic status (PIR ≤ 130%) was associated with decreased consumption of a healthful plant-based diet. These data suggest that socioeconomic disparities may limit consumption of healthier food and contribute to the high prevalence of adverse health conditions that exist in certain population groups.

The association between plant-based content in diet and testosterone levels in US adults.

PURPOSE: To evaluate the association between the plant-based content of diet and serum testosterone levels in men from the national health and nutrition examination survey (NHANES) database. MATERIALS AND METHODS: Data on demographics, diet, and testosterone levels was acquired from the NHANES database. Using the food frequency questionnaire, an overall plant-based diet index (PDI) and a healthful plant-based diet index (hPDI) was developed. A higher score on PDI and hPDI indicates higher consumption of plant foods. RESULTS: A total of 191 participants were included, average age was 45 (30-60) years and average total testosterone level was 546.7 ± 254.7 ng/dL. The mean PDI and hPDI were 50.4 ± 6 and 50.8 ± 7.2, respectively. On multiple linear regression analysis, BMI and age significantly contribute to testosterone levels (p < 0.05); however, neither of the diet indexes significantly predicted serum testosterone levels (PDI: p = 0.446; and hPDI: p = 0.056). CONCLUSIONS: In a well characterized national database, the plant-based diet index is unable to predict testosterone levels. Plant-based food content in diet is not associated with serum testosterone levels.

Safety and efficacy of holmium laser enucleation of prostate as salvage procedure for persistent or recurrent lower urinary tract symptoms secondary to bladder outlet obstruction after prior prostate artery embolization: a match analysis.

PURPOSE: To evaluate safety and efficacy of Holmium laser enucleation of Prostate (HoLEP) for management of persistent or recurrent lower urinary tract symptoms after prior prostate artery embolization (PAE). We also evaluated histopathological changes in prostate after PAE. METHODS: Ten patients who underwent HoLEP after prior PAE were matched according to age, weight of resected prostate tissue, and anticoagulation status in 1:2 ratio with patients who underwent HoLEP without prior PAE by a researcher who was blinded to patient's outcome at the time of matching. Histopathological examination of prostate tissue was performed to look for changes related to prior PAE. Patient's demographics, perioperative parameters, and follow-up data were retrospectively compared. RESULTS: The median interval between PAE and HoLEP was 25 months [IQR 14.5-37.5]. Patients demographic were comparable in both groups. Intra-operatively plane of enucleation were well-maintained in spite of prior PAE. The differences in duration of surgery, enucleation efficiency, hemoglobin drop, duration of catheterization and hospital stay, and complications were statistically insignificant. Incidental prostate cancer was identified in 10% specimens from both groups. Post-PAE prostate specimens demonstrated evidence of remote-healed infarction represented by dense hyalinized paucicellur connective tissue with surrounding squamous metaplasia. There were no statistically significant differences in AUA symptom scores, maximum urine flow rate, post-void residual urine volume, and PSA at 3- and 6-month follow-up between both groups. CONCLUSIONS: Plane of enucleation is well-maintained after prior PAE. Salvage HoLEP is safe and effective after previous PAE and provide outcome comparable with HoLEP as a primary procedure.

A prospective evaluation of high- and low-power holmium laser settings for transurethral lithotripsy in the management of adults with large bladder calculi.

PURPOSE: To prospectively investigate the efficacy and safety of high-power (100 W) vs low-power (20 W) laser settings for transurethral laser lithotripsy in the management large vesical calculi (> 4 cm). METHODS: All patients with vesical calculi > 4 cm in the maximum dimension and scheduled for transurethral holmium laser lithotripsy were invited to participate in the study. Every alternate patient was treated with either the low- or high-power laser settings. We used a continuous irrigation resectoscope with laser bridge or a laser working element (Karl Storz) for laser lithotripsy of bladder stones. We compared the operative time, intra-operative/post-operative complications (up to 1 year), and stone-free rates between the treatment groups using IBM SPSS Statistics 24 software. Comparisons between treatment groups for continuous variables were assessed using the Welch test, while categorical variables were compared with either the Chi-square or Fisher's exact test. A p value < 0.05 was considered statistically significant. RESULTS: Twenty patients with ten in each cohort were recruited. Preoperative data and mean bladder stone size were comparable in both groups. The duration of surgery was significantly reduced from 70.80 ± 25.28 min in low-power cohort to 40.90 ± 15.01 min in the high-power group (p = 0.005). There were no significant intra-operative complications in either group. All patients were stone-free following the procedure. CONCLUSION: High-power laser setting of up to 100 W results in a significant reduction in duration of surgery without any increase in the complication rate for treatment of large bladder stones.

Association between low testosterone and anaemia: Analysis of the National Health and Nutrition Examination Survey.

There is an androgen effect on haematopoiesis; however, the effect of low testosterone in anaemia has not been fully studied. In this study, we aim to explore the association of total serum testosterone, low testosterone (≤300 ng/dl), haemoglobin concentration and prevalence of anaemia in a nationally representative sample of men. We analysed data from the NHANES III database, and men between the age of 18-80 years of age were selected. We defined anaemia as haemoglobin ≤13.5 ng/dl and low serum testosterone as ≤300 ng/dl. After analysing 5,888 men, it was shown that those with anaemia had a higher prevalence of low serum testosterone (32.3%) compared to those without anaemia (24.1%) (p < .001), and in multivariable-adjusted analysis, it was shown that low testosterone was significantly associated with anaemia (OR = 1.44; 95% CI: 1.17-1.78; p = .001). Our findings suggest that men with low serum testosterone have a higher risk of anaemia, and there is a positive association between serum testosterone and serum Hb. Further prospective studies need to be performed to confirm our findings.

Elevated sperm DNA fragmentation does not predict recurrent implantation failure.

In this study, we sought to determine whether sperm DNA fragmentation (DFI%) and high DNA stainability (HDS%) evaluated by sperm chromatin structure assay (SCSA) predict recurrent implantation failure (RIF) or pregnancy rate. A retrospective study was performed of consecutive cycles of ICSI treatment from 2009 to 2018. A total of 386 couples that underwent 1,216 frozen embryo transfer (FET) cycles were analysed. Mean female and male age was 34 ± 3.6 years and 37.3 ± 6.6 years, respectively, and a median total motile sperm count (TMSC) was 43.5 [9.9-105.5] million. Overall median DFI% and HDS% was 12 [7.1-18.9] and 9.6 [6.5-14.4] respectively. On multivariable analysis, DFI% and HDS% were not associated with RIF (DFI%: OR = 1.01, 95% CI: 0.98-1.04, p = .414; HDS%: OR = 0.97, 95% CI: 0.94-1.01, p = .107) or IVF success, defined as clinical pregnancy (DFI%: OR = 1.00, 95% CI: 0.99-1.01, p = .641; HDS%: OR = 1.01, 95% CI: 0.99-1.02, p = .565). We found that neither DFI% or HDS%, as assessed by SCSA, were predictive of RIF or pregnancy rate. This finding suggests that sperm DNA fragmentation does not predict RIF or pregnancy rate.

Serum 17-Hydroxyprogesterone is a Potential Biomarker for Evaluating Intratesticular Testosterone.

PURPOSE: Intratesticular testosterone is essential for spermatogenesis and can only be reliably measured with invasive testicular sampling. Previous studies have demonstrated good correlation between intratesticular testosterone and serum 17-hydroxyprogesterone (17-OHP) in men treated with human chorionic gonadotropin. Based on this observation we hypothesized that we can use serum 17-OHP as a serum biomarker for evaluating intratesticular testosterone in men receiving medications that alter serum testosterone. MATERIALS AND METHODS: Initially, we conducted a cross-sectional analysis of men with a single serum 17-OHP evaluation from July 2018 to March 2019. We followed this with a prospective analysis from July 2018 to October 2019 with evaluation of 140 men including fertile controls, and those receiving treatments that alter serum testosterone at baseline and after 3 months of therapy. According to the data distribution, we reported the median and interquartile ranges, and used the Mann Whitney U or Wilcoxon tests. RESULTS: In the initial cross-sectional analysis of 93 men, a total of 30 men received treatments that increase or maintain intratesticular testosterone concentrations, such as clomiphene citrate and/or human chorionic gonadotropin; 21 men received treatments that suppress intratesticular testosterone concentrations (various exogenous testosterone replacement therapy formulations) and 42 fertile men with normal serum testosterone (greater than 300 ng/dl) were used as control. We demonstrated that serum testosterone levels were within normal range among men receiving the various therapies. In contrast, we found that serum 17-OHP was undetectable in men who received exogenous testosterone replacement therapy, as opposed to men receiving human chorionic gonadotropin and/or clomiphene citrate or fertile controls (p <0.05). In the prospective evaluation that ensued, 17-OHP values decreased in the 21 men who received testosterone replacement therapy (47.5 [21-70] to 13.5 [10-23] ng/dl, p <0.05). Conversely, 17-OHP increased in the 55 men who received human chorionic gonadotropin and/or clomiphene citrate when compared to their baseline levels (42 [24-72] to 88 [61-135] ng/dl, p <0.05). CONCLUSIONS: Serum 17-OHP appears to be a reliable serum marker for intratesticular testosterone levels and could potentially be used to titrate or change medications that alter intratesticular testosterone.

Pediatric Kidney Transplantation Outcomes in Children with Primary Urological Abnormalities Versus Nonurological Abnormalities: Long-Term Results.

PURPOSE: We assessed renal function, graft survival rates and the risk of graft loss in children based on etiology with a focus on differences between urological causes from congenital anomalies of the kidney and urinary tract vs other causes of end stage kidney disease. MATERIALS AND METHODS: A retrospective chart review was performed including patients younger than 18 years who underwent kidney transplantation at our institution from December 1984 to November 2010 with the last followup recorded in March 2018. Patient clinical characteristics, demographics and end stage kidney disease etiology were recorded. Patients were divided into the 2 groups of urological (congenital anomalies of the kidney and urinary tract) vs nonurological based on end stage kidney disease etiology, and survival analysis was performed. RESULTS: Of 112 kidney transplant cases 90 (80.4%) were associated with nonurological causes and 22 (19.6%) with urological causes. Median (IQR) patient age at transplantation was 12 (7-15) years. Median graft survival time was not statistically different according to end stage kidney disease etiology (nonurological 12 years 95% CI 10.01-13.99 vs urological 16 years 95% CI 7.59-24.41, p=0.532). There was a significant risk of graft loss in patients with urinary tract infections after transplantation (HR 3.15, 95% CI 1.59-6.25, p=0.001). CONCLUSIONS: Children requiring transplantation due to urological causes have no disadvantage in graft survival compared to children with end stage kidney disease with other causes. Patients with urinary tract infection after transplantation had a higher rate of graft loss.

Using Artificial Intelligence to Predict Surgical Shunts in Men with Ischemic Priapism.

PURPOSE: Ischemic priapism is a urological emergency that requires prompt intervention to preserve erectile function. Characteristics that influence escalation to surgical intervention remain unclear. We identified factors and developed machine learning models to predict which men presenting with ischemic priapism will require shunting. MATERIALS AND METHODS: We identified men with ischemic priapism admitted to the emergency department of our large county hospital between January 2010 and June 2019. We collected patient demographics, etiology, duration of priapism prior to intervention, interventions attempted and escalation to shunting. Machine learning models were trained and tested using R to predict which patients require surgical shunting. RESULTS: A total of 334 encounters of ischemic priapism were identified. The majority resolved with intracavernosal phenylephrine injection and/or cavernous aspiration (78%). Shunting was required in 10% of men. Median duration of priapism before intervention was longer for men requiring shunting than for men who did not (48 vs 7 hours, p=0.030). Patients with sickle cell disease as the etiology were less likely to require shunting compared to all other etiologies (2.2% vs 15.2%, p=0.035). CONCLUSIONS: Men with longer duration of priapism before treatment more often underwent shunting. However, phenylephrine injection and aspiration remained effective for priapism lasting more than 36 hours. Having sickle cell disease as the etiology of priapism was protective against requiring shunting. We developed artificial intelligence models that performed with 87.2% accuracy and created an online probability calculator to determine which patients with ischemic priapism may require shunting.

The Effect of Transendocardial Stem Cell Injection on Erectile Function in Men With Cardiomyopathy: Results From the TRIDENT, POSEIDON, and TAC-HFT Trials.

BACKGROUND: Despite limited human data, there is a growing interest in the use of stem cell therapy (SCT) for erectile dysfunction (ED). AIM: To determine the effect of transendocardial stem cell injection on erectile function on men with cardiomyopathy and ED. METHODS: We used International Index of Erectile Function (IIEF) scores collected from men enrolled in 3 separate randomized controlled trials: Comparison of Allogeneic vs Autologous Bone Marrow-Derived Mesenchymal Stem Cells Delivered by Transendocardial Injection in Patients With Ischemic Cardiomyopathy (POSEIDON), Transendocardial Mesenchymal Stem Cells and Mononuclear Bone Marrow Cells for Ischemic Cardiomyopathy (TAC-HFT), and Dose Comparison Study of Allogeneic Mesenchymal Stem Cells in Patients With Ischemic Cardiomyopathy (TRIDENT). These trials recruited patients with ischemic cardiomyopathy and ejection fraction less than 50%. Inclusion and exclusion criteria were identical in all 3 trials. The primary intervention in these trials included transendocardial stem cell injection of stem cells or placebo via cardiac catheterization. The follow-up period was 1 year. IIEF data were collected at baseline and at multiple time points in each trial. OUTCOMES: We investigated erectile function over time based on cell dose, cell source (autologous vs allogenic), cell type (mesenchymal stem cells vs bone marrow mononuclear cells), and comparing men who received SCT with those who received placebo. RESULTS: A total of 36 men were identified with complete IIEF data. 8 men received placebo injection, and 28 received SCT. The median age was 66.5 years. Comorbidities were similar among all men. Analysis was performed on men with ED, defined by an IIEF-EF score of 24 or less. In the placebo and all-comer SCT group, the median IIEF-EF score was 5 [1-8] and 5 [1-15] at baseline and was 3.5 [3-5.8] and 7 [1-18] at 12 months (P > .05). When analyzed by cell dose, the IIEF-EF score in men who received 200 million cells increased significantly over 12 months (14 [4-23] to 20 [15-24.5], P = .014.) Similarly, an autologous cell source resulted in a similar increase from baseline to 12 months (14 [3.8-23.3] to 20 [12-22], P = .030). CLINICAL IMPLICATIONS: Erectile function may improve after systemic delivery of SCT in men with ischemic cardiomyopathy and at least mild ED. STRENGTHS & LIMITATIONS: This post hoc analysis is the first to investigate the effect of SCT on erectile function using randomized, placebo-controlled data. Weaknesses include that ED was not a primary end point, and men were not originally recruited based on erectile function. CONCLUSION: Future trials on systemic delivery of SCT for ED should focus on high cell dose and autologous cell source, as these seem to provide the best response in men with at least mild ED. Ory J, Saltzman RG, Blachman-Braun R, et al. The Effect of Transendocardial Stem Cell Injection on Erectile Function in Men With Cardiomyopathy: Results From the TRIDENT, POSEIDON, and TAC-HFT Trials. J Sex Med 2020;17:695-701.

A Systematic Review of Reported Ejaculatory Dysfunction in Clinical Trials Evaluating Minimally Invasive Treatment Modalities for BPH.

PURPOSE OF REVIEW: To explore the sexual outcomes following the novel minimally invasive surgical procedures for benign prostatic hyperplasia- (BPH-) related lower urinary tract symptoms (LUTS), with an emphasis on ejaculatory dysfunction (EjD). RECENT FINDINGS: A database search with a 10-year time restriction was carried out until February 20, 2020 using MEDLINE through the PubMed Platform evaluating minimally invasive treatment modalities for BPH and their effect on EjD. After the article selection, we retrieved data for men randomized in 19 different studies with results in 40 separate published articles investigating minimally invasive BPH surgery and reporting EjD rates. To date, water vapor thermal therapy or Rezum, prostatic urethral lift (PUL) or UroLift®, prostate artery embolization (PAE), and Aquablation showed acceptable rates (< 2%) of retrograde ejaculation by 1 year and had very low adverse events related to the procedure. Both PUL and Rezum demonstrated lower rates when compared with PAE and Aquablation. With comparable sexual side effect profiles postoperatively, clinicians may determine which therapeutic modality is optimal for patients based on efficacy and cost-benefit. Further randomized clinical trials are required to directly compare the effect of novel minimally invasive surgical procedures for BPH-related LUTS on ejaculation and sexual function.