Sexual Medicine Society of North America (SMSNA)/American Urological Association (AUA) telemedicine and men's health white paper.

PURPOSE: The purpose of this white paper is to educate health care professionals about the evolution of telemedicine (TM) and to propose a hybrid model that leverages the strengths of traditional in-person medicine as well as virtual medicine while maximizing the safety and quality of men's sexual health care. LITERATURE SEARCH STRATEGY: A literature search focused on the use of TM in urology and men's health was performed through PubMed/MEDLINE, Embase, and Web of Science (January 1, 2012-April 26, 2022). Keywords included all known permutations of the terminology used to refer to virtual health, care as well as the terminology used to refer to urologic diseases, issues specific to men's health, and men's sexual health concerns. Publications that emerged after the literature search that met this criterion also were incorporated. Opinion pieces, letters to the editor, meeting abstracts, and conference proceedings were excluded. Additional resources were retrieved, such as governmental technical reports, legislative updates and reviews, and blogs. This search strategy yielded 1684 records across databases after removal of duplicates. Abstracts from the retrieved records were reviewed for relevance. Relevant publications were defined as those that reported data on any aspect of TM use specific to urology, men's health, and/or men's sexual health. If relevance was unclear from the abstract, then the full text of the article was retrieved for a more detailed review. In addition, the published evidence-based practice guidelines relevant to care for erectile dysfunction, Peyronie's disease, ejaculatory dysfunction, and hypogonadism were retrieved. The most common reasons for article exclusions were a focus on TM use in disciplines other than urology and the absence of data (ie, opinion pieces). After exclusions, a total of 91 publications remained and constituted the evidence base for this paper.

The efficacy, safety, and outcomes of testosterone use among transgender men patients: A review of the literature.

INTRODUCTION: Gender dysphoria is the discrepancy between biological sex and gender identity. This can be debilitating for transgender populations, including transgender men (TM), individuals who were assigned female at birth but who identify as men, that can benefit from hormonal therapy with testosterone products to address gender dysphoria. METHODS: We aim to summarize the efficacy, safety profile, and outcomes of the different testosterone replacement treatment (TRT) in the TM population. A search of the published literature regarding the various FDA-approved TRT was performed in PubMed, Web of Science and Cochrane Library from 2007 to date. RESULTS: We complied two groups of TRT based on route of administration including the conventional testosterone therapies (intramuscular and subcutaneous injectables, and transdermal gels) and newer testosterone therapies (oral, buccal, and nasal gels). For the conventional testosterone therapies, we identified nine studies discussed conventional TRT in TM population including one randomized trial, four prospective studies, one retrospective study and three reviews. For newer testosterone therapies, we identified three studies discussed newer TRT in TM population including one prospective study and two reviews. Articles were then compiled and analyzed. Albeit majority of TRT data stemming from conventional TRT, there appear to be an overwhelmingly safety and efficacy profile in TM population translated with increased free testosterone levels comparable to male range, menses cessation, anxiety/depression decline and improved quality of life. CONCLUSION: Testosterone therapy can be impactful for TM population with improved safety, efficiency, quality of life and function. With the rise of the newer FDA-approved TRT, randomized studies are warranted to determine its safety and efficacity in this TM population.

A Systematic Review of Partner Satisfaction After Penile Prosthesis with Special Emphasis on LGBTQ + Populations.

PURPOSE OF REVIEW: Despite the current surgical advances and patients' satisfactions after penile prosthesis (PP) implantation, there has been paucity of data on reported partner satisfaction and their quality-of-life (QoL). Our objective was to summarize the current literature on partner satisfaction for both heterosexual and non-heterosexual populations, respectively. We specifically conducted a systematic review according to the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards, and stratified studies into three tiers by methodological rigor. RECENT FINDINGS: After an initial search of 172 articles, 33 studies met the inclusion criteria for the final review: 30 for heterosexual partner satisfaction, and 3 for LGBTQ patient satisfaction were included due to lack of published literature on partner satisfaction for LGBTQ patients. For heterosexual partner satisfaction, 10 studies were classified as Tier 1, 11 studies were classified as Tier 2, and 9 studies were classified as Tier 3. From an initial search of 13 records, three studies consisting of 272 patients met the inclusion criteria for our LGBTQ review. Across all the tiers, studies noted satisfaction rates between 50 and 90% and improved satisfaction and sexual QoL metrics compared to pre-surgery rates. That said, partner satisfaction rates were also consistently lower than patient satisfaction rates. Although the range of evidence quality varies, the available literature suggests significant improvements in and relatively high rates of partner satisfaction after PP implantation. Given the diversity of study designs and widespread use of non-validated or non-specific questionnaires in the current literature, future research should focus on prospective studies and/or data collection using validated, PP-specific questionnaires.

Fertility Protection, A Novel Concept: Umbilical Cord Mesenchymal Stem Cell-Derived Exosomes Protect against Chemotherapy-Induced Testicular Cytotoxicity.

Currently, there is no viable option for fertility preservation in prepubertal boys. Experimentally, controlled vitrification of testicular tissue has been evaluated and found to cause potential structural damage to the spermatogonial stem cell (SSC) niche during cryopreservation. In this report, we leveraged the regenerative effect of human umbilical cord-derived Mesenchymal stem cell exosomes (h-UCMSC-Exo) to protect against testicular damage from the cytotoxic effects of polychemotherapy (CTX). A chemotherapy-induced testicular dysfunctional model was established by CTX treatment with cyclophosphamide and Busulfan in vitro (human Sertoli cells) and in prepubescent mice. We assessed the effects of the exosomes by analyzing cell proliferation assays, molecular analysis, immunohistochemistry, body weight change, serum hormone levels, and fertility rate. Our data indicates the protective effect of h-UCMSC-Exo by preserving the SSC niche and preventing testicular damage in mice. Interestingly, mice that received multiple injections of h-UCMSC-Exo showed significantly higher fertility rates and serum testosterone levels (p < 0.01). Our study demonstrates that h-UCMSC-Exo can potentially be a novel fertility protection approach in prepubertal boys triaged for chemotherapy treatment.

Aesthetic Penile Augmentation Procedures: A Comprehensive and Current Perspective.

PURPOSE OF REVIEW: Some men experience small penis syndrome (SPS), a body dysmorphic disorder in which a patient believes their penis to be small even when it is clinically average. As cosmetic surgery becomes more widely accepted, management of SPS may present a challenge for urologists. We aim to provide an updated review of aesthetic penile augmentation procedures. RECENT FINDINGS: Augmentation procedures range from invasive to noninvasive. Surgical solutions include grafts and flaps, suspensory ligament release, and suprapubic lipectomy. Minimally invasive solutions include injections of fillers (hyaluronic acid, polylactic acid, and polymethyl methacrylate). Noninvasive solutions include external devices such as vacuum pumps and traction devices. In the current climate, aesthetic penile augmentation is becoming a desirable option for many patients but remains clinically controversial. Our review summarizes recent and relevant studies and demonstrates the need for further research and consensus on penile augmentation procedures.

Female Sexual Dysfunction After Pelvic Fracture: A Comprehensive Review of the Literature.

BACKGROUND: Female sexual dysfunction (FSD) after pelvic fracture (PFx) has garnered little attention in the urology literature. AIM: To review and summarize the current evidence regarding female PFx-related sexual function. METHODS: We performed a systematic review in accordance with PRISMA guidelines, including PubMed, EMBASE, and MEDLINE. We included only English-language manuscripts and abstracts with sufficient data for inclusion. We used the search terms "female sexual dysfunction AND pelvic fracture," "sexual dysfunction AND pelvic fracture," and "female pelvic fracture AND sexual dysfunction." A total of 177 articles were identified; 41 abstracts were reviewed; of which, 19 manuscripts were reviewed. Fifteen met inclusion criteria for analysis. OUTCOMES: The main outcome measures of this study are rates and types of female sexual dysfunction after pelvic fracture. RESULTS: FSD is prevalent after PFx, with reported rates between 25% and 62%. Three studies used the validated Female Sexual Function Index. The other 12 used non-validated questionnaires or adapted quality-of-life questionnaires with specific questions regarding FSD. The most common complaints include difficulty with intercourse, dyspareunia, orgasmic dysfunction, genitourinary pain, decreased interest in intercourse, decreased satisfaction with intercourse, and pelvic floor dysfunction. Only 1 study addressed resolution of dysfunction (30 of 98 patients [30.4%]). CLINICAL IMPLICATIONS: FSD is prevalent and an under-recognized sequela of pelvic fracture. This requires future prospective study to better characterize sexual dysfunction and identify effective treatments in trauma survivors. STRENGTH AND LIMITATIONS: To Increase awareness of FSD after pelvic trauma and the impact on the quality of life in trauma survivors. The current literature is limited by a lack of standardized assessment of FSD, limited follow-up, and minimal discussion of treatment options, in addition to the inherent bias of retrospective studies. CONCLUSIONS: FSD after traumatic PFx is not uncommon, occurs mostly in young women, and can be morbid. FSD after PFx is underreported in the urology literature. Thus, all female PFx patients should be screened for FSD by validated questionnaires. The published literature offers little knowledge as to the epidemiology, evaluation, definition, and potential treatments of FSD after PFx. Prospective studies are needed to better understand female sexual function in trauma survivors and the potential methods for prevention and rehabilitation, all within the context of a multidisciplinary approach. Walton AB, Leinwand GZ, Raheem O, et al. Female Sexual Dysfunction After Pelvic Fracture: A Comprehensive Review of the Literature. J Sex Med 2021;18:467-473.

Do Minimally Invasive Benign Prostatic Hyperplasia Treatments Preserve Sexual Function? A Contemporary Review of the Literature.

PURPOSE OF REVIEW: The aim of this study is to compare the sexual function outcomes related to minimally invasive surgical therapies (MISTs) (UroLift®, Rezum™, Aquablation®, prostate artery embolization, and iTind®) for the treatment of benign prostatic hyperplasia (BPH). RECENT FINDINGS: Clinical trials and retrospective data evaluating MISTs for BPH have demonstrated improved or stable sexual function outcomes when compared to sham control or transurethral resection of the prostate. Outcomes were assessed at baseline and following treatments using patient-reported outcome measures. Rezum and Aquablation demonstrated preservation of overall ejaculatory function and erectile function at 36-month follow-up. Similar outcomes occurred with UroLift after a 60-month follow-up. Erectile function was preserved following prostate artery embolization and iTIND up to 12 months. MIST for the management of BPH has been demonstrated to be effective in improving urinary function and appears to minimize potential collateral damage on sexual function following treatment.

Self-Induced Trauma to the Genitalia: a Review of the Literature and Management Schemes.

PURPOSE OF REVIEW: Self-induced genital trauma is rare, and prompt and evidence-based early intervention can improve the urinary and sexual function of these complex patients. This review has surveyed current literature and treatment trends to evaluate the clinical approach to managing genital trauma. RECENT FINDINGS: A literature review was performed regarding self-induced genitalia trauma and trauma management between 2000 and 2019 using MEDLINE® database, the Cochrane Library® Central Search, Web of Science, and Google Scholar. In total, 42 articles were considered relevant and included in this review. Self-induced trauma can be appropriately managed with a multidisciplinary approach. Treatment goals are to preserve urinary, sexual, and reproductive function. Specific evaluation includes mechanism of injury, imaging, and determining the extent of injury and surgical repair, if indicated. Due to the rarity of these injuries and their emergent nature, much of the management is based on retrospective data. Further research is needed to improve long-term functional outcomes in trauma patients.

Renal Trauma Classification and Management: Validating the Revised Renal Injury Grading Scale.

PURPOSE: To better characterize traumatic renal injury a revision to the 1989 American Association for the Surgery of Trauma renal injury scale was proposed in which grade IV includes all collecting system and segmental vascular injuries and grade V includes main renal hilar injury. We sought to validate the 2009 grading scale, emphasizing reclassifications between the 1989 and 2009 versions, and subsequent management. MATERIALS AND METHODS: Patient demographics and renal injury characteristics, computerized tomography imaging, radiology reports and subsequent management were recorded in a prospective trauma database. Multivariable logistic regression models for intervention were compared using 1989 and 2009 grades to evaluate which grading scale better predicted management. RESULTS: Of 256 renal injury cases 56 (21.9%) were reclassified using the revised 2009 scale, including 50 (19.5%) which were upgraded, 6 (2.3%) which were downgraded and 200 (78.1%) which were unchanged. Of grade III or higher cases management was nonoperative in 112 (78.9%), angioembolization in 9 (6.3%), nephrectomy in 9 (6.3%) and renorrhaphy in 12 (8.5%). Management was significantly associated with original and revised grades (chi-square p=0.02 and <0.001, respectively). Further, the multivariable model using the 2009 grades significantly outperformed the 1989 model. Radiology reports rarely included renal injury scales. CONCLUSIONS: Using the revised renal injury grading scale led to more definitive classification of renal injury and a stronger association with renal trauma management. Applying the revised criteria may facilitate and improve the multidisciplinary care of renal trauma.

Perioperative Outcomes Following Partial Nephrectomy Performed on Patients Remaining on Antiplatelet Therapy.

PURPOSE: We evaluated the risk of bleeding complications in patients undergoing partial nephrectomy in whom perioperative antiplatelet therapy was continued, as antiplatelet therapy is increasingly used and hemorrhage is a significant concern in partial nephrectomy. MATERIALS AND METHODS: In this 2-center retrospective analysis 1,097 patients underwent partial nephrectomy between 2000 and 2014. The cohort was split into 3 groups of perioperative continuation of antiplatelet therapy (group 1-67), antiplatelet therapy stopped preoperatively (group 2-254) and no chronic antiplatelet therapy (group 3-776). Bleeding complications were defined as any transfusion, or any hospital readmission or secondary procedure performed for hemorrhage. Multivariable analysis was performed to elucidate independent risk factors for bleeding complications. RESULTS: Patients in group 1 were older (median age 66 years vs 64 and 57 years in groups 2/3, p <0.0001), and had greater comorbidity (median ASA classification score 3 vs 2 and 2, p <0.0001). Group 1 had a higher rate of bleeding complications (20.9% vs 7.1% and 6.4%, p <0.0001) and transfusions (16.4% vs 5.9% and 5.4%, p=0.002). Multivariable analysis revealed continued antiplatelet therapy was an independent predictor of bleeding complications (OR 2.19, 95% CI 1.06-4.51, p=0.03). These findings appear attributable to intraoperative clopidogrel use. On multivariable analysis the use of aspirin alone was not associated with bleeding complications (OR 1.64, 95% CI 0.72-3.75, p=0.24). CONCLUSIONS: The risk of bleeding complications due to antiplatelet therapy use at partial nephrectomy may be due to clopidogrel. The need to continue perioperative aspirin alone does not appear to be a contraindication to the safe performance of partial nephrectomy.

Impact of tumor histology and grade on treatment success of percutaneous renal cryoablation.

BACKGROUND: We analyzed oncological outcomes in patients who underwent percutaneous renal cryoablation (PRC) with documented renal cell carcinoma (RCC) by perioperative biopsy. METHODS: Multicenter retrospective analysis of 153 patients [median follow-up 48 months] who underwent PRC from 09/2005 to 08/2014 was performed. We divided the cohort into patients who developed recurrence versus no recurrence. Kaplan-Meier analyses examined recurrence-free survival (RFS) according to grade and histology. Multivariable analysis (MVA) was performed to identify factors associated with tumor recurrence. RESULTS: One hundred and fifty-three patients were analyzed [18 patients (11.8 %) with recurrence and 135 (88.2 %) patients without recurrence]. There were no differences between the groups with respect to demographics, RENAL score, and number of probes utilized. Recurrence group had larger tumor size (3.1 vs. 2.4 cm; p = 0.011), upper pole tumor location (p = 0.016), and greater proportions of high-grade tumor (33 vs. 0.7 %; p < 0.001) and clear cell histology (77.8 vs. 45.9 %; p = 0.011). Four-year RFS was 100 versus 80 % for grade 1 versus grade 2/3 tumors (p = 0.0002), and 97 versus 88 % for other RCC versus clear cell RCC (p = 0.07). MVA demonstrated tumor size >3 cm (OR 2.46; p = 0.019), clear cell histology (OR 2.12; p = 0.027), and high tumor grade (OR 2.33, p < 0.001) as independent risk factors associated with tumor recurrence. CONCLUSIONS: Association of higher grade and clear cell histology with recurrence and progression suggests need for increased emphasis on preoperative risk stratification by biopsy, with grade 1 and non-clear cell RCC being associated with improved treatment success than higher grade and clear cell RCC.

Solvent-dehydrated dermal allograft (AXIS™) augmented cystocele repair: longitudinal results.

INTRODUCTION AND HYPOTHESIS: Surgical repair options for pelvic organ prolapse (POP) include native tissue, allograft, xenograft, and synthetic grafts. Solvent-dehydrated dermal allograft (SDDG) has an improved safety profile. We evaluated the long-term safety and efficacy of SDDG use for cystocele repair. METHODS: A total of 184 patients completed a minimum follow-up of 12 months. Incontinence Impact Questionnaire (IIQ), Urogenital Distress Inventory (UDI), and Visual Analogue Scale (VAS) were used pre and post operatively. Recurrent cystocele grade ≥ II and/or repeat cystocele repair were considered objective failure. RESULTS: Preoperatively, 17 patients (10%) had grade IV cystocele, 87 (47%) grade III, 70 (38%) grade II, and 10 (5%) grade I. All patients underwent SDDG cystocele repair with/without vaginal sling and/or POP repair and/or hysterectomy. Mean hospital stay was 0.58 days (range 0-4), mean estimated blood loss (EBL) was 111 mL, and mean length of Foley catheterization was 1.85 days (range 0-28). Postoperatively, 113 patients (64%) had no recurrent cystocele, 34 (19%) had grade I, 19 (11%) grade II, and 10 (6%) grade III cystocele. None had grade IV cystocele. Nineteen patients (10.3%) underwent repeat cystocele repair. Thirty-eight patients (21.6%) had postoperative recurrence (recurrent cystocele grade ≥ II and/or repeat cystocele repair). Dermal allograft related adverse events included 1 (0.5%) allograft vaginal exposure, dyspareunia 1 (0.5%), and transient hydronephrosis in 1 (0.5%). There were no vascular, vesical, visceral or neurological injuries. CONCLUSIONS: These results indicate that SDDG augmented cystocele repair is a safe procedure, with low morbidity, and it's success is comparable to other techniques.

Development of penile hydrocele following placement of inflatable penile prosthesis: a rare entity.

INTRODUCTION: The development of a penile hydrocele following the placement of an inflatable penile prosthesis (IPP) for erectile dysfunction has never been documented. We herein report an unusual complication of penile hydrocele formation that developed following placement of an IPP for erectile dysfunction. METHODS: The penile hydrocele was successfully repaired by excision of the hydrocele sac. RESULTS: Successful surgical repair of a penile hydrocele was accomplished following placement of an IPP without removal of any implant components. The penile implant was functional at the end of the procedure as well as at all scheduled follow-up appointments. CONCLUSIONS: With advances in both surgical techniques and improved devise technology, high volume penile implanters encounter fewer IPP-related complications such as infectious or mechanical complications. We herein report for the first time a rare complication of penile hydrocele development after IPP placement that was treated successfully with surgical excision of the hydrocele sac. Urologists who perform these types of procedures should be aware of this unusual complication and know that it is curable with prompt diagnosis and meticulous surgical repair.

PCSD1, a new patient-derived model of bone metastatic prostate cancer, is castrate-resistant in the bone-niche.

INTRODUCTION: Prostate cancer bone metastasis occurs in 50-90% of men with advanced disease for which there is no cure. Bone metastasis leads to debilitating fractures and severe bone pain. It is associated with therapy resistance and rapid decline. Androgen deprivation therapy (ADT) is standard of care for advanced prostate cancer, however, bone metastatic prostate cancer (PCa) often becomes resistant to ADT. There are few pre-clinical models to understand the interaction between the bone microenvironment and prostate cancer. Here we report the castrate resistant growth in the bone niche of PCSD1, a patient-derived intra-femoral xenograft model of prostate bone metastatic cancer treated with the anti-androgen, bicalutamide. METHODS: PCSD1 bone-niche model was derived from a human prostate cancer femoral metastasis resected during hemiarthroplasty and serially transplanted into Rag2(-/-); γ c(-/-) mice intra-femorally (IF) or sub-cutaneously (SC). At 5 weeks post-transplantation mice received bicalutamide or vehicle control for 18 days. Tumor growth of PCSD1 was measured with calipers. PSA expression in PCSD1 xenograft tumors was determined using quantitative RT-PCR and immunohistochemistry. Expression of AR and PSMA, were also determined with qPCR. RESULTS: PCSD1 xenograft tumor growth capacity was 24 fold greater in the bone (intra-femoral, IF) than in the soft tissue (sub-cutaneous, SC) microenvironment. Treatment with the anti-androgen, bicalutamide, inhibited tumor growth in the sub-cutaneous transplantation site. However, bicalutamide was ineffective in suppressing PCSD1 tumor growth in the bone-niche. Nevertheless, bicalutamide treatment of intra-femoral tumors significantly reduced PSA expression (p < = 0.008) and increased AR (p < = 0.032) relative to control. CONCLUSIONS: PCSD1 tumors were castrate resistant when growing in the bone-niche compared to soft tissue. Bicalutamide had little effect on reducing tumor burden in the bone yet still decreased tumor PSA expression and increased AR expression, thus, this model closely recapitulated castrate-resistant, human prostate cancer bone metastatic disease. PCSD1 is a new primary prostate cancer bone metastasis-derived xenograft model to study bone metastatic disease and for pre-clinical drug development of novel therapies for inhibiting therapy resistant prostate cancer growth in the bone-niche.

Associations of obesity, physical activity and diet with benign prostatic hyperplasia and lower urinary tract symptoms.

PURPOSE OF REVIEW: Epidemiological and clinical data indicate that modifiable lifestyle factors - including obesity, physical activity, and diet - significantly influence the risks of symptomatic benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS). RECENT FINDINGS: Modifiable factors associated with significantly increased risks of symptomatic BPH and LUTS include obesity and consumption of meat and fat. Factors associated with decreased risks include increased physical activity, vegetable consumption, and moderate alcohol intake. Obesity potentially attenuates the clinical efficacy of 5α-reductase inhibitors (5-ARI). Randomized clinical trials of lifestyle alterations - such as weight loss, exercise, and diet - for the prevention or treatment of BPH and LUTS have yet to be performed. SUMMARY: Obesity, physical activity, and diet substantially alter the risks of symptomatic BPH and LUTS. 5-ARIs exhibit diminished efficacy in obese patients. Although clinical trials of lifestyle modifications have yet to be undertaken, it is reasonable to promote weight loss, exercise, and healthy diet within the context of standard treatments for symptomatic BPH and LUTS.

Severe penile necrotizing infection with subsequent glandular gangrene after distal corporal aspiration and irrigation procedure for ischemic priapism.

Necrotizing penile infection following ischemic priapism takedown is a rare complication. A 60-year-old man presented with 1-week history of green and pink purulent discharge, penile swelling, and inability to void. Computed tomography demonstrated gas and fluid accumulation within the corporal bodies, suggestive for bilateral penile necrotizing corporal infection with possibility of intra-corporal abscesses. The patient underwent extensive serial surgical debridement of the penile and corporal tissues which was complicated with poly-microbial tissue cultures, growing Candida albicans and Staphylococcus epidermidis. Despite maximal penile drainage, glans penis gangrene was developed to level of mid penile shaft necessitating a partial penectomy.

The percentage of men counseled by urologists who received a vasectomy mildly increased after the publication of the AUA vasectomy guideline.

This retrospective cohort study explored whether the publication of the vasectomy guideline by the American Urological Association in December 2012 increased the percentage of men counseled by urologists who received a vasectomy. We used commercial health insurance claims between 2010 and 2015 to identify the initial sterilization counseling visit for men aged 18-64 and whether each of them received a vasectomy within six months of that visit. A difference-in-differences analysis isolated the effect of the guideline on the percentage of men counseled by urologists who received a vasectomy, exploiting suspected variation in guideline exposure and adherence between urologists and non-urologists. In total, 226 012 men had an initial sterilization counseling visit, of which 182 204 (80.6%) were counseled by urologists and 43 808 (19.4%) were counseled by non-urologists. The percentage of men counseled by urologists who received a vasectomy mildly increased by 1.5% (p = 0.002) after the publication of the guideline. Therefore, the percentage of men who receive a vasectomy may in part be explained by practice guidelines and clinicians' willingness to consider the procedure, and future research should investigate how clinicians arrive at their decisions to recommend a vasectomy and whether a standardized counseling protocol would ensure consistency.

Recent technological development of penile prosthesis: a literature review.

Background and Objective: In contemporary Urology, the gold standard for treatment of erectile dysfunction refractory to medical therapy has been implantation with a penile prosthesis. The past 40 years has witnessed evolutions in technology and surgical techniques, which have led to increased patient satisfaction rates and decreased complication and infection rates. This review is an update to a prior review article that evaluates these advancements in the context of patient satisfaction and different rates of complications following surgeries. In addition, the review compares malleable and inflatable prostheses with regard to infection rate, mechanical failure rate, and erosion rate. Methods: A literature search was conducted using Medline and Google Scholar to examine papers from 1973 to the present day. Keywords, such as, "penile prosthesis surgery", "malleable penile prosthesis", "inflatable penile prosthesis", "two-piece Inflatable Penile Prosthesis (IPP)", and "three-piece IPP" were utilized during the search. A total of 76 papers were included, and all were in English. Key Content and Findings: Studies on the latest models of each of the three prostheses (malleable, two-piece IPP, three-piece IPP) revealed patient satisfaction ratings at or above 75%. Both types of IPPs were associated with greater satisfaction and lower erosion rates while malleable prostheses were associated with lower mechanical failure rates. Although no significant differences in infection rates were noted between the prosthesis types, a history of diabetes, obesity, and smoking were predictive of infection events. Conclusions: The three-piece IPP, if indicated for a suitable patient, is generally accepted as the best type of prosthesis given its biological mimicry to an erect human penis.

Penile prosthesis in priapism: a systematic review of outcomes and complications.

Background: Priapism is a rare condition characterized by persistent erection of the penis that lasts more than 4 hours in the absence of sexual stimulation and is associated with significant morbidity and complications, including erectile dysfunction and penile fibrosis. Surgical management of priapism can be extremely challenging. We herein provide a comprehensive review that aims to evaluate the role of penile prosthesis (PP) implantation in the management of priapism. Methods: A systematic literature search was performed using the following databases: PubMed, Embase, and Scopus to identify studies that evaluated the effectiveness of PP implantation in treating priapism and the long-term complications, outcomes, and patients' satisfaction rate. Results: Out of 717 English-language studies published between 2002 and 2022, 17 were chosen for this review. Majority of patients had a malleable PP (MPP) implant, either early or delayed after the priapism episode. Early placement (EP) of PP is widely defined between studies ranging from less than 72 hours, within 1 week, and within 3 weeks. Most common causes of priapism were sickle cell anemia (SCA), medication-induced, and idiopathic. Studies show a higher satisfaction rate ranging between 80% and 100%, with sexual intercourse achievement ranging between 64.2% and 100%. Based on the GRADE system, included studies rated as very low quality of evidence. Commonly reported complications that arise after PP procedures, include device infection, erosion, curvature, and mechanical malfunction, such as auto-inflation. Conclusions: PP can be an effective treatment option for priapism, particularly in cases of ischemic priapism lasting more than 36 hours or recurrent priapism that is medically refractory. However, due to the very low quality of evidence, larger, well-designed studies are warranted where long-term outcomes, patients' satisfaction, and complications following priapism-related PP implantation are measured as endpoints.