Subcoronal inflatable penile prosthesis implantation: indications and outcomes.

BACKGROUND: While implantation of an inflatable penile prosthesis (IPP) is commonly performed via infrapubic or penoscrotal approaches, the subcoronal (SC) approach for IPP implantation may safely and reliably allow for additional reconstructive procedures through a single incision. AIM: The aim of this study is to report outcomes, including complications, of the SC approach and to determine common characteristics of patients undergoing the SC approach. METHODS: A retrospective chart review from May 11, 2012, to January 31, 2022, was performed at a single, tertiary care institution to identify patients with IPP implantation via the SC approach. OUTCOMES: Postoperative information was reviewed and extracted from all clinic notes available following the date of IPP implantation in the electronic medical record, detailing any complications including wound complications, need for revision or removal, device malfunction, and infections. RESULTS: Sixty-six patients had IPP implantation via the SC approach. Median follow-up duration was 29.4 (interquartile range 14.9-50.1) months. One (1.8%) patient had a simple wound complication. Two (3.6%) experienced postoperative infection of the prosthesis, which resulted in explantation of the device. One of these infected prostheses later experienced partial glans necrosis. Revision for mechanical failure or unsatisfactory cosmetic result was performed in 3 (7.3%) IPPs placed via a SC incision. CLINICAL IMPLICATIONS: The SC approach for implantation of IPP is safe and feasible with low complication and revision rates. It offers urologists an alternative to the classic infrapubic and penoscrotal approaches, both of which would require a second incision for additional reconstructive procedures required to adequately address deformities associated with severe Peyronie's disease. Therefore, urologists who treat these specialized populations of men may benefit from having the SC approach in their array of techniques for IPP implantation. STRENGTHS AND LIMITATIONS: The limitations of this study include its retrospective nature, risk of selection bias, lack of comparison groups, and sample size. This study reports on early experience with the SC approach performed by a single high-volume reconstructive surgeon, who treats a specialized population of patients requiring complex repair during implantation of an IPP, particularly those with Peyronie's disease. CONCLUSION: The SC incision for IPP implantation has low rates of complications and remains our approach of choice for IPP implantation in patients with severe Peyronie's disease, including curvatures >60°, severe indentation with hinge, and grade 3 calcification, which are unlikely to respond adequately to manual modeling alone.

A Critical Analysis of Reporting in Systematic Reviews and Meta-Analyses in the Peyronie's Disease Literature.

BACKGROUND: Despite an increasing number of publications on Peyronie's disease (PD), evidence-based clinical decision-making remains challenging due to the small number of well-designed clinical trials. AIM: To perform a critical analysis of reporting quality in PD systematic reviews (SR) and meta-analyses (MA). METHODS: Study protocol registration was performed on the Open Science Framework platform. In January 2021, a systematic electronic search of the Medline/PubMed, Embase, Ovid, Scopus, Joanne Briggs Institute, and Cochrane databases was performed. Search terms included "Peyronie's disease" and "systematic review OR meta-analysis OR meta-analysis." Eligibility criteria were English-language, relevance to PD and specification of "systematic review" or "meta-analysis" in the title or abstract. Oxford Center for Evidence-Based Medicine levels of evidence were used to classify original studies reviewed within each publication. Risk of bias was assessed using the ROBIS tool. Data were tabulated and reported as means with standard deviation, median with interquartile range and t-testing as appropriate. Strength of association between variables was calculated using Pearson correlation coefficient. Statistical analyses were performed on RStudio (version 1.4.1106). OUTCOMES: Outcomes included review type, level of evidence, authorship, journal, publication date, "A MeaSurement Tool to Assess systematic Reviews" (AMSTAR-2) score and "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) score. RESULTS: From 1974 to 2021, 340 articles were identified. After review, 17 full length articles were included. Thirteen were SR, 2 MA and 2 was combined. Significant heterogeneity was seen in evidence level of included studies. There was median 54% adherence to AMSTAR-2 criteria and 74% adherence to PRISMA criteria. Overall AMSTAR-2 confidence rating was Critically Low in 11 of 17 studies. Correlation analysis revealed very high positive association between AMSTAR 2 and PRISMA adherence (+0.95). ROBIS revealed "High" concern regarding methods used to collect data and appraise 12/17 studies (71%), and "High" concern regarding synthesis and findings in 8 of 17 studies (47%). CLINICAL IMPLICATIONS: Many SR include markedly heterogenous levels of evidence and fail to meet accepted methodological criteria for reporting. STRENGTHS AND LIMITATIONS: Main strengths include extensive literature review and analysis of standardized study reporting. One limitation is that aggregate scoring of AMSTAR-2 and PRISMA is not intended as primary method of quality assessment; however effect was minimized by reporting critical domains, overall quality assessments and specifics on globally poorly reported domains. CONCLUSION: More high quality randomized controlled PD trials are necessary; SR and MA should focus on these studies alone. Bole R, Gottlich HC, Ziegelmann MJ, et al. A Critical Analysis of Reporting in Systematic Reviews and Meta-Analyses in the Peyronie's Disease Literature. J Sex Med 2022;19:629-640.

Surgical Correction of Adult Congenital Penile Curvature: A Systematic Review.

BACKGROUND: Congenital penile curvature (CPC) is corrected surgically by various corporoplasty or tunica albuginea plication techniques, but the optimal surgical approach is not well-defined. AIM: To provide a comprehensive evaluation of the published literature pertaining to outcomes with penile plication and corporoplasty techniques for surgical management of CPC. To determine if plication or corporoplasty offers superior outcomes in surgical correction of CPC. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Checklist. The following databases were queried from inception to March 18, 2020 to search for studies describing surgical treatment of CPC: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. OUTCOMES: Objective and subjective postoperative outcomes including penile straightening, shortening, penile sensory changes, and reoperation rates for both corporoplasty and tunica albuginea plication were summarized. RESULTS: Fifty-five articles comprising 2,956 patients with CPC who underwent a plication procedure (n = 1,375) or corporoplasty (n = 1,580) were included. The definition of "treatment success" varied widely and most often involved subjective patient reporting (22 studies; 40%) or objective assessment (15 studies; 27%). We considered curvature correction to be satisfactory if there was self-reported patient satisfaction or residual curvature after correction of <20˚. Reported rates of successful straightening ranged from 75 to 100% and 73 to 100% for plication and corporoplasty, respectively. A comprehensive and accurate assessment of surgical outcomes for CPC correction, such as satisfactory penile straightening, reoperation rates, glans sensory changes, and other complications was limited by significant inter-study heterogeneity with respect to the reporting of treatment outcomes. CLINICAL IMPLICATIONS: While both plication and corporoplasty appear to be safe and effective options in the treatment of CPC, definitive conclusions cannot be drawn with respect to treatment superiority due to low-quality study design, methodology flaws, and significant heterogeneity in reporting. STRENGTH & LIMITATIONS: This report represents the most comprehensive review of CPC surgical management. However, there is a significant lack of standardization in the reporting of treatment outcomes for CPC, thereby limiting the reliability of the published data summarization encompassed by our review. CONCLUSION: Both plication and corporoplasty demonstrate high success rates and relatively low complication rates in the treatment of CPC, albeit with low-level evidence available in most research publications. Robust comparison of the surgical techniques used to correct CPC is limited by significant variation in reporting methods used in the literature. C. J. Britton, F. A. Jefferson, B. L. Findlay, et al. Surgical Correction of Adult Congenital Penile Curvature: A Systematic Review. J Sex Med 2022;19:364-376.

Spermatic Cord Block Series as a Minimally Invasive Therapy for Chronic Scrotal Content Pain.

PURPOSE: The primary aim of our study was to evaluate relief of chronic scrotal content pain after a series of spermatic cord blocks with a combination of local anesthetic and a steroid. Secondary aims were to assess factors associated with a positive response and complications. MATERIALS AND METHODS: We performed a retrospective chart review of patients who underwent spermatic cord block series for chronic scrotal content pain at our practice between 2012 and 2019. Pain scores were compared before and after treatment using an 11-point numerical pain rating scale. We performed univariate analysis to assess differences between responders and nonresponders, and the relationship between symptom duration and response was analyzed by rank-order correlation. RESULTS: We included 44 men with chronic scrotal content pain present for a median duration of 24 months who underwent a spermatic cord block series. At a median followup of 16 months, 31 patients (70.5%) experienced sustained relief, including 9 patients (20.5%) with complete resolution of pain. There were no differences between responders and nonresponders in terms of symptom duration, perceived etiology, or previous treatments, and there was no association between response and duration of pain. Minor complications occurred in 5 cases (11.4%). CONCLUSIONS: Spermatic cord block series is a safe, minimally invasive treatment for men with refractory chronic scrotal content pain. Response to cord block series appears to be independent of symptom duration, perceived etiology or prior medical and surgical treatments. Future studies should be conducted to evaluate long-term durability and predictors of success.

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.

Chronic Scrotal Content Pain: a Review of the Literature and Management Schemes.

PURPOSE OF REVIEW: Chronic scrotal content pain (CSCP) is a complex condition with multiple etiologies that requires a thorough understanding of its pathophysiology, workup, and treatment options. We performed a comprehensive and contemporary review to augment our current understanding of CSCP. RECENT FINDINGS: We discuss new advances in CSCP-specific pain questionnaires, modern studies of microscopic spermatic cord denervation and its variations, and novel techniques including electric nerve stimulation and cryoablation in addition to randomized control trials with significant negative findings. We also present literature focusing on the prevention of CSCP secondary to surgical iatrogenic causes. The constantly evolving literature of CSCP has led to the significant evolution in its diagnosis and treatment, from oral medications to salvage options after microscopic spermatic cord denervation. With each advance, we come closer to developing a more thorough, evidence-based algorithm to guide urologists in treatment of CSCP.

Peyronie's Disease and the Female Sexual Partner: A Comparison of the Male and Female Experience.

BACKGROUND: Peyronie's disease (PD) is characterized by penile pain, deformity, and sexual dysfunction, often resulting in an impaired sexual experience and significant psychological bother for the patient. However, there are limited data on the impact of PD on female sexual partners (FSPs). AIM: To compare the psychosexual experience of men with PD and their FSPs. METHODS: We retrospectively reviewed all prospectively enrolled men and their FSPs who presented for initial PD evaluation to our sexual health clinic from July 2018 to February 2020. All men completed a PD-specific survey and the PD questionnaire (PDQ). If the patient was accompanied by an FSP during initial evaluation, she completed the PDQ for Female Sexual Partners and Female Sexual Function Index. We further queried our database that included information on patient demographics and clinical characteristics. OUTCOMES: The main outcome of this study is retrospective comparison of responses with the PDQ and PDQ for Female Sexual Partners. RESULTS: Data were available for 44 men with PD (median age, 56 years; interquartile range, 49-63) and their FSPs (median age, 54 years; interquartile range, 50-61). The majority of men presented in the chronic phase (35 of 44, 79.5%), and median objective composite curvature was 75° (interquartile range, 50-90°). Owing to PD, female and male partners reported similar difficulty with vaginal intercourse (VI) (74.3% vs 81.5%, P = .555), decreased frequency of VI (70.6% vs 85.2%, P = .228), and at least moderate discomfort/pain with VI (48.6% vs 33.3%, P = .232). FSPs were "very" or "extremely" bothered by the appearance of their partner's erect penis less often than male partners (20.0% vs 59.3%, P < .001). FSPs were "very" or "extremely" bothered by their partner's PD during VI less often than men with PD (32.3% vs 65.2%, P = .017). Few FSPs (22.9%) had "severe" or "very severe" concern with damaging their partner's penis during VI. CLINICAL IMPLICATIONS: The sexual experience for men with PD and their FSPs differs, thus emphasizing the importance of active engagement of both men with PD and FSP during initial PD evaluation. STRENGTHS AND LIMITATIONS: This initial study draws data from a single, high-volume men's health clinic with a limited sample size. Survey responses may have been shared by patients with PD and their FSPs. CONCLUSION: PD impacts the sexual experience for both men and FSPs. A similarly large proportion of men with PD and FSP noted decreased frequency of and difficulty with vaginal intercourse. Yet, FSPs were less bothered by the appearance of the erect penis and the deformity during VI compared with men. Farrell MR, Ziegelmann MJ, Bajic P, et al. Peyronie's Disease and the Female Sexual Partner: A Comparison of the Male and Female Experience. J Sex Med 2020;17:2456-2461.

Characteristics of Men With Peyronie's Disease and Collagenase Clostridium Histolyticum Treatment Failure: Predictors of Surgical Intervention and Outcomes.

BACKGROUND: A subset of patients with Peyronie's disease (PD) treated with collagenase clostridium histolyticum (CCH) experience persistent bother and some require surgery. AIM: We characterize patients experiencing persistent bother after CCH treatment and identify associations and predictors of surgical intervention/outcomes. METHODS: We retrospectively identified patients with PD from October 2014 to October 2019 and identified those presenting with persistent bother after CCH treatment by other urologists. Intracavernosal injection and penile Doppler ultrasonography were performed, and subsequent interventions/outcomes were recorded. Baseline characteristics were compared with Student t-test and chi-square test. Predictors of surgical intervention and complications were assessed using multivariable logistic regression. OUTCOMES: The primary outcome was surgery after CCH treatment. Secondary outcomes included worsened erectile function, sensory deficits, and penile length change. RESULTS: Of 573, 67 (11.7%) patients with PD had undergone prior CCH treatment with median 6 injections (range 2-24). Mean post-CCH PD Questionnaire bother score was 10.1 (SD: 3.1), and total International Index of Erectile Function-5 was 15.3 (SD: 8.7). Mean PD duration was 27.8 (SD: 35.7) months, with a mean composite curvature (MCC) of 69.0° (SD: 33.8) measured after injection. Of 67, 44 (65.7%) patients had MCC >60°. Of 67, 52 (77.6%) patients had indent, narrowing, or hourglass and 26 (38.8%) had hinge effect (buckling of the erect penis with axial pressure) on examination. Calcification was identified in 26 of 67 (38.8%) patients, with grade 3 calcifications comprising 6 of 23 (26.1%) patients. Of 67, 33 (49.3%) patients underwent surgery, with 20 (60.1%) undergoing partial plaque excision and grafting with/without tunica albuginea plication, 6 (18.2%) undergoing tunica albuginea plication alone, and 7 (21.2%) undergoing penile prosthesis with plaque incision and grafting. Surgical patients had greater mean curvature (82.6 vs 55.4, P = .001) and were more likely to have hinge (54.5% vs 20.6%, P = .005). On multivariable analysis, MCC ≥60° predicted patient's decision for surgery (odds ratio: 2.99, P < .01, 95% confidence interval: 1.62-4.35). There were no associations between surgical complications and number of injections or CCH-associated adverse events. CLINICAL IMPLICATIONS: Patients presenting with persistent bother after CCH treatment often have narrowing and calcifications (despite calcifications being a contraindication to CCH treatment), and those who have hinge or severe curvature are more likely to undergo surgery with low rates of complications. STRENGTHS/LIMITATIONS: This study's generalizability is limited by selection bias, but useful data are provided for patient counseling. CONCLUSION: Patients with persistent bother after CCH treatment had high rates of indentation/narrowing, plaque calcifications, and MCC >60° at completion of CCH treatment. Surgical intervention is more common with hinge and is safe and feasible in these patients, with low rates of complications. These findings suggest possible negative prognostic factors for CCH treatment, which merit further investigation. Bajic P, Wiggins AB, Ziegelmann MJ, et al. Characteristics of Men With Peyronie's Disease and Collagenase Clostridium Histolyticum Treatment Failure: Predictors of Surgical Intervention and Outcomes. J Sex Med 2020;17:1005-1011.

Peyronie's Disease Intervention Studies: An Exploration of Modern-Era Challenges in Study Design and Evaluating Treatment Outcomes.

INTRODUCTION: Peyronie's disease (PD) is characterized by pain, deformity, sexual dysfunction, and psychological bother. Several treatments are available with varying levels of efficacy, and significant limitations exist with the currently available literature. AIM: To explore modern-era methodological challenges inherent to PD research as they pertain to intervention studies. METHODS: We performed a critical review of the PD intervention literature to identify common methodological challenges with emphasis on aspects of patient assessment and treatment outcomes, study design, and statistical analysis. The key objective was to provide an impetus on which to build future research protocols, rather than focus on weaknesses with any individual studies. MAIN OUTCOME MEASURE: Expert opinion was used to summarize limitations with commonly reported objective outcomes such as penile curvature, girth, and length along with imaging modalities and objective questionnaires. Appropriate study design and statistical analysis were also reviewed to discuss common pitfalls in the PD literature. RESULTS: There are multiple shortcomings inherent to studying objective PD outcomes such as penile curvature, girth, and length. These include lack of standardized protocols for preintervention and postintervention assessment, interobserver and intraobserver variability, and lack of consistent definitions for what defines an objective outcome as clinically "meaningful" for patients. Similarly, imaging studies including penile ultrasound are subject to marked variation, thereby limiting their utility to measure predefined primary or secondary study outcomes including cavernosal artery hemodynamics and penile plaque size. Objective and validated questionnaires such as the Peyronie's Disease Questionnaire and International Index of Erectile Function require that patients have recently engaged in sexual activity, which is challenging for many patients as a result of penile deformity with PD. Finally, careful study design and statistical analysis (including appropriate study power) are imperative to ensure reliable results. Current shortcomings in the majority of studies contribute to the low level of evidence available for most PD interventions. CLINICAL IMPLICATIONS: Future PD intervention studies should focus on optimizing study design and statistical analysis. Furthermore, authors must incorporate standardized protocols for assessing preintervention and postintervention outcomes. STRENGTH & LIMITATIONS: The current analysis and recommendations for future study are based on the expertise and opinion of the manuscript authors. CONCLUSION: Multiple areas of weakness in study design, statistical analysis, and patient outcomes assessment limit the reliability of data derived from PD intervention studies in the modern era. The global themes identified herein should serve as a basis upon which to build future research protocols. Ziegelmann MJ, Trost LW, Russo GI, et al. Peyronie's Disease Intervention Studies: An Exploration of Modern-Era Challenges in Study Design and Evaluating Treatment Outcomes. J Sex Med 2020;17:364-377.

Clinical characteristics and surgical outcomes in men undergoing tunica albuginea plication for congenital penile curvature who present with worsening penile deformity.

PURPOSE: Men with congenital penile curvature (CPC) can develop new onset worsening of their lifelong curvature. We sought to evaluate clinical characteristics and postoperative outcomes after tunica albuginea plication (TAP) in patients presenting with CPC who reported new onset worsened curvature (CPC-WC), and compare these with patients reporting stable lifelong curve ("CPC-only"). METHODS: A retrospective review of demographics, history/exam findings, and postoperative outcomes for patients with CPC who underwent TAP from 2012 to 2018 was performed. Patients were differentiated based on whether or not they reported new onset worsening of their penile curvature preoperatively (CPC-WC versus CPC only). Statistical analysis was performed to identify differences in clinical characteristics and postoperative outcomes after TAP. RESULTS: 60 patients were included [CPC only (n = 39) and CPC-WC (n = 21)]. Mean curvature was 62° (SD 23). CPC-WC patients were older [median 34 years (IQR 27:52) versus 24 years (IQR 20:34); p = 0.004], and more likely to report penile shortening and psychological bother (p < 0.05). On physical examination, CPC-WCs were more likely to have a discrete palpable tunical scar and diminished penile elasticity (p ≤ 0.0002). With median follow up of 12 months, satisfactory straightening with TAP was reported in 56/60 patients (93%) including 35/39 (90%) CPC only and 21/21 (100%) CPC-WC. CONCLUSIONS: In men undergoing TAP for CPC, we found that 35% reported new onset worsening of their original curvature preoperatively. These patients were older and more likely to report penile shortening or exhibit palpable tunical scarring with decreased elasticity on examination compared to those with lifelong stable curvature. Regardless, TAP resulted in satisfactory penile straightening in the majority of patients.

Peyronie's disease: Contemporary evaluation and management.

Peyronie's disease is a common yet poorly understood condition characterized by penile pain, curvature, sexual dysfunction and psychological bother. Peyronie's disease represents a penile wound healing disorder, and is thought to arise from exuberant scarring in response to penile trauma in genetically predisposed men. In the absence of active treatment, the majority of men experience stable or worsening symptoms, with few reporting spontaneous resolution in penile curvature or other deformity. In contrast, penile pain improves or resolves in the majority of men. Treatment options vary based on symptom severity and stability. Several oral therapies are commonly prescribed, although to date there are no strong data to support any oral agents as monotherapy for Peyronie's disease. Other options including penile traction therapy and intralesional injections result in modest improvements for many patients, particularly when used early after symptom onset. Penile straightening through approaches, such as penile plication and plaque incision or partial excision and grafting, represent the most rapid and reliable approach to correct penile curvature once the symptoms have stabilized. Side-effects vary based on the type of surgery carried out, and include penile shortening, sensation changes and erectile dysfunction in the minority of men. In patients with drug refractory erectile dysfunction and Peyronie's disease, placement of a penile prosthesis will address both issues, and is associated with high levels of patient satisfaction. The current review provides a practical approach to the modern evaluation and management of patients presenting with Peyronie's disease.

A treatment algorithm for healthy young men with erectile dysfunction.

OBJECTIVES: To assess baseline characteristics of a cohort of young men with erectile dysfunction (ED) but no identifiable organic cause and to evaluate the efficacy of our treatment algorithm. PATIENTS AND METHODS: We retrospectively reviewed the charts of men aged <40 years referred to our tertiary care centre for evaluation and treatment of their ED between March 2010 and August 2016. Of 185 men reviewed, we included 73 men who were identified as having no identifiable organic cause for their ED and had successfully completed a detailed questionnaire regarding their medical and sexual history at the initial consultation. The questionnaire was used to obtain baseline patient characteristics and identify comorbid conditions which may predispose to ED. For these men, our standard treatment comprised a daily low-dose phosphodiesterase type 5-inhibitor along with a referral for psychosexual therapy, with the option of more invasive treatment if this initial approach failed. After a minimum of 6 months of treatment, patients were asked to complete a follow-up questionnaire via phone or e-mail. Thirty-three men successfully completed the follow-up questionnaire. Pre- and post-treatment questionnaires were compared to determine treatment adherence and efficacy. RESULTS: The mean (range) age of the study cohort was 31.9 (22-39) years. At the initial consultation, 85% of men (n = 62) reported problems obtaining an erection. After a minimum of 6 months of treatment, only 42% reported the same problem (n = 14), with 58% (n = 19) satisfied with their erectile function. Post-treatment International Index of Erectile Function (IIEF) scores showed a significant improvement in erectile function (18.8 vs 13.3; P < 0.01), orgasmic function (7.7 vs 6.2; P = 0.01) and overall satisfaction (6.1 vs 4.5; P < 0.01). No statistically significant improvement was noted in sexual desire or intercourse satisfaction. CONCLUSIONS: Our proposed treatment approach for men with ED aged < 40 years without an identifiable organic aetiology appears to be a reasonable and effective first-line approach, as demonstrated by significantly improved post-treatment IIEF scores and patient-reported outcomes. This algorithm can provide urologists with a useful framework for managing these potentially challenging patients.

The Surgical Treatment of Peyronie's Disease in the Older Man: Patient Characteristics and Surgical Outcomes in Men 65 and Older.

INTRODUCTION: Surgery remains the gold standard for the correction of penile deformities secondary to Peyronie's disease (PD). Nevertheless, there is no published data on the surgical treatment of PD in older men. AIM: Considering the aging national and international population, we sought to evaluate the pre-operative characteristics and surgical outcomes of men aged 65 or older who underwent surgical treatment for PD at our tertiary care institution. METHODS: We retrospectively reviewed the charts of all men 65 years or older who underwent surgery for PD from January 2010 to September 2017. We compared men who underwent penile prosthesis implantation with straightening maneuvers (PP+SMs), tunica albuginea plication (TAP), and plaque partial excision with grafting (PEG). MAIN OUTCOME MEASURE: The main objective of this study was to find the baseline pre-operative patient characteristics and postoperative patient-reported outcomes. RESULTS: A total of 86 men with a median age of 68 years underwent surgery during the study period. 39 men underwent PP+SM (45%), 25 men a TAP (29%), and 22 men a PEG (26%). The mean curvature for all men was 59.9 ± 22.0° (range 0-105°). Those who underwent a PEG had a mean ± SD degree of curvature of 78.6 ± 16.6°, significantly higher than those who underwent PP+SM or TAP (49.1 ± 20.2° and 61.4 ± 17.4°, respectively; P < .001). Moreover, men who underwent a PEG had significantly more complex penile deformities (eg, narrowing with hinge effect) and better reported baseline erectile function compared with men who underwent PP+SM or TAP. Overall, 95% of all men reported having a functionally straight penis postoperatively with 94% engaging in penetrative intercourse at last follow-up. Overall, patient-reported satisfaction was 85% with a median follow-up of 43.5 months. CLINICAL IMPLICATIONS: Our findings suggest that the surgical treatment of PD in older men is safe, effective, and associated with high patient satisfaction. Although this represents a surgical series susceptible to selection bias, it underscores the importance of patient selection and counseling in achieving good surgical outcomes. STRENGTHS & LIMITATIONS: Our study is the first to report on outcomes of surgical treatment of PD in an elderly patient population with relatively long-term follow-up. Our limitations include a small sample size, single operating surgeon, and the lack of a younger comparison group. CONCLUSION: Despite an aging global population, surgery remains a viable and reliable option for the properly selected and counseled older men with PD. Abdelsayed GA, Setia SA, Levine LA. The Surgical Treatment of Peyronie's Disease in the Older Man: Patient Characteristics and Surgical Outcomes in Men 65 and Older. J Sex Med 2019;16:1820-1826.

The Penile Sensitivity Ratio: A Novel Application of Biothesiometry to Assess Changes in Penile Sensitivity.

INTRODUCTION: Biothesiometry allows for evaluation of penile vibratory sensitivity and can be used as a non-invasive and rapid surrogate test of penile sexual sensitivity. However, no standardized measurement methodology currently exists. AIM: To describe and optimize a novel, standardized biothesiometry parameter-the penile sensitivity ratio (PSR). METHODS: We reviewed all biothesiometry data from men presenting to our institution from July 2013-May 2017. 3 iterations of the PSR were evaluated using the threshold for vibratory detection from a combination of different input variables including the penile glans, penile shaft, index finger, and thigh. Numerator values for the PSR included the penile glans and penile shaft, whereas denominator inputs included the index finger and thigh. PSR is inversely correlated with penile sensitivity. MAIN OUTCOME MEASURE: The primary outcome measure was the association between reported diminished penile sensitivity and PSR value. Secondary outcome measures were the association between PSR and age, diabetes, ejaculatory dysfunction, and Peyronie's disease (PD). RESULTS: Biothesiometry data were evaluated from 1,239 men. Mean age was 53.2 years (SD 14.0 years). Diabetes was present in 7.4% (n = 92); 52.0% (n = 644) had PD. Ejaculatory dysfunction was identified in 15.8% (n = 196), with 12.2% (n = 151) having premature ejaculation and 3.6% (n = 45) reporting delayed ejaculation. Decreased penile sensitivity was reported in 20.3% (n = 252). 3 PSR iterations were analyzed to identify associations with decreased penile sensation. On univariate and multivariate analysis controlling for age, diabetes, ejaculatory dysfunction, and PD, only the PSR iteration, which included data from the penile glans and finger (PSRG/F), was significantly different between patients reporting diminished penile sensitivity and those without reported diminished sensitivity (univariate P < .01, multivariate P = .03). On univariate analysis, a higher PSRG/F was associated with older age (P < .01) and diabetes (P < .01), whereas men with PD had a lower PSRG/F (P < .01). On multivariate analysis, PSRG/F remained increased for age (P < .01) and decreased for PD (P = .01); however, there was no association with diabetes (P = .12). No association existed between ejaculatory function and PSRG/F on univariate (P = .25) or multivariate analysis (P = .35). CLINICAL IMPLICATIONS: The PSR may be used as a standardized biothesiometry parameter to evaluate penile sensitivity. STRENGTH & LIMITATIONS: This study included a large cohort of men undergoing biothesiometry (n = 1,239); however, it is limited by the multifactorial nature of perceived diminished penile sensitivity. CONCLUSION: The PSR using penile glans and index finger input variables is a non-invasive, painless, office-based, standardized biothesiometry parameter that is a clinically useful tool for measuring penile sexual sensitivity. Wiggins A, Farrell MR, Tsambarlis P, et al. The Penile Sensitivity Ratio: A Novel Application of Biothesiometry to Assess Changes in Penile Sensitivity. J Sex Med 2019;16:447-451.

Preliminary Outcomes of the Male Urethral "Mini-Sling": A Modified Approach to the Andrianne Mini-Jupette Procedure With Penile Prosthesis Placement for Climacturia and Mild Stress Urinary Incontinence.

INTRODUCTION: Previous worked showed that the Andrianne Mini-Jupette (AMJ) procedure with inflatable penile prosthesis (IPP) significantly improves climacturia or stress urinary incontinence (SUI) that may accompany erectile dysfunction (ED) after radical prostatectomy. However, with the AMJ procedure, the graft is incorporated into the medial aspect of the corporotomy, thereby requiring a more complex closure. Moreover, in the original report, multiple graft materials were used. AIM: To describe our technique for "male urethral mini-sling" (MUMS) with a Virtue sling mesh, which is a modified approach to the AMJ, and to assess early postoperative outcomes. METHODS: A retrospective chart review was performed for men who underwent IPP and MUMS placement with a modified Virtue mesh by 2 high-volume prosthetic urologic surgeons using the same technique. After proximal urethral exposure, the MUMS is sutured to the latera corpora over the bulbar urethra, proximal to and separate from the planned corporotomy, with care taken to avoid excessive urethral tension. The IPP is then placed in standard fashion. Changes in patient-reported climacturia and pads per day for SUI were assessed before and after surgery. RESULTS: 36 men underwent both IPP and MUMS placement between January 2016-October 2018. Mean patient age was 68 years. Etiology for ED and urinary symptoms was prostatectomy alone in 30 of 36 (83%) and prostatectomy plus radiation in 6 of 36 (17%). Preoperative urinary symptoms included climacturia in 30 of 36 (83%) and SUI in 27 of 36 (75%). Mean (SD) follow-up was 5.9 (3.7) months. Climacturia resolved in 28 of 30 (93%), and SUI improved in 23 of 27 (85%). The mean (SD) number of pads per day for those patients with SUI decreased significantly from 1.4 (1.1) before surgery to 0.4 (0.6) after surgery (P = .02). 1 patient required MUMS explantation for urethral erosion after prolonged postoperative catheterization. CLINICAL IMPLICATIONS: The MUMS with modified Virtue mesh at the time of IPP placement can be used to treat ED with climacturia or mild SUI after radical prostatectomy. STRENGTHS & LIMITATIONS: Strengths include the use of a consistent operative technique with a single graft material by 2 experienced prosthetic urologic surgeons. Limitations include the retrospective study design, use of subjective postoperative outcomes, lack of comparison group, and relatively moderate follow-up duration. CONCLUSIONS: Our early results suggest that the MUMS significantly improves bothersome climacturia and mild SUI in addition to treating ED, with little added morbidity. Although further study, including longer-term follow-up, is needed, this approach may be considered in the appropriately counseled patient. Valenzuela RJ, Ziegelmann MJ, Hillelsohn JH, et al. Preliminary Outcomes of the Male Urethral "Mini-Sling": A Modified Approach to the Andrianne Mini-Jupette Procedure With Penile Prosthesis Placement for Climacturia and Mild Stress Urinary Incontinence. J Sex Med 2019;16:1310-1317.

Microdenervation of the spermatic cord for post-vasectomy pain syndrome.

OBJECTIVE: To evaluate the outcomes of patients who underwent microdenervation of the spermatic cord (MDSC) for post-vasectomy pain syndrome (PVPS) at our institution. METHODS: A retrospective study of all patients who underwent MDSC for PVPS by a single surgeon between March 2002 and October 2016 was performed. Pain was documented using the numerical rating scale (NRS). Spermatic cord block (SCB) was performed on all patients, and success was defined as NRS score ≤1 for >4 h. All patients had failed medical therapy prior to MDSC. All previous procedures for PVPS had been performed elsewhere. Surgical success was defined as a postoperative NRS score of ≤1. RESULTS: A total of 27 patients with 28 scrotal units underwent MDSC for PVPS. The median (1st quartile; 3rd quartile) follow-up was 10 (2; 16.5) months. The median (range) duration of pain prior to surgery was 57 (8-468) months. Pain was bilateral in 14 (52%), left-sided in eight (30%) and right-sided in five patients (19%). Data on SCB were available for 23 patients, with a success rate of 96%. The median (range) preoperative pain NRS score was 7 (2-10). The median (range) pain score after SCB on the NRS scale was 0 (0-5). The median (range) postoperative pain score on the NRS was 0 (0-9). Overall success was achieved in 20 of 28 testicular units (71%). Patients with involvement of multiple structures in the scrotum (i.e. testis, epididymis, spermatic cord) had a success rate of 81% and were more likely to have a successful surgery (P < 0.001). Five patients had failed a prior epididymectomy and three had failed a vaso-vasostomy for PVPS; this had no correlation with the success of MDSC (P = 0.89). CONCLUSION: The MDSC procedure is a reasonably successful, durable and valuable approach for PVPS, especially when pain involves multiple structures in the scrotum (testis, epididymis, spermatic cord). MDSC was equally efficacious in patients who had previously failed a procedure for PVPS. No patient had a worsening NRS score after MDSC. This is the largest study to date evaluating MDSC for the treatment of PVPS.

Ambicor 2-Piece Inflatable Penile Prosthesis: Who and How?

BACKGROUND: Currently the Ambicor is the only 2-piece inflatable penile prosthesis (IPP) available in the United States. By eliminating the separate reservoir, this provides certain advantages for patient and surgeon. Nevertheless, it composes a small percentage of all IPPs implanted in the United States. AIM: To detail the surgical technique for implantation, describe the ideal patient candidates best suited for the Ambicor, and discuss the most common and some rare complications with a review of the available published literature in combination with our clinical experience. METHODS: A PubMed literature search was performed to obtain all peer-reviewed articles published in English specifically on the Ambicor 2-piece IPP. We also reviewed our clinical experience with the Ambicor during the past 2 decades. RESULTS: The published data remain limited, because few articles on the Ambicor have been published in the past 10 years. Overall complication rates were 2.1% to 9.5%. Patient satisfaction rates were 75% to 96.4%, with similar partner satisfaction rates. Relative contraindications for implantation include patients with significant penile deformities, long narrow phalluses, or short phalluses. STRENGTHS AND LIMITATIONS: Despite the limited available published data with short follow-up periods, this review provides a comprehensive discussion on the technical aspects and relevant perioperative counseling recommended for Ambicor implantation. CONCLUSION: The prosthetic urologist should offer the Ambicor 2-piece IPP to patients with erectile dysfunction whose non-surgical treatment has failed. Certain implanters might want to avoid the blind retropubic reservoir placement that occurs with 3-piece IPPs and might not be comfortable with an ectopic approach and therefore prefer using a 2-piece device. We believe the ideal Ambicor candidate is a patient with a current or future pelvic organ transplant, decreased manual dexterity, in need of complete phallic reconstruction, or with known extensive prior abdominopelvic surgery. Abdelsayed GA, Levine LA. Ambicor 2-Piece Inflatable Penile Prosthesis: Who and How? J Sex Med 2018;15:410-415.

Surgical Outcomes of Plaque Excision and Grafting and Supplemental Tunica Albuginea Plication for Treatment of Peyronie's Disease With Severe Compound Curvature.

BACKGROUND: There are limited data in the literature that describe the management of Peyronie's disease (PD) with severe compound curvature, which often requires additional straightening procedures after plaque excision and grafting (PEG) to achieve functional penile straightening (<20 degrees). AIM: This study highlights the clinical distinction and our experience with men with PD and severe compound curvature treated with PEG and supplemental tunica albuginea plication (TAP). METHODS: We performed a retrospective chart review of patients with PD and acute angulation who underwent PEG (group 1) and patients with compound curvature who underwent PEG with TAP (group 2) between 2007 and 2016. OUTCOMES: Primary post-operative outcomes of interest include change in penile curvature, change in measured stretched penile length, and subjective report on penile sensation and sexually induced penile rigidity. RESULTS: 240 Men with PD were included in the study, of which 79 (33%) patients in group 1 underwent PEG and 161 (67%) in group 2 underwent PEG and TAP. There was no difference in associated PD co-morbidities including age, hypertension, hyperlipidemia, hypogonadism, diabetes, or tobacco use. After artificial induction of erection with intracorporal trimix injection, the average primary curvature was 73 (range, 20-120) degrees for group 1 compared to 79 (range, 35-140) degrees for group 2 (P = .01). Group 2 had an average secondary curvature of 36 (20-80 degrees). After completion of PEG, men in group 2 had an average residual curvature of 30 (range, 20-50) degrees which required 1-6 TAPs to achieve functional straightness (<20 degrees). At an average follow-up of 61 months, there was no difference for group 1 and group 2, respectively, for recurrent curvature (11.4% vs 12.4%, P = .33), change in penile length (+0.57 vs +0.36 cm, P = .27) or decreased penile sensation (6% vs 13%, P = .12). In all, 81% of group 1 and 79% of group 2 were able to engage in penetrative sex after penile straightening with or without pharmacotherapy (P = .73). CLINICAL TRANSLATION: Our review shows promising surgical outcomes for the use of PEG and supplemental TAP for this subtype of complex PD. STRENGTHS AND LIMITATIONS: This article reports the largest experience with treatment of PD with compound curvature to date. Limitations of this study include the retrospective nature of the analysis as well as the lack of a validated objective measurement of erectile function after penile straightening. CONCLUSION: Our study found no baseline difference in underlying co-morbidities in men with severe compound curvature compared with men with acute severe angulated curvature. Men with severe compound curvature represent a severe and under-recognized population of men with PD who can be surgically corrected with PEG and supplemental TAP(s) when needed without an increased risk of loss of penile length, recurrent curvature, decreased penile sensation, or erectile dysfunction when compared to men treated with PEG alone. Chow AK, Sidelsky SA, Levine LA. Surgical Outcomes of Plaque Excision and Grafting and Supplemental Tunica Albuginea Plication for Treatment of Peyronie's Disease With Severe Compound Curvature. J Sex Med 2018;15:1021-1029.