The Revised PENIS Score and proposal of the PACKAGE Checklist: a meta-epidemiologic study on penile amputation and replantation.

INTRODUCTION: Penile amputation causes severe physical and psychosocial distress. Microsurgical implementation in penile replantation is presumed to be superior to surgical repair. This assumption has been difficult to verify. OBJECTIVES: The purpose of this study was threefold: (1) to produce an updated review of penile replantation, substantiated by the largest sample size to date; (2) to appraise the comparative value of the novel PENIS Score and propose the PACKAGE Checklist, a guide for standardization of future case reports and reviews; and (3) to improve confusing terminology and recommend the standardization of vocabulary. METHODS: A literature review assessed 432 full-text case reports in 20 languages and identified 123 microsurgical and 40 surgical cases of penile replantation. The novel PENIS Score stratified penile amputations based on 5 criteria: position along the shaft, extension through the penis, neurovascular repair, ischemia time and type, and severed edge condition and contamination. For the outcome measurements, a Kendall tau coefficient evaluated the association between each PENIS criterion for short-term postoperative complications and 3 outcome measures: erection, urination, and sensation. RESULTS: Less than half of surgical reports on penile replantation are sufficiently detailed to complete all PENIS Score criteria. The viability of microsurgical and surgical replantation was equivalent at 92% and 94%, respectively. A statistically significant correlation was found between microsurgical repair and the return of sensation but not with nerve repair. Return of sensation with nerve repair was 51%, and microsurgical replantation without nerve repair was 42%; both were significantly higher than the 14% for surgical replantation. Preservation of a skin bridge was associated with a 40% reduction in severe postoperative complications. CONCLUSION: Microsurgical replantation is superior in return of sensation, with or without nerve repair. Implementing the PACKAGE Checklist and PENIS Score will help inform case reports and reviews.

Robotic vs. open surgical management of ureteroenteric anastomotic strictures: technical modifications to enhance success.

Development of ureteroanastamotic strictures (UAS) after urinary diversion is not uncommon, but is challenging to treat. Poor outcomes are likely with endoscopic and radiologic management, and definitive surgical treatment can cause significant morbidity. The comparative advantages of an operative approach have not yet been fully described in the literature. We retrospectively reviewed the prospectively maintained Tulane University Department of Urology quality assurance database of 12 patients who underwent operative UAS repair between 2012 and 2018. Data were reviewed for operative approach, demographics, baseline disease characteristics, operative variables, and perioperative and pathological outcomes. Of the 12 patients analyzed, 5 underwent open repair (OR) (2 bilateral, 2 right, 1 left) and 7 underwent robotic repair (RR) (3 right, 4 left). One robotic case required conversion to open due to significant intestinal and peri-ureteral adhesions. The median ages were 59 years in OR and 60 years in RR. Two patients in each group had failed previous endoscopic repair. Median time from cystectomy to treatment of enteroanastamotic stricture was 13 months for OR and 10 months for RR (p = 0.25). Median estimated blood loss was 80 mL in both OR and RR (p = 1.0), median operative time was 260 min in OR and 255 min in RR (p = 0.13), and median hospital stay was 8 and 4 days, respectively (p = 0.06). There were two intra-operative and one post-operative complication in the OR group, one of whom required further surgical intervention, and no complications in the robotic cohort. A minimally invasive, robotic approach offers a non-inferior alternative to OR with similar outcomes for appropriately selected patients with UAS. High success rates combined with minimal morbidity may provide definitive therapy at an earlier stage of the stricture state.

Sildenafil's impact on male infertility: what has changed in 20 years?

Sildenafil has had a dramatic influence on the field of sexual medicine over the past 20 years. Not only have phosphodiesterase-5 (PDE5) inhibitors improved the treatment of erectile dysfunction (ED), they have indirectly contributed to the treatment of male factor infertility. A review of the literature between 1998 - 2018 was performed using PubMed with regards to sildenafil and male infertility. Numerous studies have demonstrated sildenafil's safety and efficacy for treating ED. Sildenafil does not alter semen parameters, and, in fact, may positively affect semen parameters. Sildenafil is helpful for treating ED caused by the psychological stress of infertility treatments. Sildenafil has improved the treatment of ED and may have a benefit on semen parameters. This has aided in the management of male factor infertility, and has contributed to hundreds of thousands of pregnancies that would have been more difficult, as it was before its advent.

Regional Differences in the Treatment of Localized Prostate Cancer: An Analysis of Surgery and Radiation Utilization in the United States.

PURPOSE: Men with localized prostate cancer have various treatment options available in their management. The optimal approach is controversial and can be influenced by multiple factors. This study aimed to investigate the influence of geographic region on the selection of treatment for prostate cancer. METHODS AND MATERIALS: Using the National Cancer Database, we identified men diagnosed with localized prostate cancer between 2010 and 2014. The United States was divided into 11 regions per the American Cancer Society Divisions. The first course of treatment was recorded as radiation therapy (RT), radical prostatectomy (RP), or active surveillance (AS). The RT subgroup consisted of patients receiving all forms of RT, including external beam and brachytherapy, or RT plus androgen deprivation therapy. The RP subgroup consisted of patients receiving RP alone or combined with RT or androgen deprivation therapy. A χ2 test was performed to assess the association between region and frequency of RT and RP. RESULTS: This study included 462,811 men with localized prostate cancer who were treated in the United States, of whom 63.46% underwent RP, 31.54% underwent RT, and 5.00% underwent AS. Significant regional differences in RP and RT were observed (P ≤ .0001). RP was used most commonly in the Midwest (75.07%) and High Plains (73.37%) regions, whereas RP was least used in the South Atlantic (59.04%) region. Similarly, RT was used most commonly in South Atlantic (40.96%) and New England (38.98%) regions and least commonly in the Midwest (24.93%) region. AS was used most in the New England (7.27%) and Midwest (6.8%) regions and least used in the High Plains (2.57%) and Mid-South (2.84%) regions. CONCLUSIONS: Regional differences exist in the United States with regard to the definitive treatment of localized prostate cancer. The etiology for these regional differences is likely multifactorial.

Penile Prosthesis Complications: Planning, Prevention, and Decision Making.

INTRODUCTION: Inflatable penile prosthesis (IPP) is an established treatment option for men with erectile dysfunction (ED) refractory to medical therapy. Standardization of surgical technique and improvements in device construction have reduced all-cause complication rates to less than 5% in recent reports. Nonetheless, complications do exist, and can strongly impact morbidity and the quality of life of patients. Prosthetic urologists must be aware of the constellation of complications that can arise during or after IPP placement. AIM: To provide a comprehensive review of penile prosthesis complications and discuss preventative strategies, as well as proper preoperative, intraoperative, and postoperative decision making. METHODS: A review of the available literature from 1973 to 2018 was performed using PubMed with regard to IPP complications. MAIN OUTCOME MEASURES: We reviewed publications that outlined preoperative planning strategies and the following IPP complications: hematoma, floppy glans, corporal fibrosis, corporal perforation and crossover, urethral injury, infection, impending erosion, and glandular ischemia. RESULTS: Careful patient and device selection, setting realistic expectations of postsurgical outcomes, and adherence to a perioperative checklist is essential in the preoperative period. Intraoperatively, anticipate corporal fibrosis situations and always dilate laterally during corporal passage to reduce the risk of crossover and urethral injury. Limit perioperative antiplatelet therapy, apply compressive dressing, use a closed suction drain if indicated, and leave the device partially inflated postoperatively to reduce risk of hematoma. After surgery, monitor patients for potential complications that may warrant device explantation or salvage: IPP infection, glans ischemia, and impending erosion. CONCLUSIONS: By using evidence and expert opinion-based decision-making strategies in the preoperative, intraoperative, and postoperative period of IPP placement, surgeons can reduce the risk of complications and dissatisfaction, even in ED patients with multiple comorbid conditions. Scherzer ND, Dick B, Gabrielson AT, et al. Penile Prosthesis Complications: Planning, Prevention, and Decision Making. Sex Med Rev 2019;7:349-359.