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.

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.

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.

Outcomes of RestoreX Penile Traction Therapy in Men With Peyronie's Disease: Results From Open Label and Follow-up Phases.

BACKGROUND: A randomized, controlled clinical trial evaluating the efficacy of RestoreX traction therapy in men with Peyronie's disease (PD) has been completed, with the 3-month results previously reported. The present study presents outcomes from the open-label and follow-up phases of the original trial. AIM: To report 6-month (open-label phase) and 9-month (follow-up phase) outcomes from a randomized, controlled trial (NCT03389854). METHODS: A randomized controlled trial was performed from 2017 to 2019 in 110 all-comer men with PD. Men were randomized 3:1 to RestoreX (PTT) or no therapy (control) for 3 months, followed by 3-month open-label and follow-up phases. Key outcomes included adverse events (AEs), changes in penile curvature and length, erectile function, and standardized and nonstandardized assessments of PD. OUTCOMES: The primary outcomes are safety, penile length, penile curvature, Peyronie's Disease Questionnaire, International Index of Erectile Function, and satisfaction. RESULTS: 6-month (n = 64) and 9-month (n = 63) outcomes were reported, with a mean duration of PTT use of 31.1 minutes. No significant AEs were reported, with temporary erythema and discomfort being most common and resolving within minutes. On intent-to-treat analysis, control-to-PTT men experienced significant length (1.7-2.0 cm) and curvature improvements (18-20%). PTT-to-PTT men also achieved additional length (0.6-0.8 cm) without further curvature improvements. An as-treated analysis of PTT use ≥15 minute/day demonstrated 2.0- to 2.3-cm length gains (largest of any PTT to date) and 18-21% curve improvement. All sexual function domains of the International Index of Erectile Function and Peyronie's Disease Questionnaire were significantly improved (except orgasmic domain). 95% of men treated for 6 months experienced length gains (mean 2.0-2.2 cm), and 61% had curve improvements (16.8-21.4° [32.8-35.8%]). RestoreX was preferred 3-4:1 over all other PD treatments, and 100% preferred it over other PTT devices. CLINICAL IMPLICATIONS: Use of RestoreX 30 minutes daily results in significant length and curve improvements in PD men without significant AEs. STRENGTHS & LIMITATIONS: Strengths include largest randomized study of PTT, blinded assessments, and inclusion of all-comers with few restrictions; limitations include sample size that precludes comparisons between treatment cohorts and lack of long-duration (>3-9 hours) treatment arm. CONCLUSION: PTT with RestoreX results in significant improvements in length, curve, and subjective and objective measures of sexual function without significant AEs. RestoreX PTT represents a safe, conservative, low-cost option for managing men with PD. Joseph J, Ziegelmann M, Alom M, et al. Outcomes of RestoreX Penile Traction Therapy in Men With Peyronie's Disease: Results From Open Label and Follow-up Phases. J Sex Med 2020;17:2462-2471.

Prevalence and Predictors of Climacturia and Associated Patient/Partner Bother in Patients With History of Definitive Therapy for Prostate Cancer.

BACKGROUND: Climacturia is an under-reported complication of definitive therapy for prostate cancer (PCa) - that is, radical prostatectomy (RP) and/or radiation therapy (RT). AIM: We sought to identify the prevalence and predictors of climacturia and associated patient/partner bother in patients with and without prior PCa treatment. METHODS: We analyzed a database of patients who presented to our Men's Health clinic and filled out a questionnaire related to sexual function and pertinent medical histories. The prevalence of climacturia and associated patient/partner bother in patients with/without prior RP/RT was calculated. Univariable and multivariable logistic regressions were performed to identify predictors associated with climacturia and patient/partner bother. OUTCOMES: The primary outcomes were the prevalence and predictors of climacturia and associated patient/partner bother in patients with/without history of definitive PCa treatment. RESULTS: Among 1,117 patients able to achieve orgasm, 192 patients (17%) had prior history of definitive therapy for PCa (RP alone = 139 [72%]; RT alone = 22 [11%]; RP + RT = 31 [16%]). Climacturia was reported by 39%, 14%, 52%, and 2.4% of patients with history of RP alone, RT alone, RP + RT, and neither RP nor RT, respectively (P < .05 between all groups). 33 to 45 percent of patients with climacturia noted significant patient/partner bother. Factors significantly associated with climacturia were prior RP, prior RT, history of other prostate surgery, and erectile dysfunction, although erectile dysfunction was not significant on multivariable analysis. Significant reduction in climacturia prevalence was noted for patients who were ≥1 year out from RP, compared with patients who were <1 year out. Among patients with prior RP/RT, stress urinary incontinence was associated with increased risk of climacturia, whereas diabetes was associated with decreased risk. No factors were associated with patient/partner bother. Among patients with prior RP, nerve-sparing technique did not predict presence of climacturia but was associated with reduced patient/partner bother. CLINICAL TRANSLATION: Given significant prevalence of climacturia and associated patient/partner bother, patients should be counseled on the risk of climacturia before undergoing RP/RT. STRENGTHS AND LIMITATIONS: Strengths include the large study population and the focus on both RP and RT. Limitations include the facts that this is a single-institution study that primarily relies on patients' subjective reporting and that the study population may not represent the general population. CONCLUSIONS: Climacturia affects a significant proportion of patients with history of RP/RT for PCa, and many patients and their partners find this bothersome. Jimbo M, Alom M, Pfeifer ZD, et al. Prevalence and Predictors of Climacturia and Associated Patient/Partner Bother in Patients With History of Definitive Therapy for Prostate Cancer. J Sex Med 2020;17:1126-1132.

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.

Bacterial Cultures at the Time of Artificial Urinary Sphincter Revision Surgery in Clinically Uninfected Devices: A Contemporary Series.

PURPOSE: We evaluated the rate of bacterial colonization in artificial urinary sphincters during revision surgery for noninfectious etiologies. MATERIALS AND METHODS: We evaluated bacterial culture swab data on all explanted artificial urinary sphincter components (cuff, pump and reservoir) in patients who underwent revision surgery between February 2016 and July 2018. Those treated with revision for infection or erosion were excluded from study. Patient demographic variables were assessed to identify factors associated with colonization. RESULTS: Cultures were obtained from 200 components, including 86 cuffs, 56 pumps and 58 reservoirs among the total of 80 patients. The etiology of revision included urethral atrophy in 31 cases (39%) and mechanical failure in 49 (52%). Median time after prior artificial urinary sphincter placement was 4.3 years (IQR 2-9). Median operative time was 37.5 minutes (IQR 32-46). All components were explanted and replaced in 55 patients (69%) and a single component was replaced in 23 (28%). Positive culture swabs were identified in 37 of the 200 components (19%), including 25 of 86 cuffs (29%), 7 of 56 pumps (13%) and 5 of 58 reservoirs (9%). Of the 80 patients 31 (39%) had at least 1 positive component culture and were more likely to have a history of radiation (65% vs 33%, p = 0.006). Identified organisms included Staphylococcus species in 57% of cases, Propionibacterium in 10% and Aerococcus in 5%. CONCLUSIONS: Positive artificial urinary sphincter component bacterial swab cultures were found in 39% of patients undergoing artificial urinary sphincter revision in the absence of clinical infection. Those with positive cultures were more likely to have a history of pelvic radiation. These results suggest that bacterial colonization of organisms with low virulence may not lead to device infection.

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.

Modified Glanulopexy Technique for Supersonic Transporter Deformity and Glanular Hypermobility in Men With Penile Prostheses.

BACKGROUND: Glanular hypermobility (GH) or supersonic transporter (SST) deformity are occasionally encountered during penile prosthesis (PP) implantation, yet management strategies are underreported with minimal data available on surgical outcomes. AIM: To describe a modified technique for glanulopexy to correct GH/SST in men undergoing PP placement and assess outcomes associated with this technique. METHODS: Glanulopexy was performed in men with GH/SST identified at the time of or following PP placement. A modification to previously described techniques was performed, whereby a suture is passed into the glans and secured to the tissue overlying the corpora through small incisions on the lateral aspects of the distal penile shaft. OUTCOMES: Correction of the anatomic deformity (GH/SST), device infection, and changes in penile sensation were evaluated during post-operative follow-up. RESULTS: From 2014-2017, a total of 12 patients underwent modified glanulopexy for GH/SST. Nine (75%) were performed at the time of PP, while the remaining 3 were performed in a delayed fashion. At a median follow-up of 12 months (range 1-33 months), all patients with the device in situ demonstrated appropriate glanular positioning, and no patients reported changes in penile sensation. A single patient required device removal secondary to infection. CLINICAL TRANSLATION: Glanulopexy with permanent suture successfully corrects severe GH or SST in men with inflatable PP without reduced penile sensation. CONCLUSIONS: Strengths of the current study include the description of a simple, safe, and reproducible technique for GH/SST that adds minimal operative time and can be performed under local anesthesia when necessary. To our knowledge, this represents one of the largest reported series of glanulopexy outcomes reported in the literature. Limitations include that this is a single-surgeon series, there is limited follow-up, and lack of a comparison group. Further study with external validation is warranted to establish the optimal role for the procedure. Ziegelmann MJ, Alom M, Bole R, et al. Modified Glanulopexy Technique for Supersonic Transporter Deformity and Glanular Hypermobility in Men With Penile Prostheses. J Sex Med 2018;15:914-919.

Clinical Factors Negatively Impacting Sexual Relationships in Men With Peyronie's Disease.

Here, we sought to identify clinical factors associated with a negative impact on the relationships patients with Peyronie's disease (PD) have with their partners. During initial consultation, a detailed sexual questionnaire was administered, which included a question on whether or not PD negatively impacted the current sexual relationship. More than half (146/242; 60.3%) of patients reported that PD negatively impacted their sexual relationship. On multivariate analysis, penile shortening, partner pain with intercourse, and shorter relationship duration were associated with a negative relationship effect. We did not identify significant differences in negative relationship effects based on objective physical examination findings including penile curvature, calcification, hourglass deformity, or penile length.

Genital vibration for sexual function and enhancement: a review of evidence.

Vibration, as provided by a genital vibrator, is commonly regarded as a tool to enhance sexual pleasure and in modern day society falls under the category of a sex toy. However, the vibrator was not originally intended to be a toy, and its benefits reach far beyond that of a plaything. This article is a narrative review of the current evidence regarding the use of vibratory stimulation for the treatment of sexual dysfunction and/or sexual and relationship enhancement. The literature indicates that vibratory stimulation has evidence-based support for the treatment of erectile dysfunction, ejaculatory dysfunction and anorgasmia. Vibratory stimulation is positively correlated with increased sexual desire and overall sexual function. It has also shown benefit for sexual arousal difficulties and pelvic floor dysfunction. Though definitive evidence is lacking, genital vibration is a potential treatment for sexual dysfunction related to a wide variety of sexual health concerns in men and women.

Genital vibration for sexual function and enhancement: best practice recommendations for choosing and safely using a vibrator.

Vibrators are an evidence-based treatment for a variety of sexual dysfunctions and sexual enhancement; however, the use of a genital vibrator lacks best practice recommendations. This aim of this article is to provide current, best practice recommendations regarding the use of vibratory stimulation for the treatment of sexual dysfunction and/or sexual or relationship enhancement. A multidisciplinary team of sexual health specialists collaborated to develop best practice recommendations based on a narrative literature review. Recommendations for the use of vibratory stimulation for the treatment of sexual dysfunction are provided, with special attention to counseling patients on choosing and safely using a vibrator. Further study is needed to determine the most effective methods to counsel patients on vibrator use and to provide evidence-based cleaning recommendations.

Urinary collecting system invasion is associated with poor survival in patients with clear-cell renal cell carcinoma.

OBJECTIVES: To evaluate the prognostic significance of urinary collecting system invasion (UCSI) in a large series of patients with clear-cell renal cell carcinoma (RCC). MATERIALS AND METHODS: Patients with clear-cell RCC treated with nephrectomy between 2001 and 2010 were reviewed from a prospectively maintained registry. One urological pathologist re-reviewed all slides. Cancer-specific survival was estimated using the Kaplan-Meier method, and associations of UCSI with death from RCC were evaluated using Cox models. RESULTS: Of the 859 patients with clear-cell RCC, 58 (6.8%) had UCSI. At last follow-up, 310 patients had died from RCC at a median of 1.8 years after surgery. The median follow-up for patients alive at last follow-up was 8.2 years. The estimated cancer-specific survival at 10 years after surgery for patients with UCSI was 17%, compared with 60% for patients without UCSI (P < 0.001). In a multivariable model, UCSI remained independently associated with an increased risk of death from RCC (hazard ratio 1.5; P = 0.018). Further, among patients with pT3 RCC, those with USCI had survival outcomes similar to those of patients with pT4 RCC. CONCLUSIONS: Collecting system invasion is associated with poor prognosis among patients with clear-cell RCC. If validated, consideration should be given to including UCSI in future staging systems.

Artificial urinary sphincter revision for urethral atrophy: Comparing single cuff downsizing and tandem cuff placement.

OBJECTIVE: To compare outcomes for single urethral cuff downsizing versus tandem cuff placement during artificial urinary sphincter (AUS) revision for urethral atrophy. MATERIALS AND METHODS: We identified 1778 AUS surgeries performed at our institution from 1990-2014. Of these, 406 were first AUS revisions, including 69 revisions for urethral atrophy. Multiple clinical and surgical variables were evaluated for potential association with device outcomes following revision, including surgical revision strategy (downsizing a single urethral cuff versus placing tandem urethral cuffs). RESULTS: Of the 69 revision surgeries for urethral atrophy at our institution, 56 (82%) were tandem cuff placements, 12 (18%) were single cuff downsizings and one was relocation of a single cuff. When comparing tandem cuff placements and single cuff downsizings, the cohorts were similar with regard to age (p=0.98), body-mass index (p=0.95), prior pelvic radiation exposure (p=0.73) and length of follow-up (p=0.12). Notably, there was no difference in 3-year overall device survival compared between single cuff and tandem cuff revisions (60% versus 76%, p=0.94). Likewise, no significant difference was identified for tandem cuff placement (ref. single cuff) when evaluating the risk of any tertiary surgery (HR 0.95, 95% CI 0.32-4.12, p=0.94) or urethral erosion/device infection following revision (HR 0.79, 95% CI 0.20-5.22, p=0.77). CONCLUSIONS: There was no significant difference in overall device survival in patients undergoing single cuff downsizing or tandem cuff placement during AUS revision for urethral atrophy.

Outcomes of Surgical Management in Patients with Stress Urinary Incontinence and/or Neovesicovaginal Fistula after Orthotopic Neobladder Diversion.

PURPOSE: To our knowledge there are no guidelines for the evaluation and management of incontinence in women with an orthotopic neobladder. We propose a treatment algorithm based on our experience with treating this patient population. MATERIALS AND METHODS: We identified women in whom orthotopic neobladder diversion and surgery for incontinence were performed from January 1, 1995 to January 1, 2014. Charts were reviewed for management, outcomes and complications within 30 days of surgery. RESULTS: At this institution 12 women with orthotopic neobladder diversion were treated with surgery for incontinence between 1995 and 2014. Six women (50%) had an undiagnosed neovesicovaginal fistula, of whom 3 (50%) underwent successful fistula repair. A total of 12 bulking agent injections were performed in 6 women (50%). The outcomes were continued dryness after 1 injection (8%), transient improvement after 9 (75%), immediate failure after 1 (8%) and secondary fistula development after 1 (8%). Four transobturator slings and 4 pubovaginal slings were placed in a total of 6 patients (50%), of whom 1 (17%) was dry and 1 (17%) was improved. At a median followup of 22.9 months (IQR 11.1-46.4) 6 women (50%) were dry or improved and 6 (50%) had no improvement in leakage. Of the 6 (50%) women who were dry or improved 2 (17%) achieved planned intermittent catheterization after surgery and 2 (17%) underwent ileal conduit conversion. CONCLUSIONS: Bulking agents have low long-term efficacy and carry the risk of fistula formation. The efficacy of tension-free sling placement is low and continence requires an obstructing sling. Counseling should include acceptance of multiple procedures, which may be necessary to achieve continence, and consideration of conduit diversion.