The Who, How and What of Real-World Penile Implantation in 2015: The PROPPER Registry Baseline Data.

PURPOSE: To date, the published data on patients treated with penile implantation generally consist of small series of single surgeon, retrospective experiences rather than prospective or large, multicenter evaluations. This study establishes a baseline of data collection from the PROPPER (Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration). The PROPPER is the first large, prospective, multicenter, multinational, monitored, and internal review board approved study of real-world outcomes for patients with penile implants. MATERIALS AND METHODS: Data from the PROPPER study were examined to determine patient baseline characteristics and primary and secondary etiologies before treatment of erectile dysfunction. Data include type and size of implant received, surgical steps/techniques used during implantation, and duration of hospital stay. RESULTS: Through April 2, 2015 a total of 1,019 patients were enrolled in the study at 11 sites, with radical prostatectomy being the predominant etiology in 285 (28%). Of those 285 patients treated with radical prostatectomy 280 (98.2%) received an AMS 700™. Of these patients 65.0% (182 of 280) had placement of the reservoir in the traditional retropubic space vs 31.8% (89 of 280) in a submuscular location. Of those patients not treated with radical prostatectomy receiving an AMS 700, fewer underwent reservoir placement in the submuscular location (17.7%, 124 of 702, vs 80.9%, 568 of 702; p <0.001). Of those patients receiving an AMS 700, those treated with radical prostatectomy and those with diabetes had more outpatient admissions (less than 24 hours, 56.8% and 52.1%, respectively) compared to those with cardiovascular disease and Peyronie's disease (42.0% and 35.6%, respectively, p <0.001). CONCLUSIONS: This first-of-its-kind, large, prospective, multicenter study reveals most penile implant cases in North America receive an inflatable penile prosthesis and that radical prostatectomy is the most common primary etiology of penile implant surgery. Moreover, patients treated with radical prostatectomy were more likely to have the reservoir placed in a submuscular location, have a longer operating room time and be admitted to the hospital overnight compared with other patient groups.

Penile Prosthesis Surgery: Current Recommendations From the International Consultation on Sexual Medicine.

INTRODUCTION: Penile prosthesis implantation has emerged as a definitive treatment to restore sexual function to the motivated man with erectile dysfunction. Substantial improvements in the design of inflatable devices have been made since they first became available more than four decades ago. AIM: To review the history of the penile prosthesis, the indications, preoperative evaluation, and patient and partner satisfaction. The current approaches to addressing intra- and postoperative complications, provide an understanding of prosthesis infection, and placement of these devices will be reviewed. METHODS: A committee of worldwide experts in this field was assembled during the 2015 International Consultation on Sexual Medicine (ICSM) and performed a systematic review of the peer-reviewed published medical literature pertaining to penile prosthesis. Particular attention was given to higher level trials when available. Recommendations are based upon the Oxford Criteria. MAIN OUTCOME MEASURES: Unfortunately there is limited level 1 and 2 evidence, and where expert opinion was utilized, the decision was unanimous within the committee with a goal of presenting a clinically relevant guideline pertaining to penile prostheses. RESULTS: Penile prosthesis has undergone an evolution over the past 40 years resulting in a more effective and reliable treatment for advanced erectile dysfunction not responding to less invasive methods including oral treatment with PDE5 inhibitors, vacuum erection device, and intracorporal injection therapy. It should be considered an appropriate treatment option for the man who wishes to restore erectile function and who understands the potential risk of mechanical failure and infection, both of which are less common now as a result of improvements made in device design as well as surgical protocols adhered to in the operating room. Patients must be clearly informed of the risks associated with penile prosthesis including mechanical failure, infection, shortening of the penis, change in sensation and configuration of the penis, as well as injury to local structures. Intraoperative complications are unusual but do occur and can usually be addressed intraoperatively to allow placement of the device at the time of initial surgery. Postoperative complications may also be addressed when they occur but may require more advanced reconstructive surgical techniques. Men with Peyronie's disease, corporal fibrosis due to infection, trauma, prior prosthesis explantation, priapism, and men who have undergone construction of a neophallus may require additional advanced maneuvers to obtain optimum results with a penile prosthesis. CONCLUSION: Penile prosthesis remains as an important, viable, and effective treatment for male erectile dysfunction that does not respond to other less invasive approaches or when these approaches are contraindicated or not acceptable to the patient. These devices provide the patient with the ability to engage in penetrative sexual activity without interfering with urination, ejaculation, sensation, or orgasm. Although mechanical failure can occur, the current devices are more reliable as a result of design modifications. Infection remains the most dreaded complication but since the introduction of antibiotic and hydrophilic coatings, infection is less common. Overall, patient and partner satisfaction appear to be reasonably high when a penile prosthesis is used to restore erectile function.

Reservoir alternate surgical implantation technique: preliminary outcomes of initial PROPPER study of low profile or spherical reservoir implantation in submuscular location or traditional prevesical space.

PURPOSE: Alternative reservoir site placement has become an accepted technique for patients who require an inflatable penile prosthesis. To our knowledge there has been no prospective evaluation of this technique, which is currently off label. We performed a prospective, multicenter, multinational, internal review board approved study to evaluate the effectiveness and safety of alternative reservoir site placement. MATERIALS AND METHODS: PROPPER initiated in June 2011, is a database containing patient outcomes of inflatable penile prosthesis implantation. Patients with AMS® penile prostheses continue to be enrolled at 13 North American sites. We examined PROPPER study data to determine surgical implantation use patterns for the AMS 700™ series. We evaluated reservoir implantation site and complications by implantation site. RESULTS: A total of 759 patients had been implanted with an AMS 700 series implant by the time of evaluation. Mean patient followup was 17.8 months (range 0 to 36). There was no reported case of revision surgery for a palpable reservoir and no report of vascular or hollow viscous injury associated with alternative reservoir site placement. Two cases of reservoir herniation in the alternative reservoir site placement group and 2 in the space of Retzius group were treated with reservoir reimplantation. Patients with 1-year assessment available were satisfied or very satisfied with the device and reported a frequency of use of more than once per month. CONCLUSIONS: Alternative reservoir placement in the submuscular location is an option in patients who undergo inflatable penile prosthesis surgery. Implant surgeons should consider alternative reservoir site placement a safe, effective alternative to reservoir placement in the space of Retzius.

Technological Improvements in Three-Piece Inflatable Penile Prosthesis Design over the Past 40 Years.

INTRODUCTION: The advent of the penile prosthesis revolutionized the treatment of erectile dysfunction (ED), resulting in near-complete treatment efficacy and high patient satisfaction rates. While several types of penile prosthesis are available, the inflatable penile prosthesis (IPP) is the most commonly used device in the United States. AIMS: To describe the key modifications to IPPs from the two major manufacturers-American Medical Systems (AMS) and Coloplast-since the invention of the IPP, and to relate these changes to improvements in prosthesis function and patient outcomes based on available literature. METHODS: Review and evaluation of the literature between 1973 and present describing modifications in IPP design and the influence of these modifications on IPP durability and patient-related factors. MAIN OUTCOME MEASURES: Data describing the impact of iterative improvements in three-piece IPP design on device function, durability, and patient outcomes. RESULTS: There were progressive improvements in IPP technology from both major manufacturers not only on the durability of the prosthesis but also on patient outcomes, with fewer device failures and lower infection rates. Notable improvements include incorporation of kink-resistant tubing, changes in the weave or addition of shear- and infection-resistant coatings to cylinder layers, pump and tubing connection modifications, the addition of rear tip extenders, and the incorporation of lockout valves to prevent autoinflation. CONCLUSIONS: Numerous incremental modifications to the IPP from both major manufacturers since its invention have increased its durability and improved patient outcomes.

GGF2 is neuroprotective in a rat model of cavernous nerve injury-induced erectile dysfunction.

INTRODUCTION: Erectile dysfunction is a major complication of radical prostatectomy, commonly associated with penile neuropathy. In animal models of peripheral nerve injury, glial growth factor-2 (GGF2), a member of the neuregulin family of growth factors, has neuroprotective and neurorestorative properties, but this potential has not been established after cavernous nerve (CN) injury. AIMS: The effectiveness of GGF2 in preserving axonal integrity and recovering erectile function in a rat model of radical prostatectomy-associated CN injury. METHODS: Adult male Sprague-Dawley rats underwent bilateral CN crush injury (BCNI) or sham surgery. Rats were administered GGF2 (0.5, 5, or 15 mg/kg) or vehicle subcutaneously 24 hour pre and 24-hour post-BCNI, and once weekly for 5 weeks. Erectile function was assessed in response to electrical stimulation of the CN. CN survival was assessed by fluorogold retrograde axonal tracing in major pelvic ganglia (MPG). Unmyelinated axons in the CNs were quantitated by electron microscopy. MAIN OUTCOME MEASURES: Erectile function recovery, CN survival, and unmyelinated CN axon preservation in response to GGF2 treatment following BCNI. RESULTS: Erectile function was decreased (P < 0.05) after BCNI, and it was improved (P < 0.05) by all doses of GGF2. The number of fluorogold-labeled cells in the MPG was reduced (P < 0.05) by BCNI and was increased (P < 0.05) by GGF2 (0.5 and 5 mg/kg). The percentage of denervated Schwann cells in the BCNI group was higher (P < 0.05) than that in the sham-treated group and was decreased (P < 0.05) in the GGF2-treated (5 mg/kg) BCNI group. In the BCNI + GGF2 (5 mg/kg) group, the unmyelinated fiber histogram demonstrated a rightward shift, indicating an increased number of unmyelinated axons per Schwann cell compared with the BCNI group. CONCLUSIONS: GGF2 promotes erectile function recovery following CN injury in conjunction with preserving unmyelinated CN fibers. Our findings suggest the clinical opportunity to develop GGF2 as a neuroprotective therapy for radical prostatectomy.

Basic Science Evidence for the Link Between Erectile Dysfunction and Cardiometabolic Dysfunction.

INTRODUCTION: Although clinical evidence supports an association between cardiovascular/metabolic diseases (CVMD) and erectile dysfunction (ED), scientific evidence for this link is incompletely elucidated. AIM: This study aims to provide scientific evidence for the link between CVMD and ED. METHODS: In this White Paper, the Basic Science Committee of the Sexual Medicine Society of North America assessed the current literature on basic scientific support for a mechanistic link between ED and CVMD, and deficiencies in this regard with a critical assessment of current preclinical models of disease. RESULTS: A link exists between ED and CVMD on several grounds: the endothelium (endothelium-derived nitric oxide and oxidative stress imbalance); smooth muscle (SM) (SM abundance and altered molecular regulation of SM contractility); autonomic innervation (autonomic neuropathy and decreased neuronal-derived nitric oxide); hormones (impaired testosterone release and actions); and metabolics (hyperlipidemia, advanced glycation end product formation). CONCLUSION: Basic science evidence supports the link between ED and CVMD. The Committee also highlighted gaps in knowledge and provided recommendations for guiding further scientific study defining this risk relationship. This endeavor serves to develop novel strategic directions for therapeutic interventions.

The effect of vasectomy on the sexual life of couples.

INTRODUCTION: There are several contraceptive methods to prevent pregnancy, reversible as well as nonreversible ones. The sexual satisfaction of couples is affected by many types of contraceptives used. AIM: The aim of this study was to evaluate prospectively the effect of vasectomy on the sexual life and satisfaction of couples. METHODS: Seventy-six couples took part in this evaluation and filled out respective questionnaires before and after vasectomy. All the questionnaires were evaluated statistically for differences in the respective sexual domain scores. MAIN OUTCOME MEASURES: Standardized questionnaires were used. The International Index of Erectile Function (IIEF) as well as postoperative pain score were completed by men. Female Sexual Function Index (FSFI) was completed by the female partner. For statistical analysis, the T-Square Test was used. RESULTS: The average age of couples, who chose the vasectomy procedure, was 37 years for women and 39 years for men. The contraception method most frequently used prior to the vasectomy was the birth control pill. For the male partner, the IIEF showed no significant change in the respective domains. Out of the 76 couples, 93% of the males and 96% of their female partners would recommend and do vasectomy again. The postoperative pain score was 3.5 on 0-10 scale, and there were no postoperative complications reported. The best improvement of the sexual function was noticed for the female partners. The FSFI showed a significant improvement in the domains desire (P < 0.05), arousal (P < 0.05), orgasm (P < 0.05), lubrication (P < 0.05), and satisfaction (P < 0.05). CONCLUSION: This is the first report to our very best knowledge that showed the positive impact of vasectomy on sexual satisfaction of couples. Vasectomy is a safe operation with minimal complication rates.

A guide for inflatable penile prosthesis reservoir placement: pertinent anatomical measurements of the retropubic space.

INTRODUCTION: The primary concern for many prosthetic urologic surgeons in placing the three-piece inflatable penile prosthesis (IPP) is the concept of "blind reservoir placement." Extensive reports permeate the literature regarding bladder, bowel, vascular, and various hernial complications occurring while attempting to place the reservoir into the retropubic space. However, despite these widely documented complications, there is a paucity of published literature on surgically pertinent anatomical measurements of the retropubic space relating to reservoir placement. The focus of this project was to evaluate the special relationships and anatomical measurements of the retropubic space to better aid the surgeon in the safe placement of the reservoir. AIM: Analyses of the spatial measurements of reservoir placement into the retropubic space with a focus on utilizing a penoscrotal approach were conducted. In addition, we reviewed and evaluated the published literature for important contributions surrounding the various surgical techniques during placement of a penile prosthesis reservoir. METHODS: Cadaveric pelvic specimens were dissected to determine the distance and angulation (in degrees) from the inguinal ring to several critical anatomic structures in the pelvis. This format was utilized to simulate the basic features of reservoir placement into the classic retropubic space. We also reviewed and evaluated the published literature for important contributions describing the various surgical techniques in the placement of penile prosthesis reservoirs into the retropubic space. MAIN OUTCOME MEASURES: Anatomic measurements were obtained from the inguinal ring to the bladder, external iliac vein, and superior origin of the dorsal suspensory ligament at the anterior apex of the pendulous penis. The angle was measured from the inguinal ring to these structures and recorded. We also reviewed the published literature for various penoscrotal IPP surgical techniques involving placement of the reservoir into the retropubic space to further supplement the pertinent spatial relationships data acquired in this study. RESULTS: Of the 28 cadavers, 3 were excluded because of signs of major pelvic surgery, and an additional 6 sides were excluded because of unilateral fibrosis/surgery or difficulty in exposure. Distance to the decompressed bladder was 5-8 cm (average 6.45 cm) at a 15-30 (22.8) degrees medial measurement from the inguinal ring. The filled bladder was 2-4 cm (average 2.61 cm) from the inguinal ring. The external iliac vein distance from the inguinal ring was 2.5-4 cm (average 3.23 cm) at a 20-60 (36.4) degrees lateral measurement from the inguinal ring. Heretofore, the published literature does not appear to have detailed measurements that are provided in this study. CONCLUSIONS: These anatomical measurements of the retropubic space demonstrate the importance of decompressing the bladder and avoiding deep dissection lateral to the inguinal ring, as the external iliac vein is much closer than currently espoused. We feel that these data are significant to the surgeon proceeding with reservoir placement during IPP surgery.

Traditional plant aphrodisiacs and male sexual dysfunction.

INTRODUCTION: There has been a long history of man's fascination with better and stronger sex drive and performance across different cultures. Several literature texts from the Hindu, Egyptian, Chinese and Roman civilizations document the human endless search for substances that can enhance sexual experiences and/or treat erectile dysfunction. AIM: This review will discuss the current research done on the most popular plant aphrodisiacs and provide evidence to support or discourage the use of any of them to enhance sexual desire and/or function in men. METHODS: We review the current evidence on the use of natural substances as aphrodisiacs. RESULTS: We found very little evidence to support the use of plant aphrodisiacs in the treatment of male sexual dysfunction. The vast majority of studies were conducted on animals with very few clinical studies. Available data suggest a beneficial effect of ginseng as a pro-sexual supplement and not an independent treatment for male sexual dysfunction. CONCLUSIONS: Trans-culturally, many herbal therapies show some potential benefits in improving men's sexual function; however, adequate studies on the specific benefits and health risks associated with their use are needed. We strongly recommend the design and execution of well-controlled clinical studies to determine the efficacy and safety of plant aphrodisiacs.

Impact of cannabis use on male sexual health.

INTRODUCTION: Cannabis (marijuana) is the most widely used illicit drug globally. Given the prevalence of nonprescription illicit drug abuse, there is a growing interest in the study of its potential effects on male sexual health. In this review, we discuss the effects of cannabis on male sexual health. OBJECTIVE: In this review, we discuss the effects of cannabis on male sexual health. METHODS AND MAIN OUTCOME MEASURE: Critical review of scientific literature examining the impact of cannabis use on male sexual health. RESULTS: Studies examining the effects of cannabis use on male sexual function have been limited in both quality and quantity. Most results of these studies are conflicting and contradictory. While some did outline the beneficial effects of cannabis in enhancing erectile function, others did not. However, recent animal and in vitro studies have identified potential links between cannabis and sexual health. It appears that cannabis may actually have peripheral antagonizing effects on erectile function by stimulating specific receptors in the cavernous tissue. CONCLUSIONS: Given the prevalence of cannabis use, and the potential relationships between use and the development of potentially hazardous effects on male sexual function, we encourage renewed use of research resources to determine in-depth mechanistic knowledge, and new clinically oriented studies examining the effect of cannabis on male sexual function.

Neurotrophic effects of brain-derived neurotrophic factor and vascular endothelial growth factor in major pelvic ganglia of young and aged rats.

OBJECTIVE: To investigate the neurotrophic effect of brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF) in cultured major pelvic ganglia (MPG) derived from young and aged rats. MATERIALS AND METHODS: The dorsocaudal region of the MPG was isolated from 12 6-month-old male rats and 12 24-month-old male rats. The MPGs were treated with BDNF, VEGF, or both, at 0, 12.5, 25, 50, 100 and 150 ng/mL to determine the effective concentration for 50% activity (EC(50)) and optimum dosage for promoting neurite growth. Neurite outgrowth from treated MPGs was measured by microscopy. NADPH diaphorase and tyrosine hydroxylase (TH) staining was used to characterize neurites. RESULTS: Both BDNF and VEGF promoted neurite sprouting from MPG. Neurite growth was more robust in MPGs derived from young rats (6 months) than from aged rats (24 months). The EC(50) for BDNF, VEGF and combined treatment were 10.6, 11.9 and 52 ng/mL in young rats, and 11.3, 12 and 0.75 ng/mL in old rats, respectively. The optimum dosage of both factors for promoting MPG neurite growth in all groups was 25-50 ng/mL. VEGF appeared to favour NADPH diaphorase-positive neurites, whereas BDNF favoured TH-positive neurites. CONCLUSION: BDNF and VEGF promote neurite growth from cultured MPG; combined treatment produced the most robust neurite outgrowth. Neurite growth from MPGs derived from aged rats was not as robust as it was from MPGs from younger rats. Further studies on the effect of neurotrophins after cavernous nerve injury are warranted.

Sexual selection and genital evolution: an overview.

INTRODUCTION: Genital morphology (especially male) among the animal kingdom is characterized by extensive differences that even members of closely related species with similar general morphology may have remarkably diverse genitalia. AIM: To present the sexual medicine specialist with a basic understanding of the current hypotheses on genital evolution with an emphasis on the sexual selection theories. METHODS: A review of current literature on the theories of genital evolution. MAIN OUTCOME MEASURES: Analysis of the supporting evidence for the sexual selection theories of genital evolution. RESULTS: Several theories have been proposed to explain genital evolution. Currently, the sexual selection theories are being considered to present valid and solid evidence explaining genital evolution. However, other theories, including sexual conflict, are still being investigated. All theories of genital evolution have their own weaknesses and strengths. CONCLUSIONS: Given that many complex biological mechanisms, mostly unknown yet, are involved in the process of genital evolution, it is thus reasonable to conclude that not one theory can independently explain genital evolution. It is likely that these mechanisms may prove to have synergistic rather than exclusive effects.

Transglanular repair of impending penile prosthetic cylinder extrusion.

INTRODUCTION: Penile prosthetic devices are highly satisfactory in the management of erectile dysfunction but carry a number of risks including the potential for erosion. In some cases, impending extrusion can be identified and managed before frank erosion occurs. AIMS: To report our results using a transglanular approach for management of impending distal erosion of penile prosthetic devices. METHODS: Patients who presented with impending erosion of penile prosthetics were identified by retrospective chart review. Patients who were managed with a transglanular surgical approach constitute the study group. MAIN OUTCOME MEASURES: Clinical data were culled from the charts. Identified patients were contacted and were asked a battery of questions regarding their subjective assessment of the treatment's efficacy. RESULTS: Six men were identified. Mean age at time of surgery was 56 years. Four men had had implants placed within the past 2 years and two had implants that had been in place for greater than 12 years. Mean operative time was 25 minutes. Four patients were successfully managed with a single repair procedure. Two men required repeat revision surgery. Of men that were available for additional postoperative contact, three of four reported satisfaction with the procedure. CONCLUSIONS: The transglanular approach for repair of impending distal erosion of penile prosthetics is a quick and minimally morbid procedure that produces satisfactory results in the majority of patients. Further refinements of technique will likely lead to greater overall improvement in outcomes.

Erectile function rehabilitation in the radical prostatectomy patient.

INTRODUCTION: Prostate cancer is common and is being diagnosed in younger men now compared with two decades ago. Long-term functional outcomes are of significant importance to patient and impact upon the patient decision-making process regarding choice of therapy. Erectile function preservation (rehabilitation) has gained significant traction worldwide despite the absence of definitive evidence in its favor. AIM: To define the role of rehabilitation in the prostate cancer patient who has undergone radical prostatectomy (RP). METHODS: A committee of five experts in the field from three countries was convened, and using a thorough analysis of the literature and the Delphi approach to expert opinion, recommendations were arrived at for clinicians treating men with prostate cancer before and after definitive surgical management. RESULTS: Recommendations arrived at included: that clinicians should discuss prevalence rates, the pathophysiology of erectile dysfunction after RP and the predictors of erectile function recovery, that validated instruments should be used using the published cut-offs for normalcy, that rehabilitation be discussed with patients, and that they be informed that significant potential benefits may be associated with rehabilitation. CONCLUSIONS: The International Consensus of Sexual Medicine (ICSM) 2001 committee on rehabilitation after radical prostatectomy recommended that a discussion occur regarding rehabilitation in all patients undergoing or who have undergone RP. However, the committee recognized the absence of definitive data to date and could not comment on the optimal approach to rehabilitation at this time.

Protein biomarker analysis of primary Peyronie's disease cells.

INTRODUCTION: The molecular pathogenesis of Peyronie's Disease (PD) remains unclear more than 250 years after its initial description. Because of this, no test is currently available to accurately predict PD progression among those affected. AIM: To investigate the expression of wound healing and fibrosis-associated proteins in primary cell cultures of PD fibroblasts to determine whether altered protein expression patterns can be used as predictors of clinical course and natural history. METHODS: Primary cell cultures derived from normal Tunica albuginea tissue and PD plaque tissue were examined by immuno-cytochemistry. Protein expression profiles were analyzed by Surface-Enhanced Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (SELDI-TOF-MS) and Western immunoblotting. MAIN OUTCOME MEASURES: Expression of wound healing and fibrosis-associated proteins and protein expression patterns were assessed. RESULTS: Statistically significant increases in smooth muscle alpha-actin, beta-catenin, and Heat shock proteins (Hsp47) were identified in cells derived from PD relative to cells derived from normal Tunica albuginea tissue. Changes in TGFbeta-1 receptor and Fibronectin were also observed. In addition, altered expression of additional as yet unidentified proteins at 4.7, 8.9, 10.8, 16.8, and 76.8 kDa were detected by complementary SELDI-TOF-MS approaches. CONCLUSIONS: Primary cells derived from PD plaques display up-regulated expression of several proteins that are established components of fibrosis and wound healing. In addition, changes in other, as yet unidentified proteins were measured. It will be of interest to conduct further studies to see whether these dysregulated protein peaks represent potential biological markers of disease progression.

Oral phosphodiesterase-5 inhibitors and hormonal treatments for erectile dysfunction: a systematic review and meta-analysis.

BACKGROUND: Erectile dysfunction (ED) is a common male sexual disorder. The relative benefits and harms of pharmacologic therapies for ED, as well as the value of hormonal testing in men with ED, are uncertain. PURPOSE: To evaluate the efficacy and harms of oral phosphodiesterase-5 (PDE-5) inhibitors and hormonal treatments for ED and assess the effect of measuring serum hormone levels on treatment outcomes for ED. DATA SOURCES: English-language studies from MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, PsycINFO, AMED, and SCOPUS through April 2009. Trial reference lists also were scanned. STUDY SELECTION: Randomized, controlled trials (RCTs) of oral PDE-5 inhibitors and hormonal treatment for ED, and observational studies reporting measurement of serum hormone levels, prevalence of hormonal abnormalities, or both in men with ED. DATA EXTRACTION: Two independent reviewers abstracted data on study, participant, and treatment characteristics; efficacy and harms outcomes; and prevalence of hormonal abnormalities. DATA SYNTHESIS: Data, primarily from short-term trials (

Laparoscopic excision of urachal cysts in elderly men and woman following pregnancy.

BACKGROUND AND OBJECTIVE: Persistent urachus rarely presents in the aging male or during pregnancy. The authors report their experience with the laparoscopic excision of urachal cysts in two elderly men with significant co-morbidities and following pregnancy in a 32-year-old female. MATERIAL AND METHOD: The two male patients (65 and 70 years old, respectively) presented with a lower abdominal mass and umbilical discharge, while persistent urachus was identified incidentally during pregnancy; patients were managed with laparoscopic excision at 4 weeks, 6 weeks, and one year after diagnosis, respectively. Using 3 port accesses, the urachus and medial umbilical ligament were clipped and divided In 2 cases, specimens were separated from the bladder dome with a bladder cuff. In one patient, an additional port was required to facilitate intracorporeal freehand suturing of the bladder defect. RESULTS: All procedures were completed successfully via laparoscopy. No intraoperative or postoperative complications were reported Operative time ranged from 120, 180 and 160 minutes, respectively; in-hospital convalescence was 1, 7, and 6 days, respectively. Pathological evaluation revealed a benign urachal remnant in each case. CONCLUSION: Laparoscopic excision of urachal cysts in the aging male or following pregnancy is safe and effective.

T-shaped shunt and intracavernous tunneling for prolonged ischemic priapism.

PURPOSE: Conservative management of prolonged ischemic priapism is rarely effective. Interventions include corporal aspiration/irrigation, injection of vasoconstrictive agents or surgical procedures. We describe a technique that fulfills several important criteria in the surgical management of ischemic priapism in that immediate resolution of ischemic pain is achieved, a wide area, reliably patent shunt is created, the procedure is technically simple and it may be performed with the patient under a local anesthetic. MATERIALS AND METHODS: We reviewed the records of 13 patients treated with the T-shunt for whom followup, including erectile function, was available. RESULTS: Records were available for review for 13 men who underwent the T-shunt procedure from April 2006 to January 2008. In most cases priapism had lasted for more than 24 hours and previous irrigation/intracorporal administration of sympathomimetics had been unsuccessful. Of these 13 men 6 had undergone unsuccessful distal or proximal shunt procedures before presentation to our service. All procedures were performed using local anesthetic only. Cavernous blood flow was restored in all but 1 patient and another required a second procedure. T-shunts resulted in resolution of penile pain in all patients and all but 2 had recovery of erectile function. CONCLUSIONS: The T-shunt technique results in immediate resolution of ischemic penile pain and rigidity. Ultrasonography confirms that blood flow is usually restored to the previously ischemic corpora cavernosa after the procedure. The T-shaped shunt is simple and reliable, and access also allows for proximal trans-shunt dilation. We observed surprisingly excellent recovery of erectile function. This procedure may facilitate recanalization of corporal circulation and could make proximal shunts obsolete.

Potential of adipose-derived stem cells for treatment of erectile dysfunction.

INTRODUCTION: Adipose-derived stem cells (ADSCs) are a somatic stem cell population contained in fat tissue that possess the ability for self-renewal, differentiation into one or more phenotypes, and functional regeneration of damaged tissue, which may benefit the recovery of erectile function by using a stem cell-based therapy. AIM: To review available evidence concerning ADSCs availability, differentiation into functional cells, and the potential of these cells for the treatment of erectile dysfunction (ED). METHODS: We examined the current data (from 1964 to 2008) associated with the definition, characterization, differentiation, and application of ADSCs, as well as other kinds of stem cells for the cell-based therapies of ED. MAIN OUTCOME MEASURES: There is strong evidence supporting the concept that ADSCs may be a potential stem cell therapy source in treating ED. RESULTS: The ADSCs are paravascularly localized in the adipose tissue. Under specific induction medium conditions, these cells differentiated into neuron-like cells, smooth muscle cells, and endothelium in vitro. The insulin-like growth factor/insulin-like growth factor receptor (IGF/IGFR) pathway participates in neuronal differentiation while the fibroblast growth factor 2 (FGF2) pathway is involved in endothelium differentiation. In a preliminary in vivo experiment, the ADSCs functionally recovered the damaged erectile function. However, the underlying mechanism needs to be further examined. CONCLUSION: The ADSCs are a potential source for stem cell-based therapies, which imply the possibility of an effective clinical therapy for ED in the near future.

Nerve growth factor modulation of the cavernous nerve response to injury.

INTRODUCTION: Surgical therapies for prostate cancer and other pelvic malignancies often result in neuronal damage and debilitating loss of sexual function due to cavernous nerve (CN) trauma. Advances in the neurobiology of growth factors have heightened clinical interest in the development of protective and regenerative neuromodulatory strategies targeting CN recovery following injury. AIM: The aim of this review was to offer an examination of current and future nerve growth factor (NGF) modulation of the CN response to injury with a focus on brain-derived nerve growth factor (BDNF), growth differentiation factor-5 (GDF-5), and neurturin (NTN). METHODS: Information for this presentation was derived from a current literature search using the National Library of Medicine PubMed Services producing publications relevant to this topic. Search terms included neuroprotection, nerve regeneration, NGFs, neurotrophic factors, BDNF, GDF-5, NTN, and CNs. MAIN OUTCOME MEASURES: Basic science studies satisfying the search inclusion criteria were reviewed. RESULTS: In this session, BDNF, atypical growth factors GDF-5 and NTN, and their potential influence upon CN recovery after injury are reviewed, as are the molecular pathways by which their influence is exerted. CONCLUSIONS: Compromised CN function is a significant cause of erectile dysfunction development following prostatectomy and serves as the primary target for potential neuroprotective or regenerative strategies utilizing NGFs such as BDNF, GDF-5, and NTN, and/or targeted novel therapeutics modulating signaling pathways.