Experience With Extra-Tunical Grafting and Tunica Albuginea Plication for Correction of Indentation Deformity in Men With Peyronie's Disease.

OBJECTIVE: To further evaluate extra-tunical grafting (ETG), a relatively new surgical option to treat corporal indentation in those with Peyronie's disease without buckling or hinge effect, we report our experience, patient satisfaction, and surgical outcomes. METHODS: Retrospective review of patients following ETG, including pre-operative deformity, type of graft, graft location (under or over Buck fascia), patient characteristics, and satisfaction. Overall cosmetic satisfaction with deformity correction between patients undergoing 2 different ETG locations and 3 different types of grafts, as well as perceived bother of graft visibility and palpability were assessed. RESULTS: From 2018-2023, 35 patients underwent ETG and tunica albuginea plication (TAP) with 89.6% of patients having persistent correction on office examination at a median (interquartile range) follow-up of 23.5 (15.2) months. Overall satisfaction with penile appearance by grafting location via patient-reported questionnaires showed no statistical difference (P = .47). Patients undergoing TAP and ETG were satisfied with their erect appearance regardless of graft material. Patients reported grafting tissue was palpable (74.3%) and visible (48.6%) in the flaccid state as compared to the erect state (8.6% and 5.7%). CONCLUSION: ETG presents a less invasive surgical option than traditional approaches to correct indentation deformities not associated with instability. Our experience shows high patient satisfaction rate following correction of indentation using graft tissue when placed under or over Buck fascia. At a median follow-up of almost 2 years, patients had persistent correction, and while some report visibility of the graft and palpability in the flaccid state, this tends to disappear in the erect state.

Circumcision and Sexual Medicine.

INTRODUCTION: Male circumcision is one of the most frequently performed and debated urological procedures due to its possible implications for sexual health. OBJECTIVES: The objective of this article is to review the literature on male circumcision and reconcile the scientific evidence to improve the quality of care, patient education, and clinician decision-making regarding the effects on sexual function of this procedure. METHODS: A review of the published literature regarding male circumcision was performed on PubMed. The criteria for selecting resources prioritized systematic reviews and cohort studies pertinent to sexual dysfunction, with a preference for recent publications. RESULTS: Despite the conflicting data reported in articles, the weight of the scientific evidence suggests there is not sufficient data to establish a direct association between male circumcision and sexual dysfunction. CONCLUSION: This review provides clinicians with an updated summary of the best available evidence on male circumcision and sexual dysfunction for evidenced-based quality of care and patient education.

Genital Mutilation in Males.

PURPOSE OF THE REVIEW: Genital mutilation in males can range from minor injuries (cuts from a blade) to severe urological emergencies (testicular or penile amputation). Due to the rarity of these events, there is a lack of extensive reports, as most of the available literature is regarding single cases. Genital mutilation has been associated with psychotic and non-psychotic causes, psychiatric conditions, drug consumption, sexual practices, or even cultural or religious beliefs. It is crucial to perform a psychiatric evaluation of these patients to obtain the best therapeutic approach. This manuscript serves as a review of the currently available knowledge regarding male genital mutilation. RECENT FINDINGS: A great variety of reasons have been associated with genital mutilation. Previous authors have distinguished between those that present with a clear mental health precursor from cases with no psychotic background. Nevertheless, sometimes, it is difficult to make this distinction. Recently, reconstructive techniques for amputation cases have moved towards a microsurgical approach in order to improve outcomes. A holistic therapeutic approach must be performed to increase the chances of effective treatment. Close collaboration between urologists, psychiatrists, and emergency doctors is essential to ensure the best care for patients performing genital mutilation. Future publications must evaluate differences in treatment options and the impact that these have on the long-term well-being of patients undergoing genital self-mutilation.

Penile Implant Instrument Innovations.

PURPOSE OF REVIEW: Numerous innovations have been made since the first inflatable penile prosthesis was introduced in 1973-not just of the implant apparatus itself, but crucially also in the surgical instruments used for prosthetic surgery. Starting with Dr. Furlow's revolutionary inserter tool, advancements were quickly made in dilators, retractors, and cavernotomes. RECENT FINDINGS: More recent innovations have been made in inserter tools, forceps, needle holders, clamps, and disposable instruments. Leading companies Boston Scientific and Coloplast have contributed significantly to the evolution of IPP surgical placement, and companies such as Uramix and Rigicon are developing a wide array of new specialized tools. We aim to summarize the instruments needed for IPP placement, with a focus on describing the variety of instrument innovations since Dr. Brantley Scott designed and placed the first IPP.

Extended Reality-Assisted Surgery as a Surgical Training Tool: Pilot Study Presenting First HoloLens-Assisted Complex Penile Revision Surgery.

BACKGROUND: Extended reality-assisted urologic surgery (XRAS) is a novel technology that superimposes a computer-generated image on the physician's field to integrate common elements of the surgical process in more advanced detail. An extended reality (XR) interface is generated using optical head-mounted display (OHMD) devices. AIM: To present the first case of HoloLens-assisted complex penile revision surgery. METHODS: We describe our pilot study of HoloLens-assisted penile revision surgery and present a thorough review of the literature regarding XRAS technology and innovative OHMD devices. OUTCOMES: The ability of XRAS technology to superimpose a computer-generated image of the patient and integrate common elements of the surgical planning process with long-distance experts. RESULTS: XRAS is a feasible technology for application in complex penile surgical planning processes. CLINICAL TRANSLATION: XRAS and OHMD devices are novel technologies applicable to urological surgical training and planning. STRENGTHS AND LIMITATIONS: Evidence suggests that the potential use of OHMD devices is safe and beneficial for surgeons. We intend to pioneer HoloLens technology in the surgical planning process of a malfunctioning penile implant due to herniation of the cylinder. This novel technology has not been used in prosthetic surgery, and current data about XRAS are limited. CONCLUSION: OHMD devices are effective in the operative setting. Herein, we successfully demonstrated the integration of Microsoft HoloLens 2 into a penile surgical planning process for the first time. Further development and studies for this technology are necessary to better characterize the XRAS as a training and surgical planning tool. Quesada-Olarte J, Carrion RE, Fernandez-Crespo R, et al. Extended Reality-Assisted Surgery as a Surgical Training Tool: Pilot Study Presenting First HoloLens-Assisted Complex Penile Revision Surgery. J Sex Med 2022;19:1580-1586.

Active surveillance in renal tumors: Clinical and oncological outcomes.

CONTEXT: Some patients diagnosed with small renal solid masses or complex cystic lesions may benefit from active surveillance (AS) instead of immediate treatment. AIMS: Report our series of patients undergoing AS for small renal solid and complex cystic lesions, and compare growth rates and outcomes between both types of lesions. MATERIALS AND METHODS: A retrospective review AS database for renal lesions was conducted. From 1995 to 2017, a total of 82 patients with 89 renal lesions were included. We describe our AS protocol, patient and tumor characteristics, comparisons between solid and cystic lesions, and final outcome of patients who underwent delayed intervention (DI). STATISTICAL ANALYSIS USED: Categorical and continuous data were analyzed by the Chi-square and the Student's t-test, respectively. The Wilcoxon/Kruskal-Wallis test was used for growth rate comparisons of solid and complex cystic lesions. RESULTS: Median age of patients at the beginning of AS was 77-year-old, median size for solid and cystic lesions was 2.3 cm (0.08-3.8) and 2.6 cm (1.2-4.0), respectively. No differences in annual growth rate between solid and complex cystic lesions (0.04 cm [0.00-1.5] and 0.05 cm [0.01-1.7]) were observed at a similar median follow-up of 61 months for both groups (range: 15-182, and 14-254). Five patients with solid lesions underwent DI, 3 for rapid growth (>0.5 cm/year), 1 demanded treatment, and 1 due to hematuria. Adherence to AS protocol was high (94%). No cancer-related deaths or metastatic progression was observed, six patients died of another medical condition, being cardiovascular disease the most frequent cause. CONCLUSIONS: AS is a reasonable and safe option for the management of small renal masses. No difference was observed in the growth rate between solid and complex cystic lesions during AS. Centers offering AS should present a standardized protocol and give exhaustive information to patients regarding benefits and risks.

Immunotherapy toxicity. Diagnosis and treatment.

Anti CTLA-4, anti PD-L1 and anti PD-1immune check point inhibitors (ICI) down regulate natural inhibitory pathways of the immune system, in turn increasing tumour surveillance and elimination. Cancer treatment through immune regulation has revolutionised many cancer therapies. However, these new treatments have also brought unique immune related adverse events (irAEs). OBJECTIVE: This paper presents a review of the available knowledge regarding irAE grading, incidence, diagnosis and management, serving as a clinical aid forall clinicians involved with ICI therapy. EVIDENCE ACQUISITION: A comprehensive English-language literature research of original and review articles in the Medline database until June 2020 has been carried out, using the MeSH terms: "immune checkpoint inhibitor toxicities" and "immune related adverseevent". CONCLUSIONS: Further research should aim to investigate if the greater effect of combining ICI treatments issufficient to justify the increased risk of complications, as well as to identify specific subgroups that will benefit the most from these.

Los fármacos anti CTLA-4, anti PD-L1 y antiPD-1 inhiben vías inhibidoras del sistema inmunitario, consiguiendo una vigilancia y eliminación de células tumorales aumentada. El uso de terapias de regulación inmune ha revolucionado el manejo de muchos cánceres. Sin embargo, estos tratamientos también han traído una nueva serie de eventos adversos relacionados conel sistema inmune.OBJETIVO: Este artículo presenta una revisión de los conocimientos disponibles sobre la clasificación, incidencia, diagnóstico y mantenimiento de los efectos adversos relacionados con el sistema inmune, de manera que pueda servir como una ayuda clínica para todos los médicos involucrados en las terapias inmunes.ADQUISICIÓN DE EVIDENCIA: Realizamos una búsqueda bibliográfica exhaustiva de la literatura en inglés sobre artículos originales y de revisión utilizando la base de datos Medline hasta junio de 2020, utilizando los términos MeSH: "toxicidades del inhibidor del punto de control inmunitario" y "evento adverso relacionado con el sistema inmunitario". CONCLUSIONES: En el futuro se debe investigar si el mayor riesgo de complicaciones ocasionado por las terapias inmunomoduladores de combinación está justificado por su mayor efecto terapéutico, debiéndose igualmente identificar subgrupos de pacientes que más pueden beneficiar.

Organ-sparing cystectomy techniques: Functional and oncological outcomes, review and current recommendations.

INTRODUCTION: With increasing survival from bladder cancer, quality of life, should be one of the main goals following radical cystectomy and bilateral pelvic lymph node dissection (PLND). This techniqueis associated with significant morbidity, which may have a critical effect on quality of life. Concerns about functional outcomes, such as continence, potency, and sexual function in women, play a role in decision making for urologists and younger patients with muscle-invasive bladder cancer. Several modifications to the classic radical cystectomy technique, include preservation of genital or pelvic organs, developing in the improvement of postoperative continence, potency rates and sexual functionin female patients. OBJECTIVE: This review summarizes the organ-sparing cystectomy techniques and its functional and oncological outcomes. EVIDENCE ACQUISITION: A PubMed-based literature search was conducted up to April 2020. We selected the most recent and relevant original articles, metanalysis and reviews that have provided relevant information to guide organ-sparing cystectomy techniques and its functional and oncological outcomes. EVIDENCE SYNTHESIS: In this review, we discuss selection criteria for male and female patients, organ-sparing cystectomy surgical techniques and its functional and oncological outcomes. CONCLUSIONS: Radical cystectomy is associated with significant morbidity, which may have a critical effect on quality of life. Preservation of genital or pelvic organsin men and women, yield better sexual outcomes compared to radical cystectomy without compromising oncological outcomes in well selected patients. But no one of these techniques can be recommended over the classical standard radical cystectomy. Large-scale of prospective and multi-institutional studies are needed to conclude which patients are suitable for these techniques.

INTRODUCCIÓN: Con el aumento de la supervivencia del cáncer de vejiga, la calidad de vida debe ser uno de los objetivos principales después de la cistectomía radical y linfadenectomía pélvica (LNP). Esta técnica está asociada con una morbilidad significativa, que puede tener un efecto crítico en la calidad de vida. El interés sobre los resultados funcionales, como la continencia, la potencia y la función sexual en las mujeres, juegan un papel en la toma de decisiones para los urólogos y pacientes jóvenes con cáncer vesical musculo infiltrante. Varias modificaciones a la técnica clásica de cistectomía radical incluyen la preservación de los órganos genitales o pélvicos, desarrollando mejoría de la continencia postoperatoria, la potencia y función sexual femenina.OBJETIVO: Esta revisión resume las técnicas de cistectomía con preservación de órganos y sus resultados funcionales y oncológicos.ADQUISICIÓN DE EVIDENCIA: Se realizó una búsqueda bibliográfica en PubMed hasta Abril 2020. Seleccionamos los artículos originales retrospectivos y prospectivos, revisiones sistemáticas, revisiones bibliográficas más recientes y relevantes que han proporcionado información de técnicas de cistectomía con conservación de órganos y sus resultados funcionales y oncológicos.SÍNTESIS DE EVIDENCIA: En esta revisión, discutimos los criterios de selección de pacientes masculinos y femeninos, las técnicas quirúrgicas de cistectomía con preservación de órganos y sus resultados funcionales y oncológicos.CONCLUSIONES: La cistectomía radical se asocia con una morbilidad significativa, que puede tener un efecto crítico en la calidad de vida. La preservación de los órganos genitales o pélvicos en hombres y mujeres produce mejores resultados sexuales en comparación con la cistectomía radical sin comprometer los resultados oncológicos en pacientes bien seleccionados. Pero ninguna de estas técnicas se puede recomendar sobre la cistectomía radical estándar clásica. Se necesitan estudios prospectivos y multiinstitucionales a gran escala para concluir qué pacientes son adecuados para estas técnicas.

Radical penectomy, a compromise for life: results from the PECAD study.

BACKGROUND: The use of organ sparing strategies to treat penile cancer (PC) is currently supported by evidence that has indicated the safety, efficacy and benefit of this surgery. However, radical penectomy still represents up to 15-20% of primary tumor treatments in PC patients. The aim of the study was to evaluate efficacy in terms of overall survival (OS) and disease-free survival (DFS) of radical penectomy in PC patients. METHODS: Data from a retrospective multicenter study (PEnile Cancer ADherence study, PECAD Study) on PC patients treated at 13 European and American urological centers (Hospital "Sant'Andrea", Sapienza University, Roma, Italy; "G.D'Annunzio" University, Chieti and ASL 2 Abruzzo, Hospital "S. Pio da Pietrelcina", Vasto, Italy; Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA; Hospital of Budapest, Hungary; Department of Emergency and Organ Transplantation, Urology and Andrology Unit II, University of Bari, Italy; Hospital "Spedali Civili", Brescia, Italy; Istituto Europeo di Oncologia, University of Milan, Milan, Italy; University of Modena & Reggio Emilia, Modena, Italy; Hospital Universitario La Paz, Madrid, Spain; Ceara Cancer Institute, Fortaleza, Brazil; Virginia Commonwealth University, Richmond, VA, USA; Aristotle University of Thessaloniki, Thessaloniki, Greece; Maria Sklodowska-Curie Memorial Cancer Center, Warsaw, Poland) between 2010 and 2016 were used. Medical records of patients who specifically underwent radical penectomy were reviewed to identify main clinical and pathological variables. Kaplan-Meier method was used to estimate 1- and 5-year OS and DFS. RESULTS: Of the entire cohort of 425 patients, 72 patients (16.9%) treated with radical penectomy were extracted and were considered for the analysis. The median age was 64.5 (IQR, 57.5-73.2) years. Of all, 41 (56.9%) patients had pT3/pT4 and 31 (43.1%) pT1/pT2. Moreover, 36 (50.0%) were classified as pN1-3 and 5 (6.9%) M1. Furthermore, 61 (84.7%) had a high grade (G2-G3) with 6 (8.3%) positive surgical margins. The 1- and 5-year OS rates were respectively 73.3% and 59.9%, while the 1- and 5-year DFS rates were respectively 67.3% and 35.1%. CONCLUSIONS: PC is an aggressive cancer particularly in more advanced stage. Overall, more than a third of patients do not survive at 5 years and more than 60% report a disease recurrence, despite the use of a radical treatment.

Ureteral injury during abdominal and pelvic surgery: immediate versus deferred repair.

INTRODUCTION: The incidence of ureteral damage during abdominal surgery is <1%. Repair of these lesions can be performed immediately when the injury is detected or deferred when it has been missed. MATERIAL AND METHODS: We retrospectively reviewed ureteral injuries that required surgical repair and were made during gynaecological and general surgery procedures between the years 2004 and 2016. We compared the clinical and functional outcomes between immediate and deferred repair. RESULTS: We registered 84 lesions after 4000 abdominal procedures (2.1%). A total of 20 injuries were noted during general surgery interventions (24%) and 64 during gynaecological procedures (76%). The approach was laparoscopic in 66 of these cases and open in the other 18. Mean time of follow-up was 24 months. Immediate repair was accomplished in 35 cases (41%) and deferred in 49 (59%), with a median time to repair of 5.7 months. The laparoscopic approach was more frequent in deferred repairs (76% vs. 16%), while the open approach was more common in immediate repairs (54% vs. 40%). Procedures used for ureteral repair included 62 ureteral reimplantations using a psoas hitch technique, 8 end-to-end ureteral anastomoses, 6 ureterorraphies and 6 ureteral catheterisations. Two nephrectomies were also performed. Success rates and complications were similar for both immediate and deferred procedures (68% vs. 73% and 26% vs. 23% respectively, both p >0.05). CONCLUSIONS: The occurrence of ureteral injury during abdominal surgery is low. Immediate repair is preferred when feasible, but delayed recognition of the injury is more common. We found no difference between immediate and deferred repair in terms of success rates.

High-risk prostate cancer. Optimal treatment. New evidences.

There are multiple definitions of high risk prostate cancer and each definition is associated with a different prognosis. Men classified as having high-risk disease warrant treatment because durable outcomes can be achieved. Radical prostatectomy, radiation therapy and androgen deprivation therapy play pivotal roles in the management of men with high-risk disease, and potentially in men with metastatic disease.

Hay múltiples definiciones del cáncer de próstata de alto riesgo y cada definición se asocia con un pronóstico diferente. En varones con cáncer de próstata clasificado cómo enfermedad de alto riesgo se justifica el tratamiento porque se pueden conseguir resultados duraderos. La prostatectomía radical, la  radioterapia y el tratamiento de deprivación androgénica juegan un papel fundamental en el manejo de los pacientes con enfermedad de alto riesgo, y potencialmente en varones con enfermedad metastásica.

SENP1, but not fetal hemoglobin, differentiates Andean highlanders with chronic mountain sickness from healthy individuals among Andean highlanders.

Chronic mountain sickness (CMS) results from chronic hypoxia. It is unclear why certain highlanders develop CMS. We hypothesized that modest increases in fetal hemoglobin (HbF) are associated with lower CMS severity. In this cross-sectional study, we found that HbF levels were normal (median = 0.4%) in all 153 adult Andean natives in Cerro de Pasco, Peru. Compared with healthy adults, the borderline elevated hemoglobin group frequently had symptoms (headaches, tinnitus, cyanosis, dilatation of veins) of CMS. Although the mean hemoglobin level differed between the healthy (17.1 g/dL) and CMS (22.3 g/dL) groups, mean plasma erythropoietin (EPO) levels were similar (healthy, 17.7 mIU/mL; CMS, 12.02 mIU/mL). Sanger sequencing determined that single-nucleotide polymorphisms in endothelial PAS domain 1 (EPAS1) and egl nine homolog 1 (EGLN1), associated with lower hemoglobin in Tibetans, were not identified in Andeans. Sanger sequencing of sentrin-specific protease 1 (SENP1) and acidic nuclear phosphoprotein 32 family, member D (ANP32D), in healthy and CMS individuals revealed that non-G/G genotypes were associated with higher CMS scores. No JAK2 V617F mutation was detected in CMS individuals. Thus, HbF and other classic erythropoietic parameters did not differ between healthy and CMS individuals. However, the non-G/G genotypes of SENP1 appeared to differentiate individuals with CMS from healthy Andean highlanders.

Giant insulinoma: a report of 3 cases and review of the literature.

Insulinoma is a rare pancreatic neuroendocrine tumor that is usually described as benign, sporadic, and very small (<2 cm). However, there have been rare case reports of insulinoma presenting as a giant tumor. We describe 3 cases of giant insulinomas, all of which developed liver metastases. The patients were aged 38, 63, and 67 years. Clinically, all patients presented with Whipple's triad associated with a large mass located in the pancreatic tail. The tumors ranged in size from 10 to 15 cm. On microscopic examination, the tumors were well differentiated with amyloid deposition ranging between 20% and 30%. Immunohistochemically, all 3 tumors showed strong diffuse expression of chromogranin and synaptophysin, whereas they were only focally positive for insulin. One patient developed liver recurrence 3 years after resection of the primary tumor yet remained asymptomatic without treatment. Another patient with liver recurrence underwent right hepatectomy and has been free of disease for 2 years. The third patient died of metastatic disease 13 years after initial surgery. Giant insulinomas are characterized by focal expression of insulin and high rates of liver metastases. Long-term follow-up is mandatory in these patients, as recurrence is expected after primary surgery.