Minimally invasive techniques in quest of Holy Grail of surgical management of enlarged prostates: a narrative review.

PURPOSE: Past decade has seen a renewed interest in minimally invasive surgical techniques (MISTs) for management of enlarged prostate. This narrative review aims to explore newer MIST for benign prostatic hyperplasia (BPH) which are not yet integrated into established societal guidelines. METHODS: We conducted a literature search across PubMed, Google Scholar, and FDA ClinicalTrials.gov databases on June 1st, 2023, to identify studies published within the past decade exploring various MISTs for BPH. Additionally, we gathered insights from abstracts presented in meetings of professional associations and corporate websites. We broadly classified these procedures into three distinct categories: energy-based, balloon dilation, and implant/stent treatments. We collected detail information about the device, procedure details, its inclusion and exclusion criteria, and outcome. RESULTS: Our review reveals that newer energy-based MISTs include Transperineal Laser Ablation, Transurethral Ultrasound Ablation, and High-Intensity Focused Ultrasound. In the sphere of balloon dilation, Transurethral Columnar Balloon Dilation and the Optilume BPH Catheter System were gaining momentum. The noteworthy implants/stents that are on horizon include Butterfly Prostatic Retraction Device, Urocross Expander System, Zenflow Spring System, and ProVee Urethral Expander System. CONCLUSION: The exploration of various MISTs reflects ongoing efforts to enhance patient care and address limitations of existing treatments. This review provides a bird-eye view and valuable insights for urologists and researchers seeking to navigate the dynamic landscape of MISTs in the quest for effective and minimally invasive solutions for enlarged prostates.

Antegrade ejaculation preservation in surgical treatment for benign prostatic hyperplasia: quest for balance between voiding and sexual function.

PURPOSE OF REVIEW: Surgical treatment of benign prostatic hyperplasia (BPH) carries a significant risk of ejaculation dysfunction. Preservation of antegrade ejaculation while providing effective, well tolerated, and durable treatment of BPH is a paramount component of physical and sexual well being for significant number of men. We reviewed available literature with an aim of providing status on antegrade ejaculation preserving BPH surgical therapies. RECENT FINDINGS: Minimally invasive surgical therapies for BPH have been developed over the last decade, with significant marketing emphasis on their potential for preservation of antegrade ejaculation. However, the question about durability of relief of bladder outlet obstruction remains. Parallel to this technological development, the understanding of anatomical structures involved in ejaculation have resulted in technical modifications of well established surgical treatments modalities like transurethral resection of prostate, endoscopic enucleation of prostate and simple prostatectomy, thereby providing safe and durable relief of bladder outlet obstruction secondary to BPH with a satisfactory preservation of antegrade ejaculation. SUMMARY: Preservation of antegrade ejaculation is an important goal for significant number of men needing BPH surgery. Novel minimally invasive surgical technologies have been developed for this purpose; but understanding of the anatomical structures essential for antegrade ejaculation have allowed technical modification of existing surgical techniques with excellent preservation of antegrade ejaculation.

Trans-Fascial Placement of a High, Sub Muscular Reservoir in Patients Following Radical Cystectomy: Safety, Efficacy, and Predictability of Final Reservoir Location Verified With Abdominal Imaging.

INTRODUCTION: With the increasing utilization of ectopic reservoir placement during multicomponent penile implant surgery, safety concerns have been raised about whether passing the reservoir through the floor of the inguinal canal consistently results in placement of the reservoir within the correct location. AIM: To evaluate the safety, efficacy, and patient satisfaction associated with direct-vision, trans-fascial sub muscular reservoir placement in consecutive patients who had previously undergone radical cystectomy. METHODS: Perioperative data, complications, and follow up for the 12 cystectomy patients were evaluated using a comprehensive database of consecutive patients undergoing penile prosthesis placement at our center. Efficacy and patient satisfaction were based upon responses to the Erectile Function and Satisfaction Domains of the International Index of Erectile Function (IIEF). Taking advantage of the need for post cystectomy imaging in monitoring for cancer recurrence, we reviewed post- implant imaging with the purpose of ascertaining the final reservoir location. MAIN OUTCOME MEASURE: Using intraoperative photographs, we describe the technique of trans-fascial sub muscular reservoir placement. Perioperative complications, device efficacy and satisfaction, and the accuracy of reservoir placement are also evaluated. RESULTS: Average patient age was 65 ± 7 years old and the mean time between cystectomy and implant placement was 41 ± 29 months. With a mean follow up of 26 ± 21 months, complications included: 1 reservoir herniation and 1 high riding pump requiring repositioning. Mean IIEF-EF domain was 29.8 ± 0.5 and mean IIEF-satisfaction domain was 17.7 ± 4.5. Other than the herniated reservoir, imaging confirmed accurate reservoir placement in 8 of 9 cases. In 3 patients a small cephalad portion of the reservoir extends posteriorly into the peritoneal or preperitoneal space, with no clinical consequences. CLINICAL IMPLICATIONS: Ectopic reservoir placement using a trans-fascial submuscular approach seems to be a safe method for multicomponent penile implant surgery in patients who have undergone radical cystectomy. Post-implant imaging confirms that the device is consistently placed in the correct sub muscular location. STRENGTHS & LIMITATIONS: This is a novel approach to performing the procedure and a practical manner to ascertain the reservoir position. The limited number of patients prevents generalization of our findings. CONCLUSION: Trans-fascial, sub muscular reservoir placement is a safe means of ectopically placing the reservoir of a multicomponent penile implant following radical cystectomy. Post implant IIEF scores indicate high device efficacy and patient satisfaction. Post implant imaging confirms that the reservoir is almost always in the desired location. Kava BR, Lopatagui DM, Levine A, et al. Trans-Fascial Placement of a High, Sub Muscular Reservoir in Patients Following Radical Cystectomy: Safety, Efficacy, and Predictability of Final Reservoir Location Verified With Abdominal Imaging. J Sex Med 2019;16:338-345.

The Impact of Immediate Salvage Surgery on Corporeal Length Preservation in Patients Presenting with Penile Implant Infections.

PURPOSE: Removal of an infected penile implant often results in corporeal fibrosis, irreversible penile shortening and dissatisfaction with future implant surgery. Salvage surgery may avoid these problems but to our knowledge no study to date has evaluated these specific end points. We evaluated patients who presented to our center with an infected implant to determine the impact of salvage surgery on penile length. MATERIALS AND METHODS: We evaluated consecutive patients undergoing removal of an infected penile prosthesis with immediate salvage or delayed reimplantation using a comprehensive, prospective database. Total corporeal length prior to and following immediate salvage or delayed reimplantation were compared. The impact of patient age, comorbidities, bacterial species, initial penile length and time to reimplantation on subsequent total corporeal length was evaluated. RESULTS: The cohort consisted of 40 patients. Overall 81% of salvaged cases were successful, resulting in a mean 0.6 cm (95% CI 0.20 to 1.1) reduction in total corporeal length. Delayed reimplantation resulted in a mean 3.7 cm (95% CI 2.9-4.5) total corporeal length loss. In patients who underwent delayed reimplantation the total corporeal length reduction was directly proportionate to the initial penis size of the patient. No statistically significant impact on penile length was attributable to patient age, diabetes, bacterial species or time to reimplantation. CONCLUSIONS: When possible, salvage surgery should be offered to patients with an infected penile implant. Our data confirmed that successful salvage surgery preserves penile length. When a device is explanted and replaced at a later date, patients can expect to lose 15% to 30% of penile length irrespective of age, diabetes, type of infecting organism and time to reimplantation.

Changes in Management of Poorly Compliant Bladder in Botulinum Toxin A Era.

Bladder compliance is a measure of distensibility. Maladies such as myelodysplasia, myelomeningocele, spinal cord injury, multiple sclerosis and obstructive uropathy are known to decrease bladder compliance. Decrease in bladder compliance is a characteristic of neurogenic bladders. The pathophysiology of bladder compliance is complex but ultimately leads to high pressure during filling and storage phases. These high pressures lead to renal impairment, incontinence, and recurrent urinary tract infections. This review presents management of poorly compliant bladders with onabotulinumtoxinA.

Application of Natural Language Processing in Electronic Health Record Data Extraction for Navigating Prostate Cancer Care: A Narrative Review.

Introduction: Natural language processing (NLP)-based data extraction from electronic health records (EHRs) holds significant potential to simplify clinical management and aid research. This review aims to evaluate the current landscape of NLP-based data extraction in prostate cancer (PCa) management. Materials and Methods: We conducted a literature search of PubMed and Google Scholar databases using the keywords: "Natural Language Processing," "Prostate Cancer," "data extraction," and "EHR" with variations of each. No language or time limits were imposed. All results were collected in a standardized manner, including country of origin, sample size, algorithm, objective of outcome, and model performance. The precision, recall, and the F1 score of studies were collected as a metric of model performance. Results: Of the 14 studies included in the review, 2 articles focused on documenting digital rectal examinations, 1 on identifying and quantifying pain secondary to PCa, 8 on extracting staging/grading information from clinical reports, with an emphasis on TNM-classification, risk stratification, and identifying metastasis, 2 articles focused on patient-centered post-treatment outcomes such as incontinence, erectile, and bowel dysfunction, and 1 on loneliness/social isolation following PCa diagnosis. All models showed moderate to high data annotation/extraction accuracy compared with the gold standard method of manual data extraction by chart review. Despite their potential, NLPs face challenges in handling ambiguous, institution-specific language and context nuances, leading to occasional inaccuracies in clinical data interpretation. Conclusion: NLP-based data extraction has effectively extracted various outcomes from PCa patients' EHRs. It holds the potential for automating outcome monitoring and data collection, resulting in time and labor savings.

Variations in Opioid Use Following Robotic Radical Prostatectomy in South Florida.

Introduction: Opioid dependency has been a persistent issue in the United States over the past two decades. Increased efforts have been made to reduce opioid prescribing. Our objective was to quantify at-home opioid requirements following radical prostatectomy. Methods: Written questionnaires were administered to patients 1 week following robot-assisted laparoscopic radical prostatectomy (RALP). Patients provided data on opioid use, pain levels, and demographic characteristics. Results: Sixty-five patients were included. Median age (interquartile range [IQR]) was 69 (62-72) years. The majority were white (85%) and hispanic (67%). Prescriptions ranged from 6 to 15 pills of 5-mg oxycodone equivalents. Twenty-two percent (145/663) of the prescribed pills in the study were consumed. Fifty-four percent (35/65) of patients did not take opioids. Of the 30 patients who took opioids, median use (IQR) was 4.5 (3-6) pills. Forty-six percent (30/65) reported catheter-related pain. Patients who took opioids reported higher levels of pain. On generalized linear regression, younger age, lower levels of education, and living with a family member were factors associated with increased risk for opioid use (all p < 0.05). Conclusions: Despite the Florida Department of Health's restriction on narcotic prescriptions to 3-day supplies, opioids are still overprescribed in our region. The majority of patients do not require opioids after RALP, and patients who do require an opioid analgesic can be adequately managed with less than 6 pills of 5-mg oxycodone equivalents.

Melanotan Tanning Injection: A Rare Cause of Priapism.

Melanotan II, an injectable melanocortin analog, is illicitly available on the internet to generate a sunless tan through melanocyte induction. It is also used as a sexual stimulant in unlicensed performance enhancement clinics, and has been investigated as a possible treatment agent in erectile dysfunction. We describe in this case report a patient presenting with acute ischemic priapism after subcutaneous injection of melanotan II. The patient was initially managed with cavernosal aspiration and irrigation, and intracavernous injection of phenylephrine without achieving detumescence. After failing initial management, the patient underwent operative management with penoscrotal decompression, a promising alternative technique for the management of refractory ischemic priapism. Priapism after melanotan II injection has only been reported in the literature twice before. This case report highlights a rare presentation of acute ischemic priapism after melanotan II use, managed with surgical decompression. Future therapeutic applications of these agents and updated management guidelines should consider priapism as a possible side effect. CW. Mallory, DM Lopategui, BH. Cordon. Melanotan Tanning Injection: A Rare Cause of Priapism. Sex Med 2021;9:100298.

Totally robotic intracorporeal Monti-Yang continent ileovesicostomy in patient with previous robotic surgery-Technique description.

We present a video case report of a pediatric patient with previous robotic abdominal surgery who underwent robotic assisted Monti-Yang continent ileovesicostomy. This 10-year-old female had a history of spina bifida, with previous myelomeningocele repair and ventriculoperitoneal shunt as an infant and robotic-assisted Malone procedure and artificial urethral sphincter placed 4 years ago. After undergoing bilateral hip surgery, she presented with difficult urethral catheterization due to reduced leg mobility. A Monti-Yang ileovesicostomy procedure was planned. A 5 mm laparoscopic port placed through the umbilicus followed by four additional DaVinci XI working ports. Twenty centimeters proximal the ileocecal valve, a 3 cm segment of ileum was dissected, then transected, detubularized, and retubularized around a 10 Fr catheter. This conduit was reimplanted to the anterior bladder wall. The other edge was fixed to the umbilicus. A 10 Fr Foley catheter was left clamped in the conduit, and a urethral Foley was left to gravity. Total operative time was 3 h 56 min. The patient did well post-operatively. She was discharged home on POD 6. Starting three weeks after surgery, the patient began catheterizing through the umbilical stoma. At 3 month follow-up, the patient catheterizes through her stoma every 3 h without leakage between catheterizations.

Melanosis of the bladder: A rare diagnosis.

Melanosis of the bladder is characterized by dark, velvety bladder mucosa due to melanin deposition. Less than 25 cases have been reported. We present a 45-year-old male undergoing work up for obstructive and storage irritative lower urinary tract symptoms, found to have diffuse bladder melanosis on cystoscopy with bladder biopsy, and detrusor overactivity on urodynamic study. Although bladder melanosis has been found before in conjunction with storage voiding symptoms, this is the first report to our knowledge of an association with overactive bladder with urodynamic and histologic confirmation.

Whole Exome Sequencing Identifies a Rare Nonsense Mutation in FAM47C as a Possible Cause of Severe Oligospermia in Brothers With Varicocele.

Varicocele is a common cause of impaired semen parameters in men with infertility. Here, we investigated genetic variants as possible causes of varicocele with impaired semen parameters using whole exome sequencing in a family with 2 brothers with severe oligospermia, 1 unaffected brother, father, and the mother. Results showed a premature stop codon alteration on Chromosome X (37028866 CT) in the gene FAM47C. The affected brothers were found to be hemizygous for the variant, while the mother was a heterozygous carrier. In conclusion, identifying men with varicocele that would have impaired spermatogenesis, using approaches like whole-exome sequencing, can be paradigm shifting.

Whole-Exome Sequencing Identifies Novel Heterozygous Mutation in RAF1 in Family With Neonatal Testicular Torsion.

OBJECTIVE: To investigate a genetic cause of neonatal testicular torsion in 2 siblings and paternal cryptorchidism in a Caucasian family without history of consanguinity, we performed whole exome sequencing. PATIENTS AND METHODS: Targeted exon/whole-exome sequencing was performed in 2 siblings with testicular torsion. Potentially pathogenic variants passing filter criteria were validated with Sanger sequencing of parents to confirm familial segregation. Additionally, immunofluorescence staining for Raf-1, pERK (downstream from Raf-1) and c-Kit was performed on a testicular biopsy on the preserved testicle from the proband brother and compared with testicular biopsies from fertile men. RESULTS: A potentially pathogenic variant was identified in the RAF1 gene (serine/threonine-protein kinase) in exon 7 of chromosome 3: 12645786 G > C; both brothers and father were heterozygous for the variant, while the mother was negative for this mutation. This mutation in exon 7 (chr3:) of RAF1 is predicted to be damaging as a highly conserved splicing site is disrupted. The mutation is not found in the single nucleotide polymorphism database, the 1000 Genomes Project, ExACT, or esp6500. Immunofluorescence of the testis biopsy from one of the brothers demonstrated markedly decreased expression of Raf-1 as well as pERK but similar expression of c-kit when compared with fertile controls. CONCLUSION: We identified a novel nonsynonymous mutation in RAF1 in n Caucasian family with testicular torsion and cryptorchidism. We present the first human evidence that the RAF/MEK/ERK pathway is associated with testicular descent.

How long does it take a man to collect his semen specimen in a busy infertility clinic?

BACKGROUND: The duration of time required for male patients to collect their semen specimen heavily impacts the workflow of a busy infertility clinic. We analyzed this parameter to optimize the scheduling clinic space in the setting of growing male infertility practices. METHODS: Prospective observational study on men collecting semen specimens for fertility evaluation, sperm cryopreservation or vasectomy at a male infertility clinic. Duration of time required for semen collection by masturbation was measured. RESULTS: Patients were 136 men with a mean age ± standard deviation of 35.7±7.8 years (range, 18.8 to 62.5 years). Indications for semen collection were: evaluation for male factor infertility in 125 cases (92%), of which 12 (9%) underwent sperm cryopreservation; post-vasectomy evaluation in 7 cases (5%); and post vasoepididymostomy in 4 cases (3%). The median collection time was 11 minutes 57 seconds ± IQR 9 minutes 8 seconds to 17 minutes 5 seconds; and ranging from 3 minutes 9 seconds to 39 minutes 50 seconds. Patients accompanied by their female partner in the collection room were significantly more likely to take longer than 15 minutes compared to unaccompanied patients (P=0.012). Age and indication for semen collection were not associated with duration. CONCLUSIONS: Median collection time in our sample was 11 minutes 57 seconds, with significant variability across the sample. Patients accompanied by their female partners required significantly longer time to collect their sample, while age does not seem to have an impact.

Effect of a formal oncofertility program on fertility preservation rates-first year experience.

BACKGROUND: A formal fertility preservation program was initiated at our institution in 2016 as part of a multi-disciplinary oncofertility initiative to improve the reproductive needs of oncologic patients. After 1 year of initial experience, we assessed sperm banking rates in men diagnosed with cancer, as well as examined the trends in the use of fertility preservation services. METHODS: We performed a chart review from 2011 to 2017 for men newly diagnosed with cancer, and for all men who underwent fertility preservation during that period of time at our institution. We assessed the rates of sperm banking among patients newly diagnosed with cancer, before and after the implementation of a standardized oncofertility program in 2016. The program includes nursing and physician education regarding indications of fertility preservation. Additionally, we evaluated the overall population undergoing sperm cryopreservation at our institution during the study period. RESULTS: From 2011 to 2016, 30 of 902 oncologic patients underwent sperm banking prior to their treatment (3.3% of total cancer patients). After the program was implemented, 42 of 218 patients underwent fertility preservation between June 2016 and August 2017 (19.3% of total cancer patients). In this group, patients' mean age was 30.14 years old (range, 13-69 years old), with 6 pediatric patients; 36 of the samples (85.7%) were obtained from masturbation. When viable sperm could not be obtained from ejaculation, patients underwent either testicular or epididymal sperm extraction (6 cases). Overall, 98 men used the formal fertility preservation service. Of these, 42 were cancer patients and 56 were non-cancer patients. Of the non-cancer patients, 17 banked sperm after varicocelectomy, 6 prior to vasectomy and 6 because of hypogonadism. CONCLUSIONS: Rate of sperm banking increased nearly six-fold after institution of a formal fertility preservation program, indicating the clinical need for such a program at academic institutions. Oncofertility is a relevant part of the care for oncologic patients, and should be considered as part of counseling before cancer treatment.

Lymph node yield as a predictor of overall survival following inguinal lymphadenectomy for penile cancer.

OBJECTIVE: To determine whether a specific lymph node yield (LNY) affects overall survival (OS) in patients with penile cancer. MATERIALS AND METHODS: Using the National Cancer Database, we identified 364 men diagnosed with pSCC who underwent ILND between 2004 and 2013. Men diagnosed on autopsy or at the time of death, patients with preoperative chemotherapy or radiotherapy, M+ and N3 disease, or with less than 3-month of follow-up were excluded. Kaplan-Meier analysis was used to compare Overall Survival (OS). A multivariable Cox regression model was developed to assess predictors of OS. RESULTS: The median number of LN retrieved was 16 (IQR: 9-23). There was no significant difference in race, stage, grade for men with LNY ≤15 vs. >15. However, men with LNY ≤15 were significantly older than those with LNY >15 (65 vs. 59 years, p<0.001). On multivariable analysis, radical surgery, age, N+ disease, and LNY ≤15 were independent predictors of worse OS. Patients with LNY ≤15 showed significantly worse 5-year OS versus those with LNY >15 (49% vs. 67%, p=0.008). Nodal density (ND) ≥12.5% was also associated with decreased 5-year OS versus ND <12.5% (31% vs. 70%, p<0.0001). CONCLUSIONS: LNY following ILND for pSCC appears to be an independent predictor of OS. A total LNY of >15 following ILND may have a beneficial impact on OS and serve as the threshold for defining an adequate ILND.