Diagnostic performance of photodynamic diagnosis with oral 5-aminolevulinic acid for upper tract- and bladder urothelial carcinoma: a single-centre, retrospective analysis.

PURPOSE: To compare the diagnostic performance of photodynamic diagnosis (PDD) enhanced with oral 5-aminolaevulinic acid between the suspected upper tract urothelial carcinoma (UTUC) and bladder urothelial carcinoma (BUC) cases. METHODS: This retrospective study included 18 patients with suspected UTUC who underwent ureteroscopy (URS) with oral 5-ALA in the PDD-URS cohort between June 2018 and January 2019; and 110 patients with suspected BUC who underwent transurethral resection of bladder tumour (TURBT) in the PDD-TURBT cohort between January 2019 and March 2023. Sixty-three and 708 biopsy samples were collected during diagnostic URS and TURBT, respectively. The diagnostic accuracy of white light (WL) and PDD in the two cohorts was evaluated, and false PDD-positive samples were pathologically re-evaluated. RESULTS: The area under the receiver operating characteristic curve (AUC) of PDD was significantly superior to that of WL in both cohorts. The per biopsy sensitivity, specificity, and positive and negative predictive values of PDD in patients in the PDD-URS and PDD-TURBT cohorts were 91.2 vs. 71.4, 75.9 vs. 75.3, 81.6 vs. 66.3, and 88.0 vs. 79.4%, respectively. The PDD-URS cohort exhibited a higher AUC than did the PDD-TURBT cohort (0.84 vs. 0.73). Seven of four false PDD-positive samples (57.1%) in the PDD-URS cohort showed potential precancerous findings compared with eight of 101 (7.9%) in the PDD-TURBT cohort. CONCLUSION: The diagnostic performance of PDD in the PDD-URS cohort was at least equivalent to that in the PDD-TURBT cohort.

Comparison of Cabozantinib and Axitinib as Second-line Therapy After Nivolumab Plus Ipilimumab in Patients With Metastatic Clear Cell Renal Cell Carcinoma: A Comparative Analysis of Retrospective Real-world Data.

BACKGROUND: To date, no studies have compared the treatment outcomes of second-line therapies in patients with metastatic clear cell renal cell carcinoma (ccRCC). This study retrospectively evaluated the efficacy of cabozantinib and axitinib as second-line treatments in patients with metastatic ccRCC who previously received immune-oncology combination therapy. PATIENTS AND METHODS: Patients with metastatic ccRCC treated with cabozantinib and axitinib as second-line therapy after nivolumab-ipilimumab treatment were identified among 243 patients with RCC treated between August 1, 2018 and January 31, 2022 at 34 institutions belonging to the Japanese Urological Oncology Group. Patients were assessed for treatment outcomes, including progression-free survival (PFS), overall survival, objective response rate (ORR), and incidence rate of treatment-related adverse events (AEs). RESULTS: Forty-eight patients treated with cabozantinib and 60 treated with axitinib as second-line therapy after nivolumab-ipilimumab treatment for metastatic ccRCC were identified. The median PFS (95% confidence interval) was 11.0 months (9.0-16.0) with cabozantinib and 9.5 months (6.0-13.0) with axitinib. The ORRs were 37.5% (cabozantinib) and 38.3% (axitinib). The rates of any-grade AEs and grade ≥3 AEs were 79.2% (cabozantinib) versus 63.3% (axitinib; P = .091) and 35.4% (cabozantinib) versus 23.3% (axitinib; P = .202), respectively. In the poor-risk group, PFS was longer in the cabozantinib group than in the axitinib group (P = .033). CONCLUSION: The efficacy and safety of cabozantinib and axitinib were comparable. In the poor-risk group, cabozantinib was more effective than axitinib. These findings provide valuable insights into the selection of second-line treatment options after nivolumab-ipilimumab treatment in patients with metastatic ccRCC.

Controversy and Consensus on Indications for Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations.

PURPOSE: Sperm DNA fragmentation (SDF) testing was recently added to the sixth edition of the World Health Organization laboratory manual for the examination and processing of human semen. Many conditions and risk factors have been associated with elevated SDF; therefore, it is important to identify the population of infertile men who might benefit from this test. The purpose of this study was to investigate global practices related to indications for SDF testing, compare the relevant professional society guideline recommendations, and provide expert recommendations. MATERIALS AND METHODS: Clinicians managing male infertility were invited to take part in a global online survey on SDF clinical practices. This was conducted following the CHERRIES checklist criteria. The responses were compared to professional society guideline recommendations related to SDF and the appropriate available evidence. Expert recommendations on indications for SDF testing were then formulated, and the Delphi method was used to reach consensus. RESULTS: The survey was completed by 436 experts from 55 countries. Almost 75% of respondents test for SDF in all or some men with unexplained or idiopathic infertility, 39% order it routinely in the work-up of recurrent pregnancy loss (RPL), and 62.2% investigate SDF in smokers. While 47% of reproductive urologists test SDF to support the decision for varicocele repair surgery when conventional semen parameters are normal, significantly fewer general urologists (23%; p=0.008) do the same. Nearly 70% would assess SDF before assisted reproductive technologies (ART), either always or for certain conditions. Recurrent ART failure is a common indication for SDF testing. Very few society recommendations were found regarding SDF testing. CONCLUSIONS: This article presents the largest global survey on the indications for SDF testing in infertile men, and demonstrates diverse practices. Furthermore, it highlights the paucity of professional society guideline recommendations. Expert recommendations are proposed to help guide clinicians.

Evaluation of sexual function after dutasteride treatment in patients with once-negative prostate biopsy and benign prostate hyperplasia.

INTRODUCTION: Patients with benign prostatic hyperplasia are usually treated with 5α-reduced inhibitors (5ARIs) such as finasteride and dutasteride. However, studies on the influence of 5ARIs on sexual function have been controversial. In this study, we evaluated the impact of dutasteride treatment for erectile function in patients with once-negative prostate biopsy and benign prostate hyperplasia. PATIENTS AND METHODS: 81 patients with benign prostate hyperplasia were enrolled in a one-armed prospective study. They were administrated 0.5 mg/day of dutasteride for 12 months. Patient characteristics and changes of International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF)-15 scores at baseline and 12 months after dutasteride administration were examined. RESULTS: The mean ± standard deviation (SD) age of the patients was 69.4 ± 4.9 years and the prostate volume was 56.6 ± 21.3 mL, respectively. The mean ± SD prostate volume and PSA levels were decreased 25.0 and 50.9%, respectively, after 12 months of dutasteride administration. IPSS total, voiding subscore, storage subscore, and quality of life score significantly improved after 12 months of dutasteride administration. No statistically significant change in IIEF-total score from 16.3 ± 13.5 to 18.8 ± 16.0 (p = 0.14), IIEF-EF score from 5.1 ± 6.9 to 6.4 ± 8.3 (p = 0.13) were observed. There was no decrease in erectile function severity. CONCLUSION: Twelve months administration of dutasteride for patients with BPH improved urinary function and did not increase the risk of sexual dysfunction.

Predictors of Curvature Improvement in Men With Peyronie's Disease Treated With Intralesional Collagenase Clostridium Histolyticum.

INTRODUCTION: Penile curvature is the most common abnormality that is observed by men with Peyronie's disease (PD). Collagenase Clostridium histolyticum (CCH) has become a standard treatment for PD patients. AIM: To identify predictor factors associated with improvements of penile curvature outcomes in men with PD treated with CCH. METHODS: We retrospectively collected the data of patients with PD treated with CCH up to 8 injections divided into 4 cycles between January 2014 and July 2020. Per protocol, penile curvature was assessed at baseline, and after the second and ford CCH cycle. If after cycle 2, curvature demonstrated no improvement, or penile curvature was significantly improved and the patient was happy, no further treatment was recommended. However, if penile curvature was significantly improved and the patient remained dissatisfied, 4 cycles were completed. Three categories of response were evaluated: improvement (≥10 degrees or ≥20%, either 1 happens), unchanged (±10 degrees or ±20%) or worsened (≥10 degrees or ≥20%, either 1 happens). Logistic regression analyses were performed to evaluate predictive factors associated with penile curvature improvements. OUTCOMES: Degrees of the curvature changes between the baseline and after the cycles of CCH. RESULTS: A total of 114 patients underwent CCH treatment. Median age was 57 years. Median PD duration was 11 months. At baseline, mean curvature was 47 degrees, 65% had dorsal curvature, 53% mid-shaft location, and 15% calcification. After CCH treatment, the mean final curvature was 40 degrees. A total of 44% improved the curvature, 39% had no change while 17% worsened after CCH treatment. Of men who had penile curvature improvement with CCH treatment, the mean curvature decreasing in degrees and percentage were 22 degrees and 41%, respectively. Men with baseline curvature ≤ 30, 31-59, and ≥ 60 degrees, the percentage curvature improvement were 29%, 43%, and 60%, respectively. Baseline curvature was the only significant predictor of penile curvature improvement after CCH (OR 1.33, 95% CI = 1.1, 1.7). CLINICAL IMPLICATIONS: We confirmed baseline penile curvature is the most important predictive factor, and this is the first report describing proportions of penile curvature improvement with CCH treatment. STRENGTHS AND LIMITATIONS: This study has several strengths, including the use of validated instruments. Nonetheless, there are limitations: the retrospective nature of the study, a single institution; and modelling device was not controlled. CONCLUSION: Penile curvature improvement was significantly more common in patients with greater baseline curvature, reaching up to 60% for patients with ≥ 60 degrees. Flores JM, Nascimento B, Punjani N, et al. Predictors of Curvature Improvement in Men With Peyronie's Disease Treated With Intralesional Collagenase Clostridium Histolyticum. J Sex Med 2022;19:1680-1686.

PBRM1 Immunohistochemical Expression Profile Correlates with Histomorphological Features and Endothelial Expression of Tumor Vasculature for Clear Cell Renal Cell Carcinoma.

Loss of the polybromo-1 (PBRM1) protein has been expected as a possible biomarker for clear cell renal cell carcinoma (ccRCC). There is little knowledge about how PBRM1 immunohistochemical expression correlates with the histomorphological features of ccRCC and the endothelial expression of tumor vasculature. The present study evaluates the association of architectural patterns with the PBRM1 expression of cancer cells using a cohort of 425 patients with nonmetastatic ccRCC. Furthermore, we separately assessed the PBRM1 expression of the endothelial cells and evaluated the correlation between the expression of cancer cells and endothelial cells. PBRM1 loss in cancer cells was observed in 148 (34.8%) patients. In the correlation analysis between architectural patterns and PBRM1 expression, macrocyst/microcystic, tubular/acinar, and compact/small nested were positively correlated with PBRM1 expression, whereas alveolar/large nested, thick trabecular/insular, papillary/pseudopapillary, solid sheets, and sarcomatoid/rhabdoid were negatively correlated with PBRM1 expression. PBRM1 expression in vascular endothelial cells correlated with the expression of cancer cells (correlation coefficient = 0.834, p < 0.001). PBRM1 loss in both cancer and endothelial cells was associated with a lower recurrence-free survival rate (p < 0.001). Our PBRM1 expression profile indicated that PBRM1 expression in both cancer and endothelial cells may be regulated in an orchestrated manner.

[A Case of Retroperitoneal Bronchogenic Cyst Diagnosed by Fluorescence in situ Hybridization].

A 50-year-old woman was referred to our hospital for consultation for a suspected left adrenal tumor detected by ultrasonography during a health check. Computed tomography and magnetic resonance imaging revealed a 4.7×3.4 cm tumor in the retroperitoneal space near the adrenal gland. The patient subsequently underwent laparoscopic tumor resection. Using fluorescence in situ hybridization (FISH), the resected tumor was diagnosed as a retroperitoneal bronchial cyst. Here we present a case of a definitive diagnosis of a retroperitoneal bronchial cyst using FISH, and review the cases of retroperitoneal bronchial cyst in the literature.

Tumor volume and tumor crossing of the axial renal midline predict renal function after robotic partial nephrectomy.

There are several nephrometry scoring systems for predicting surgical complexity and potential perioperative morbidity. The R.E.N.A.L. scoring system, one of the most well-known nephrometry scoring systems, emphasizes the features on which it is based (Radius, Exophytic/endophytic, Nearness to collecting system or sinus, Anterior/posterior, and Location relative to polar lines). The ability of these nephrometry scoring systems to predict loss of renal function after robotic partial nephrectomy (RPN) remains controversial. Therefore, we verified which combination of factors from nephrometry scoring systems, including tumor volume, was the most significant predictor of postoperative renal function. Patients who underwent RPN for cT1 renal tumors in our hospital were reviewed retrospectively (n = 163). The preoperative clinical data (estimated glomerular filtration rate [eGFR], comorbidities, and nephrometry scoring systems including R.E.N.A.L.) and perioperative outcomes were evaluated. We also calculated the tumor volume using the equation applied to an ellipsoid by three-dimensional computed tomography. The primary outcome was reduced eGFR, which was defined as an eGFR reduction of ≥ 20% from baseline to 6 months after RPN. Multivariable logistic regression analyses were used to evaluate the relationships between preoperative variables and reduced eGFR. Of 163 patients, 24 (14.7%) had reduced eGFR. Multivariable analyses indicated that tumor volume (cutoff value ≥ 14.11 cm3, indicating a sphere with a diameter ≥ approximately 3 cm) and tumor crossing of the axial renal midline were independent factors associated with a reduced eGFR (odds ratio [OR] 4.57; 95% confidence interval [CI] 1.69-12.30; P = 0.003 and OR 3.50; 95% CI 1.30-9.46; P = 0.034, respectively). Our classification system using these two factors showed a higher area under the receiver operating characteristic curve (AUC) than previous nephrometry scoring systems (AUC = 0.786 vs. 0.653-0.719), and it may provide preoperative information for counseling patients about renal function after RPN.

Integration of NRP1, RGS5, and FOXM1 expression, and tumour necrosis, as a postoperative prognostic classifier based on molecular subtypes of clear cell renal cell carcinoma.

Molecular mechanisms of progression of clear cell renal cell carcinoma (ccRCC) have been proven with recent genomic or transcriptional analyses. However, it is still difficult to apply these analyses to daily clinical practice owing to economical and practical issues. Here, we established a pathology-based, postoperative prognostic classification based on the well-validated transcriptional classifier, ClearCode34, in ccRCC. A total of 342 cases with available tissue were identified and randomly allocated into a discovery cohort (n = 138) and a validation cohort (n = 204). Levels of mRNA were quantified using a nCounter Digital Analyzer, and the ccA/ccB subtypes were determined. Histological and immunohistochemistry (IHC) analyses were subsequently performed to establish a pathology-based classification based on the mRNA levels. Finally, the prognostic ability of the new classifier was evaluated in both the discovery and validation cohorts. Of 138 cases in the discovery cohort, 78 (56.5%) and 60 (43.5%) were assigned to the ccA and ccB subtypes, respectively. Proangiogenic genes, neuropilin 1 (NRP1) and regulator of G protein signalling 5 (RGS5), were especially overexpressed in all ccRCC samples and were enriched in ccA-assigned tumours. Histologically, tumour necrosis and the sarcomatoid feature were associated with the ccB subtype. In IHC analyses, expression of NRP1, RGS5, and forkhead box M1 (FOXM1), an epithelial-mesenchymal transition-related factor, significantly correlated with the ccA/ccB subtypes. Combining these three IHC factors and tumour necrosis, we developed the IHC/histology-based classifier, which showed good concordance with the ClearCode34 classifier with an accuracy of 0.80. The established classification significantly stratified relapse-free, cancer-specific, and overall survival rates in both the discovery and validation cohorts. The novel molecular pathology classifier integrating NRP1, RGS5, FOXM1, and tumour necrosis may enable the stratification of oncological outcomes for patients with ccRCC undergoing resection surgery.

Predictors of Pursuing Intralesional Xiaflex in Peyronie's Disease Patients.

BACKGROUND: Intralesional collagenase such as Xiaflex (ILX) has become a standard treatment for Peyronie's disease (PD). Many robust studies have demonstrated its clear efficacy in the treatment algorithm. AIM: To examine predictors of the patient decision to pursue ILX in PD patients. METHODS: The study included PD patients (i) with stable disease (ii) who had doppler duplex ultrasonography (DUS) at least 6 months prior to analysis date and (iii) did not choose an operation. All patients received a standard discussion regarding treatment options, specifically, observation, ILX and penile reconstructive surgery (plication, plaque incision and grafting, implant surgery). Patients who opted to use ILX were compared to those who opted against it. Comorbidity, demographic and PD characteristics were recorded at the initial PD visit. All patients completed three validated questionnaires including the PD questionnaire (PDQ), Self-Esteem and Relationship (SEAR) questionnaire and a depression questionnaire (CES-D). Logistic regression was used to determine predictors of ILX use. OUTCOMES: Predictors of ILX utilization. RESULTS: Four hundred and fifty stable PD men had DUS completed 6 months before to allow sufficient time for treatment decision. Of these, 111 (24.7%) patients had ILX treatment and 339 (75.3%) did not. Mean age, relationship status and pain occurrence were similar between groups, but ILX patients had less bother defined as PDQ ≥ 9 (46.8% vs 53.7%, P = .02). ILX patients had more complex curves (79.3% vs 47.8%, P < .01) and more severe instability (32.4% vs 15.3%, P = .01). ILX patients also had higher PDQ domain scores (Psychological 11.5 ± 6.4 vs 7.5 ± 6.2, P < .01; Pain 6.2 ± 6.0 vs 4.3 ± 5.6, P = .02; and Bother 9.8 ± 4.7 vs 6.6 ± 4.8, P < .01). On univariable statistics, significant bother (OR 2.41, 95% CI 1.36-4.28, P<0.01), complex curvature (OR 4.18, 95%CI 2.52-6.93, P < .01), moderate and/or severe instability (OR 1.98, 95%CI 1.18-3.30, P < .01) and PDQ-Bother scores (OR 1.15, 95%CI 1.08-1.22 P < .01) predicted ILX use. On multivariable analysis, instability (OR 2.58, 95%CI 1.02-6.57, P = .05) and significant bother (OR 1.23, 95%CI 1.04-1.45, P = .01) predicted ILX use. CLINICAL IMPLICATIONS: Educates providers as to which patients are more likely to choose ILX. STRENGTHS & LIMITATIONS: Our study has a large sample size and all patients received the same standardized treatment discussion. Our study is limited by the absence of insurance data on all patients, and its retrospective single center design. CONCLUSION: ILX was chosen by the minority of stable PD patients. While moderate to severe instability and significant bother is predictive of ILX use, other demographic factors including relationship status, sexual orientation or pain were not. Punjani N, Nascimento B, Salter C, et al. Predictors of Pursuing Intralesional Xiaflex in Peyronie's Disease Patients. J Sex Med 2021;18:1258-1264.

Predictors of Depression in Men With Peyronie's Disease Seeking Evaluation.

BACKGROUND: Peyronie's disease (PD) has negative impacts on the psychosocial status of men including depression warranting clinical evaluation in up to 50% of men. AIM: To examine predictors of depression in patients with early PD seeking evaluation. METHODS: All PD patients at a high-volume PD practice underwent screening and curvature assessment after intracavernosal injection. Complex deformity was defined as any degree of multiplanar curvature, curvature >60 degrees, or presence of hourglass deformity. Men completed the PD questionnaire (PDQ), a validated depression questionnaire (CES-D) as well as the Self-Esteem and Relationship (SEAR) questionnaire. Scores of ≥16 on CES-D were considered indicative of moderate/severe depression. Predictors of the presence of depression were defined using univariable and multivariable logistic regression. OUTCOMES: Demographic, bother and curve related predictors of depression in men with PD. RESULTS: 408 men completed all questionnaires. Mean age was similar between depressed and nondepressed groups (57 ± 10 years overall, P = .60 between groups). Proportions of erectile dysfunction were similar between groups (P = .96). Mean PD duration was similar between groups (19 ± 35 months overall, P = .46 between groups). Mean degree of curvature was 38 ± 2 degrees in the depressed vs 33 ± 1 degrees in the nondepressed groups (P = .03). A complex deformity was seen in 64.5% in the depressed vs 61.5% in the nondepressed (P = .56). A total of 110 (27%) patients had CESD scores ≥16. 74% depressed men were in relationships compared to 84% nondepressed men (P < .01). Other characteristics including bother, pain, duration of disease, curve complexity and instability were similar between the two groups. On univariable analysis, factors protective against depression included being partnered (OR 0.42, 95%CI 0.24-0.75, P < .01) and higher total SEAR scores (OR 0.95, 95%CI 0.94-0.97, P < .01). Elevated PDQ domain scores were associated with depression (Psychologic Symptoms 1.05, 95%CI 1.02-1.10, P < .01; Pain 1.08, 95%CI 1.03-1.12, P < .01; Bother 1.11, 95% CI 1.05-1.68, P < .01) as well as baseline history of depression (OR 2.93, 95%CI 1.67-5.14, P < .001). On multivariable analysis, only total SEAR score remained protective against depression (OR 0.96, 95%CI 0.94-0.97, P < .001). CLINICAL IMPLICATIONS: Providers must recognize that men with PD seeking evaluation have meaningful rates of depression for which early recognition is necessary. STRENGTHS AND LIMITATIONS: Retrospective review of a large prospectively collected dataset from a single center of men with PD utilizing a validated screening tool for depression. CONCLUSION: While no significant demographic, bother or curve related factors predicted depression in early PD men seeking evaluation, it remains a significant problem warranting further prospective evaluation. P. Nahid, N. Bruno, S. Carolyn, et al. Predictors of Depression in Men With Peyronie's Disease Seeking Evaluation. J Sex Med 2021;18:783-788.

Defining the impact of Peyronie's disease on the psychosocial status of gay men.

BACKGROUND: Little sexual health research has been conducted in gay men. Anecdotally, this population seems to experience more bother related to Peyronie's disease (PD). OBJECTIVES: To examine the impact of PD on psychosocial factors in gay vs straight men. MATERIALS AND METHODS: All PD patients who were seen in the sexual medicine clinic were included. They completed three instruments: the PD questionnaire (PDQ), Self-Esteem and Relationship (SEAR) questionnaire, and a depression questionnaire (CES-D). We described demographics and sexual variables by sexual orientation. We then compared PDQ items and summary scores by sexual orientation, using a series of independent samples t tests. RESULTS: 34 consecutive gay and 464 straight men were included. Age and baseline characteristics were similar between the two cohorts, with the exception that fewer gay men were partnered (56% vs 87%, P < .01), and those with a partner had a shorter relationship duration: 109 ± 9 months vs 262 ± 175 months, P < .01. For the SEAR questionnaire, gay men demonstrated a more significant psychosocial impact of PD overall with lower SEAR sums (41 vs 57, P = .01) and a lower sexual relationship subdomain score (28 vs 47, P < .01). 41% of gay men vs 26% of straight men had CES-D scores consistent with depression as defined by a score of ≥16 (P = .09). In the PDQ domains, gay men scored less favorably with regard to bother scores (7 vs 5, P = .03) and pain scores (8 vs 4, P = .04). DISCUSSION: Gay men with PD experience significantly more psychosocial impact as evidenced by less favorable SEAR sum and sexual relationship scores, CES-D scores, and PDQ pain and bother domain scores. CONCLUSION: The psychosocial impact of PD is significant in all men, but it appears to be greater in gay men.

Robot-assisted laparoscopic vesicule prostatectomy for mixed epithelial-stromal tumor of seminal vesicle.

INTRODUCTION: Mixed epithelial-stromal tumor is a biphasic tumor with stromal and benign epithelial components. Only 40 cases of mixed epithelial-stromal tumor originating from a seminal vesicle have previously been published in English. CASE PRESENTATION: A 52-year-old man was transferred to our hospital for evaluation of a 3.0-cm pelvic tumor detected incidentally by computed tomography. Robot-assisted laparoscopic vesicle prostatectomy was performed. We approached the Retzius space from both levels of the pouch of Douglas and peritoneal top of the bladder to clarify the tumor's environment. Pathologically, the tumor was diagnosed as a low-grade mixed epithelial-stromal tumor originating from the right seminal vesicle. There was no evidence of disease recurrence within 51 months. CONCLUSION: This is the first report of robot-assisted laparoscopic vesicle prostatectomy for a seminal vesicle mixed epithelial-stromal tumor. Long-term observation is warranted due to the lack of reports with sufficient follow-up to ensure the procedure's safety.

Evaluating the Impact of Penile Girth Discrepancy on Patient Bother in Men With Peyronie's Disease: An Observational Study.

BACKGROUND: Men with Peyronie's disease (PD) may experience penile narrowing. Little data on penile girth changes and their psychosocial impact exist. AIM: To assess girth discrepancy in men with PD and its association with patient bother. METHODS: This was a retrospective observational study. All patients with PD at our institution who were seen in the sexual medicine clinic and who completed 3 validated instruments the PD questionnaire (PDQ), Self-Esteem and Relationship (SEAR) questionnaire, and a depression questionnaire, the Center for Epidemiologic Studies Depression Scale (CES-D), and a curvature assessment were included. Patient and PD characteristics are described. Associations of instability and bother to girth differences are assessed. 2 outcomes for girth differences are classified as (i) girth difference of ≥ 1 cm vs less and (ii) girth differences of ≥10% vs less. Unadjusted and adjusted effects of PD and patient characteristics are assessed on the outcome of high bother using logistic regression models. OUTCOMES: The main outcomes of this study were penile girth changes, instability, and questionnaire scores. High bother was defined as a PDQ bother score of ≥9. RESULTS: A total of131 men had midshaft curvature and were the focus of the study. Their mean age was 59 ± 9 (range 31-78) years. PD duration was 16 ± 25 (range 1-180) months, with a mean degree of primary curvature of 37 ± 20o. Mean girth difference between base and point of maximum curvature was 0.78 ± 0.53 cm equating to a mean girth difference at point of maximum curvature of 6 ± 4%. Instability was present in 53% of men. There were 54 men with a girth difference of ≥ 1 cm and 23 men with a ≥10% change in girth. There was no difference in CES-D, SEAR, or PDQ domain scores or high bother in men with significant girth changes. Univariable analysis of predictors of high bother included the degree of curvature (odds ratio [OR]: 1.06; P < .001), instability (OR 6.62; P < .001), CES-D sum (OR 1.09; P = .002), and SEAR score (OR 0.96; P = .001). On multivariate analysis, only the degree of primary curvature was predictive of high bother (OR 1.06; P < .001). CLINICAL IMPLICATIONS: Penile girth changes have little impact on overall psychosocial well-being. The degree of penile curvature is the primary predictor of patient bother. STRENGTHS AND LIMITATIONS: Strengths include a large patient population and use of validated questionnaires. Limitations include single-center, retrospective study and subjective instability grading. CONCLUSIONS: Penile girth discrepancy in men with PD has limited psychosocial impact. Clinically significant bother was associated with the degree of primary curvature. Salter CA, Nascimento B, Terrier, JE, et al. Evaluating the Impact of Penile Girth Discrepancy on Patient Bother in Men With Peyronie's Disease: An Observational Study. J Sex Med 2020;17:1560-1565.

Adherent Perinephric Fat Is a Surgical Risk Factor in Laparoscopic Single-Site Donor Nephrectomy: Analysis Using Mayo Adhesive Probability Score.

BACKGROUND: The host-related risk factors for surgical difficulty of partial nephrectomy include the presence of thick and adherent adipose tissue surrounding the kidney (adherent perinephric fat [APF]). The kidney and perirenal fat must be isolated in donor nephrectomy. Thus, APF is an important surgery-related factor. We analyzed whether the Mayo adhesive probability (MAP) score is related to APF and surgical outcomes in laparoscopic single-site donor nephrectomy (LESS-DN). METHODS: Forty-six donors who underwent LESS-DN were selected. Determination of APF was based on a retrospective review of video-recorded surgical procedures during anterior perinephric fat dissection. The MAP score was evaluated from computed tomography images. Data regarding patient characteristics and operative outcomes were collected. We then examined the MAP score, APF, and related factors. RESULTS: Eleven patients (23.9%) had APF. The patients were divided into 2 groups (MAP score of 0 points and ≥ 1 point). The 2 groups showed significant differences in sex, age, body mass index, history of hypertension, and history of dyslipidemia. The operation time was significantly longer and the estimated blood loss volume was higher in patients with a MAP score of ≥ 1. Eight of 9 patients with a MAP score of ≥ 1 had APF. The only significant differences between patients with and without APF were in the body mass index, history of hypertension, and history of dyslipidemia. The operation time was significantly longer and the estimated blood loss volume was larger in patients with APF. CONCLUSIONS: The MAP score could be useful when predicting surgical difficulty in patients undergoing LESS-DN.

Intraoperative Intracavernosal Liposomal Bupivacaine (Exparel) Injection Does Not Affect Systemic Hemodynamics.

INTRODUCTION: The systemic effect of intracavernosal liposomal bupivacaine (Exparel) injection during inflatable penile prosthesis (IPP) implantation on systemic hemodynamics has not been clarified. AIM: To evaluate whether intraoperative intracavernosal Exparel injection affects systemic hemodynamics. METHODS: We studied 56 consecutive patients who underwent IPP implantation under general anesthesia using the transverse scrotal approach. Exparel [10 mL of 1.3% (13.3 mg/mL)] was instilled bilaterally intracavernosally via a 25-gauge needle around 30 min after starting the surgery. All patients graded their postoperative pain using a standard 10-point scale. MAIN OUTCOME MEASURE: Perioperative vital signs at defined time intervals and postoperative pain were monitored. The degree of postoperative pain were analyzed using a standard 10-point scale. RESULTS: Medians and interquartile ranges (IQRs) of the patients' age [64 years (57.3-69.3)], operation time [85 min (78-96)], and estimated blood loss [75 mL (29-100)] were recorded. Although the median preoperative systolic noninvasively measured blood pressure of 131 mm/Hg (IQR: 122-139) fell by 25% to 98 mm/Hg (IQR: 90-100) (P < .001) after anesthesia started, there was no significant decrease in blood pressure between before and after Exparel injection. The perioperative pulse rate and pulse oximetry oxygen saturation were stable. Neither arrhythmia nor convulsion occurred. Patients reported postoperative pain as 0 (IQR: 0-2.25) on a scale of 0-10. CLINICAL IMPLICATIONS: Intraoperative intracavernosal Exparel injection is safe and effective in patients undergoing IPP implantation surgery. STRENGTH & LIMITATIONS: This is the first report to describe systemic hemodynamics of intracavernosal Exparel injection. Limitations are lack of blood concentration of Exparel at various time points and long-term follow-up for pain assessment. CONCLUSION: Although limited by a lack of the blood concentration of Exparel and short follow-up for pain assessment, we concluded that intraoperative intracavernosal Exparel injection does not affect systemic hemodynamics. Taniguchi H, Mulhall JP. Intraoperative Intracavernosal Liposomal Bupivacaine (Exparel) Injection Does Not Affect Systemic Hemodynamics. J Sex Med 2020;17:526-530.

Laparoendoscopic Single-Site Surgery for Urachal Remnants: A Single-Center Experience.

INTRODUCTION: Urachal remnants are relatively rare. Generally, urachal remnants are detected in young people, and the removed specimen is small, comprising a good indication for laparoscopic surgery. Laparoendoscopic single-site surgery (LESS) for urachal remnants is considered to be safe and result in an excellent cosmetic outcome. Therefore, we report our single-center experience with LESS for urachal remnants. METHODS: We retrospectively reviewed 30 patients with urachal remnants who underwent LESS from January 2011 to December 2017. The patients' characteristics, surgical data, postoperative pain, and cosmetic assessment results were retrospectively collected and analyzed. RESULTS: Mean total operative time was 151 min, mean pneumoperitoneal surgery time was 83 min, and mean estimated blood loss was 5.0 mL. All patients were started on an oral diet and began ambulating on postoperative day 1. Mean hospital stay was 5.5 days. LESS was completed successfully in all patients, with no conversion to conventional or open surgery. CONCLUSIONS: LESS is a viable option for the surgical treatment of urachal remnants. This technique may result in less pain than conventional techniques. Further accumulation of surgical outcomes (especially regarding safety and cosmesis) is required for LESS to become an established treatment for urachal remnants.

Testosterone Profiles After Brachytherapy for Localized Prostate Cancer.

OBJECTIVE: To evaluate patients' serum total testosterone levels (STLs) after brachytherapy (BT) for prostate cancer. METHODS: We enrolled 102 men who underwent permanent interstitial BT using I125 without androgen deprivation therapy for localized prostate cancer. Seed BT radiation dose was 145 Gy. Patients were followed for 24-60 months after BT. The primary outcome was STL kinetics after BT. Predictors of testosterone decrease were also analyzed. RESULTS: Median preimplantation STL was 4.18 ng/mL. STL decreased significantly to a median nadir of 89.4% of baseline (3.72 ng/mL) occurring at 6 months, and then recovered to baseline at 18 months after BT. The group of patients whose STLs fell below 3.00 ng/mL (biochemical hypogonadism) after BT started with lower baseline STLs (median: 3.54 ng/mL) than patients whose STLs did not fall below 3.00 ng/mL (median: 4.90 ng/mL). The group of patients whose STLs decreased by more than 1.00 ng/mL over the study period had significantly higher median baseline STLs (median: 5.05 ng/mL) than the group whose STLs decreased by less than 1.00 ng/mL (median: 3.64 ng/mL). CONCLUSION: Although STL decreased significantly after I125-based BT, STL decline after treatment for localized prostate cancer was not large and recovered over time.

The narrow vesicourethral angle measured on postoperative cystography can predict urinary incontinence after robot-assisted laparoscopic radical prostatectomy.

OBJECTIVE: Radical prostatectomy is associated with complications including urinary incontinence. A significant association between specific features of the vesicourethral anastomosis and urinary incontinence after radical prostatectomy has been demonstrated. The aim of this study was to identify the most useful predictor of postoperative urinary incontinence after robot-assisted laparoscopic radical prostatectomy (RALP) according to the features of the vesicourethral anastomosis as determined by postoperative cystography. MATERIALS AND METHODS: The final study cohort consisted of 150 patients. Postoperative cystography was performed within 1 week after RALP. The ratio between the longitudinal and horizontal lengths (L/H) of the bladder, the position of the urethrovesical junction (UVJ) and the bladder neck angle as seen on the cystogram were evaluated. Postoperative continence status was evaluated by a 1 h pad test 1 day after catheter removal and by the use of safety pads, retrieved retrospectively from patient records. The association between these variables and urinary incontinence was then analyzed. All patients were followed for at least 1 year postoperatively. RESULTS: The continence rates on the 1 h pad test and 1 month and 1 year after RALP were 31.3%, 56% and 93.3%, respectively. In multivariate analyses, urinary incontinence was significantly associated with nerve sparing, L/H and the vesical angle as determined on the 1 h pad test, but only with the vesical angle at 1 month and 1 year postoperatively. CONCLUSION: A narrow vesical angle measured on cystography is a useful predictor of postoperative urinary incontinence after RALP.

Laparoendoscopic single-site surgery for treatment of urachal remnants.

INTRODUCTION: To evaluate safety and excellent cosmetic outcome with laparoendoscopic single-site surgery (LESS). In this study, we compared the usefulness and efficacy of LESS versus conventional laparoscopic surgery for the treatment of urachal remnants. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 20 consecutive patients who underwent either conventional laparoscopic surgery or LESS from January 2007 to February 2015 at Kansai Medical University Hospital. Ten patients underwent surgery using the standard laparoscopic 3-port technique, and 10 patients underwent LESS. The patients included 12 males and 8 females (mean age, 24.5 years; range, 10-68 years). The patients' characteristics, surgical data, and postoperative pain assessment results were retrospectively collected and analyzed. RESULTS: The median operative time, pneumoperitoneal surgery time, and estimated blood loss did not differ between the LESS and conventional laparoscopic groups. However, the total incision length was longer in the conventional laparoscopic group than in the LESS group. The degree of pain at 2 to 5 days postoperatively according to the Wong-Baker FACES Pain Rating Scale was lower in the LESS group than in the conventional laparoscopic group (p < 0.05). CONCLUSIONS: Less is a possible option in the surgical treatment for urachal remnants. In this very small cohort, there is no conversion to traditional laparoscopic surgery or open surgery. This technique is possibly feasible and may achieve less pain. Accumulation of surgical outcomes especially in safety and cosmesis is required to be an established method.