Artificial Urinary Sphincters for Moderate Post-Prostatectomy Incontinence: Current Research and Proposed Approach.

Male urinary incontinence is a common complication after radical prostatectomy. The severity of incontinence can be assessed in various ways and helps determine the best surgical intervention to restore continence. While most patients with mild incontinence receive a sling and those with severe incontinence receive an artificial urinary sphincter (AUS), there are no clear guidelines on how to manage patients with moderate post-prostatectomy incontinence (PPI). Our discussion will focus on the current literature, which demonstrates that an AUS should be considered first-line in men with moderate PPI despite perceived concerns over complications and reintervention rates.

Current Perspectives on Complications of Surgical Treatments for Male Stress Urinary Incontinence.

INTRODUCTION: Treatments for male stress urinary incontinence (SUI) include behavioral modifications, pelvic floor strengthening exercises, bulking agents, and surgical management. The most common surgical therapies for male stress incontinence include male slings and artificial urinary sphincters. Complications of these treatments are discussed in this review. AIM: To review the current literature on SUI diagnosis and the management of common complications that occur after surgical treatments of male SUI. METHODS: A literature search was performed using PubMed and Ovid to identify leading articles on the management of male SUI and the diagnosis and management of operative complications for male incontinence surgery. MAIN OUTCOME MEASURE: Main outcomes measured were complications and management strategies for operative complications after surgical therapies for male SUI. RESULTS: 26 publications were cited after an extensive review of the current literature on surgical treatment of male SUI. Commonly cited issues included infection, erosion, and recurrent incontinence after implantation of male slings and artificial urinary sphincters. CONCLUSION: Complications are inherent to any surgery; a thorough understanding of complications and treatment strategies after surgery for male SUI is essential for the practicing clinical urologist. Shelton TM, Brimley S, Tsambarlis P, Hellstrom WJG. Current Perspectives on Complications of Surgical Treatments for Male Stress Urinary Incontinence. Sex Med Rev 2020;8:443-449.

Complex penile prosthesis reservoir extraction: a case series.

Explantation of an inflatable penile prosthesis (IPP) reservoir in the setting of acute infection can be challenging. We identified three such cases of infection and simultaneous extraction of multiple reservoirs among patients with the most recent prosthetic surgeries performed between March 2016 and November 2018. These cases were reviewed with particular emphasis on preoperative and operative management. All three patients underwent successful simultaneous explantation of all retained hardware with subsequent clinical improvement in their clinical status. Prior to surgery, none of the patients were aware of the presence of more than one reservoir. All three patients recovered well post operatively. A subset of prosthetics patients have undergone multiple implant procedures at various sites. Due to the importance of retrieving all foreign material in the setting of acute infection, the authors advocate for a low threshold to obtain cross-sectional imaging to identify the tissue plane and laterality of any retained components, with particular emphasis on creating an operative plan for reservoir retrieval.

The Penile Sensitivity Ratio: A Novel Application of Biothesiometry to Assess Changes in Penile Sensitivity.

INTRODUCTION: Biothesiometry allows for evaluation of penile vibratory sensitivity and can be used as a non-invasive and rapid surrogate test of penile sexual sensitivity. However, no standardized measurement methodology currently exists. AIM: To describe and optimize a novel, standardized biothesiometry parameter-the penile sensitivity ratio (PSR). METHODS: We reviewed all biothesiometry data from men presenting to our institution from July 2013-May 2017. 3 iterations of the PSR were evaluated using the threshold for vibratory detection from a combination of different input variables including the penile glans, penile shaft, index finger, and thigh. Numerator values for the PSR included the penile glans and penile shaft, whereas denominator inputs included the index finger and thigh. PSR is inversely correlated with penile sensitivity. MAIN OUTCOME MEASURE: The primary outcome measure was the association between reported diminished penile sensitivity and PSR value. Secondary outcome measures were the association between PSR and age, diabetes, ejaculatory dysfunction, and Peyronie's disease (PD). RESULTS: Biothesiometry data were evaluated from 1,239 men. Mean age was 53.2 years (SD 14.0 years). Diabetes was present in 7.4% (n = 92); 52.0% (n = 644) had PD. Ejaculatory dysfunction was identified in 15.8% (n = 196), with 12.2% (n = 151) having premature ejaculation and 3.6% (n = 45) reporting delayed ejaculation. Decreased penile sensitivity was reported in 20.3% (n = 252). 3 PSR iterations were analyzed to identify associations with decreased penile sensation. On univariate and multivariate analysis controlling for age, diabetes, ejaculatory dysfunction, and PD, only the PSR iteration, which included data from the penile glans and finger (PSRG/F), was significantly different between patients reporting diminished penile sensitivity and those without reported diminished sensitivity (univariate P < .01, multivariate P = .03). On univariate analysis, a higher PSRG/F was associated with older age (P < .01) and diabetes (P < .01), whereas men with PD had a lower PSRG/F (P < .01). On multivariate analysis, PSRG/F remained increased for age (P < .01) and decreased for PD (P = .01); however, there was no association with diabetes (P = .12). No association existed between ejaculatory function and PSRG/F on univariate (P = .25) or multivariate analysis (P = .35). CLINICAL IMPLICATIONS: The PSR may be used as a standardized biothesiometry parameter to evaluate penile sensitivity. STRENGTH & LIMITATIONS: This study included a large cohort of men undergoing biothesiometry (n = 1,239); however, it is limited by the multifactorial nature of perceived diminished penile sensitivity. CONCLUSION: The PSR using penile glans and index finger input variables is a non-invasive, painless, office-based, standardized biothesiometry parameter that is a clinically useful tool for measuring penile sexual sensitivity. Wiggins A, Farrell MR, Tsambarlis P, et al. The Penile Sensitivity Ratio: A Novel Application of Biothesiometry to Assess Changes in Penile Sensitivity. J Sex Med 2019;16:447-451.

Limited success with clostridium collagenase histolyticum following FDA approval for the treatment of Peyronie's disease.

Collagenase clostridium histolyticum (CCH) was approved for the treatment of Peyronie's disease (PD) in December of 2013. Recently, further research has supported its use. The aim of this study was to objectively evaluate the effects of CCH on penile curvature associated with Peyronie's disease at our high volume institution. Since the approval of CCH for PD, 45 men have undergone between 1 and 4 treatment cycles (mean 3.13, standard deviation (SD) = 0.87) at our institution. Primary as well as secondary curvature, if any, was measured before beginning therapy and after each cycle of therapy. The degree of curvature was compared. We also questioned these men about their subjective experience with CCH. The mean age of this cohort was 55.7 years (range 35-70). The mean primary curvature was 53.6° (SD = 16.5). Post-treatment mean primary curvature was 48.2° (SD = 19.5), p = 0.10. Secondary curvature was reduced from 24.1° (SD = 11.3) to 20.4° (SD = 11.5) before and after treatment with CCH, respectively, p = 0.27. There were two tunical ruptures in this series after which both ceased therapy with CCH. Additionally, 37/45 patients in this series expressed some degree of dissatisfaction in their post-therapy visits with most of these men stating that they did not notice a change in their curvature. CCH remains an option for the treatment of PD. Predictors of success, however, are lacking. Our experience showed a less-robust response to CCH than previous studies and underscores the need for effective and clear patient counseling prior to the initiation of therapy with CCH for PD in the post-FDA-approval setting.

Nonsurgical management of Peyronie's disease.

Peyronie's disease is not a rare disorder, and it can be devastating to the affected man. Although the gold-standard treatment of Peyronie's disease is surgery in the stable phase, nonoperative management is preferred by some men and is the only treatment option in the acute phase of the disease, when surgery is contraindicated. No oral or topical therapy has been shown to be efficacious when administered alone, but some evidence supports their use as part of a combination therapy regimen. Intralesional therapies, particularly collagenase clostridium histolyticum (CCH), have shown promise. Mechanical therapies can provide benefit when applied for prolonged periods of time, improving penile curvature, indentation, and even restoring length. Regardless of the modality chosen, patient counselling is paramount, as recovery of the penis to its predisease state is highly unlikely. Thus, although many options exist for nonsurgical management of Peyronie's disease, surgery remains the best option for men who desire the most reliable and rapid pathway to a functionally straight, erect penis. The goal of nonsurgical therapy should be a scientifically feasible, safe approach to prevent the progression of, or reduce, deformity and improve sexual function.

Microdenervation of the spermatic cord for post-vasectomy pain syndrome.

OBJECTIVE: To evaluate the outcomes of patients who underwent microdenervation of the spermatic cord (MDSC) for post-vasectomy pain syndrome (PVPS) at our institution. METHODS: A retrospective study of all patients who underwent MDSC for PVPS by a single surgeon between March 2002 and October 2016 was performed. Pain was documented using the numerical rating scale (NRS). Spermatic cord block (SCB) was performed on all patients, and success was defined as NRS score ≤1 for >4 h. All patients had failed medical therapy prior to MDSC. All previous procedures for PVPS had been performed elsewhere. Surgical success was defined as a postoperative NRS score of ≤1. RESULTS: A total of 27 patients with 28 scrotal units underwent MDSC for PVPS. The median (1st quartile; 3rd quartile) follow-up was 10 (2; 16.5) months. The median (range) duration of pain prior to surgery was 57 (8-468) months. Pain was bilateral in 14 (52%), left-sided in eight (30%) and right-sided in five patients (19%). Data on SCB were available for 23 patients, with a success rate of 96%. The median (range) preoperative pain NRS score was 7 (2-10). The median (range) pain score after SCB on the NRS scale was 0 (0-5). The median (range) postoperative pain score on the NRS was 0 (0-9). Overall success was achieved in 20 of 28 testicular units (71%). Patients with involvement of multiple structures in the scrotum (i.e. testis, epididymis, spermatic cord) had a success rate of 81% and were more likely to have a successful surgery (P < 0.001). Five patients had failed a prior epididymectomy and three had failed a vaso-vasostomy for PVPS; this had no correlation with the success of MDSC (P = 0.89). CONCLUSION: The MDSC procedure is a reasonably successful, durable and valuable approach for PVPS, especially when pain involves multiple structures in the scrotum (testis, epididymis, spermatic cord). MDSC was equally efficacious in patients who had previously failed a procedure for PVPS. No patient had a worsening NRS score after MDSC. This is the largest study to date evaluating MDSC for the treatment of PVPS.

Peyronie's graft surgery-tips and tricks from the masters in andrologic surgery.

BACKGROUND: Grafting techniques in the surgical management of Peyronie's disease (PD) are challenging, especially in inexperienced hands. In order to improve surgical outcomes the urologist should follow a standard surgical approach, preferably of an established and reliable grafting technique. The aim of this study is to provide tips and tricks for graft surgery for PD. METHODS: This report offers a step-by-step tutorial for grafting techniques in PD, especially for the Sealing technique and the partial plaque excision and grafting (PEG) procedure. Two senior surgeons (GH, LAL) describe their surgical technique in detail, and provide important aspects and tips one has to be aware of when performing a grafting technique in patients with PD. Special attention is also paid to preoperative considerations and adequate patient counseling. Moreover, postoperative penile rehabilitation programs are discussed. RESULTS: Adequate preoperative counseling of patients is crucial, and should include possible adverse effects and negative outcomes, such as persistent or recurrent curvature, diminished sensation at the glans penis, diminished erectile function, or penile shortening. The correct indication for a grafting technique is imperative. There are many surgical details during grafting techniques, which have to be considered in order to achieve the best result possible. These include the correct preparation of the neurovascular bundle, the following partial plaque excision without damaging the underlying erectile tissue, and the sufficient closure of the resulting tunica albuginea defect. Defect closure can be done by grafts like pericardial graft (PEG procedure) or the collagen fleece (Sealing technique). Postoperatively, the patient should refrain from sexual activities for at least 6 weeks, and follow a penile rehabilitation program with Phoshodiesterase-Type-5 inhibitors, manual stretch, penile massage, and penile traction therapy. CONCLUSIONS: The present paper offers a step-by-step tutorial for grafting techniques in PD, especially for the Sealing technique and the PEG procedure, in order to help the reader to understand major steps during surgery and to avoid pitfalls. Careful patient selection, a reliable and established surgical technique and a postoperative rehabilitation program are main predictors for treatment success. In summary, the ultimate goal should be improved patient care, safety and satisfaction.

Successful Placement of Penile Prostheses in Men With Severe Corporal Fibrosis Following Vacuum Therapy Protocol.

INTRODUCTION: Penile prosthesis (PP) implantation in men with severe corporal fibrosis presents a significant surgical challenge. For the past 7 years, we have used a novel, preoperative protocol of daily vacuum therapy (VT) using a vacuum erection device for at least 3 months before PP placement for men with severe corporal fibrosis from PP infection or ischemic priapism. AIM: To evaluate this standardized preoperative regimen. METHODS: We retrospectively reviewed all patients who underwent three-piece PP placement at our institution from 2008 through 2015. Of these, 13 men had severe corporal fibrosis from prior PP infection (11 of 13) or prolonged ischemic priapism (2 of 13). Our protocol included VT for 10 to 15 minutes at least two times daily in all patients for at least 3 months (mean = 3.5 months). MAIN OUTCOME MEASURES: We report on our surgical experience and post-VT stretched flaccid penile length (SFPL) compared with baseline SFPL. RESULTS: All 13 men underwent successful three-piece PP placement with standard-size cylinders without additional surgical maneuvers. There was one infection and one erosion requiring revision. Daily average use of VT was 32.5 minutes. SFPL increased 0.92 cm (range = 0-2 cm, SD = 0.76 cm) after VT and three-piece PP placement compared with preoperative SFPL. These men also noted improved quality of life and sexuality as measured by postoperative office interviews. CONCLUSION: The use of VT before surgery appears to result in softening of corporal fibrosis and facilitates placement of a PP regardless of the period from developing corporal fibrosis to starting VT. We strongly recommend preoperative corporal tissue rehabilitation with VT to improve surgical outcomes and to decrease difficulty during PP implantation in men with severe corporal fibrosis.