Evidence of restorative therapies in the treatment of Peyronie disease: A narrative review

ABSTRACT Objective: To describe the evidence of Platelet Rich Plasma (PRP), Stem cells therapy (SCT) and Extracorporeal shockwave therapy (ESWL) for the treatment of Peyronies disease (PD), including information from the main urological society guidelines. Materials and Methods: A literature review of PubMed articles published between 2000 and 2023 was conducted, utilizing keywords such as "Peyronie's Disease", "Penile curvature", "Platelet Rich Plasma", "Stem cells", and "Extracorporeal shockwave therapy". Only full-text articles in English were included, excluding case reports and opinions. Results: A considerable number of clinical trials were conducted using PRP penile injections for therapy of PD, showing reduction of curvature, plaque size and improvement in quality of life. Preclinical studies in rats have shown the potential benefit of adipose-derived stem cells, with improvements in erectile function and fibrosis. Human studies with mesenchymal stem cells demonstrated promising results, with reduction of curvature and plaque size. ESWL effects on PD were investigated in randomized clinical trials and demonstrated no significant impact in curvature or plaque size, but reasonable effect on pain control. Conclusion: Restorative therapies has emerged as an innovative treatment option for PD and the results from current studies appear to be promising and demonstrated good safety profile. Unfortunately, due to scarce evidence, PRP and SCT are still considered experimental by American Urological Association (AUA) and European Association of Urology (EAU) guidelines. ESWT is recommended, by the same guidelines, for pain control only. More high-quality studies with long-term follow-up outcomes are needed to evaluate efficacy and reproducibility of those therapies.

Current status and future perspectives for endoscopic treatment of local complications in chronic pancreatitis.

Chronic pancreatitis is a progressive disease characterized by irregular fibrosis, cellular infiltration, and parenchymal loss within the pancreas. Chronic pancreatitis treatment includes lifestyle modifications based on disease etiology, dietary adjustments appropriate for each stage and condition, drug therapy, endoscopic treatments, and surgical treatments. Although surgical treatments of symptomatic chronic pancreatitis provide good pain relief, endoscopic therapies are recommended as the first-line treatment because they are minimally invasive. In recent years, endoscopic therapy has emerged as an alternative treatment method to surgery for managing local complications in patients with chronic pancreatitis. For pancreatic stone removal, a combination of extracorporeal shock wave lithotripsy and endoscopic extraction is used. For refractory pancreatic duct stones, intracorporeal fragmentation techniques, such as pancreatoscopy-guided electrohydraulic lithotripsy and laser lithotripsy, offer additional options. Interventional endoscopic ultrasound has become the primary treatment modality for pancreatic pseudocysts, except in the absence of disconnected pancreatic duct syndrome. This review focuses on the current status of endoscopic therapies for common local complications of chronic pancreatitis, including updated information in the past few years.

The effect of compression therapies and therapeutic modalities on lymphedema secondary to cancer: a rapid review and evidence map.

The identification of effective therapeutic modalities to manage lymphedema secondary to cancer is a high priority among patients and clinicians. Complex decongestive therapy (CDT) remains a fundamental intervention for individuals with lymphedema; however, interventions involving modalities such as low level laser therapy, specially designed compression systems, and compression pumps may be helpful to improve outcomes and reduce costs of care. We conducted a rapid review of the literature examining compression therapies and therapeutic modalities in the treatment of lymphedema secondary to cancer. A search of the electronic databases from June 2018 to October 2023 was performed including MEDLINE, EMBASE, and CINAHL. The electronic search yielded 438 potentially relevant citations with 40 randomized controlled trials included in the review, and 30 in the mapping process. Ninety-three percent (n = 37) of the trials included participants with a diagnosis of breast cancer. Across all categories and domains, all but two trials were rated as having 'some concerns' or a 'high risk of bias'. Intervention effects ranged from clinically insignificant to large effects on lymphedema volume. Evidence mapping suggests potential for benefit from (1) compression garments for the prevention of lymphedema, (2) interventions added to CDT in the intensive reduction phase, and (3) nighttime compression and compression pump treatments in the maintenance phase. A multi-centre collaborative research approach is needed to support the conduct of high-quality large-scale trials to inform the optimal type, timing, and combination of compression therapies and therapeutic modalities in the treatment of lymphedema secondary to cancer.

Regenerative Medicine in Orthopedic Surgery: Expanding Our Toolbox.

Regenerative medicine leverages the body's inherent regenerative capabilities to repair damaged tissues and address organ dysfunction. In orthopedics, this approach includes a variety of treatments collectively known as orthoregeneration, encompassing modalities such as prolotherapy, extracorporeal shockwave therapy, pulsed electromagnetic field therapy, therapeutic ultrasound, and photobiomodulation therapy, and orthobiologics like platelet-rich plasma and cell-based therapies. These minimally invasive techniques are becoming prominent due to their potential for fewer complications in orthopedic surgery. As regenerative medicine continues to advance, surgeons must stay informed about these developments. This paper highlights the current state of regenerative medicine in orthopedics and advocates for further clinical research to validate and expand these treatments to enhance patient outcomes.

Comparative Effectiveness of Acupuncture Versus Non-surgical Modalities for Treating Plantar Fasciitis: A Network Meta-Analysis.

Plantar fasciitis, or plantar heel pain, causes inflammation of the plantar fascia due to various causes, with no clear consensus on the treatment protocol. Standard first-line treatment includes non-steroidal anti-inflammatory drugs and physiotherapy. Second-line treatment prior to surgery includes extracorporeal shockwave therapy (ESWT), ultrasound-guided (USG) therapy, corticosteroid injection (CSI), and platelet-rich plasma (PRP) injection. Recently, the use of acupuncture treatment has been gaining popularity, with increasing published evidence showing its effectiveness in treating plantar fasciitis. The objective of this study was to determine whether acupuncture intervention was a viable alternative treatment method for managing plantar fasciitis when compared to ESWT, USG therapy, CSI, and PRP injection. Data sources from PubMed, Google Scholar, Scopus, Science Direct, and China National Knowledge Infrastructure were reviewed. Clinical trials were searched from their inception over the period of January 2000 to October 2020. A total of 32 relevant papers were included for analysis, totaling 2390 samples. Visual Analog Scale (VAS) scores measuring pain were analyzed in terms of outcome after one and three months of treatment. Each time point was analyzed separately through a network meta-analysis using the frequentist approach. VAS scores for each intervention at baseline and the two-time points (i.e., one and three months) were included in the comprehensive meta-analysis. Then, differences in VAS scores were calculated in R studio (V4.1.2; RStudio: Integrated Development for R, RStudio, Inc., Boston, USA) using the netmeta package. The netmeta package was also used to perform the network meta-analysis and generate corresponding figures. Direct and indirect effects were assessed and visualized through a direct evidence plot and a node-splitting forest plot. Randomized controlled trials (RCTs) and non-RCTs involving treatments of acupuncture, ESWT, USG therapy, CSI, or PRP injection, either in comparison with each other or with a placebo, were included in our review. Our meta-analysis showed that at one month, VAS scores for acupuncture treatment had the highest mean difference (MD) of -1.33 (95% confidence interval (95% CI) = -2.19 to -0.46) compared to placebo, indicating that acupuncture treatment was more effective than other treatment arms when compared to placebo. Analysis at threemonths showed that the highest-ranked treatment was PRP injection, with an MD of -2.67 (95% CI = -6.23 to 0.89). However, the CI for the net effect of all treatments crossed the null effect on the forest plot, indicating no statistically significant difference between the treatment and placebo. Acupuncture treatment should be considered as a second-line treatment for treatment of plantar fasciitis together with other common treatment options such as ESWT, PRP injection, CSI, and USG therapy. Further long-term studies measuring acupuncture treatment outcomes would be beneficial in the future.

Assessment of Plasma Cystatin C as a Marker of Acute Renal Injury in Patients Undergoing Extracorporeal Shock Wave Lithotripsy for Renal Stone Disease.

Introduction This study aimed to assess plasma cystatin C (CysC) as a marker of acute kidney injury (AKI) in patients undergoing extracorporeal shock wave lithotripsy (ESWL). We compared serum levels of CysC, C-reactive protein (CRP), and creatinine before and after ESWL. The study results may have implications for early detection of AKI and prevention of progression to chronic kidney disease. Methodology This prospective observational study included 105 adult participants and was conducted from August 2022 to July 2024. ESWL was the only modality of treatment. Results Forty-eight (46%) patients developed AKI after ESWL. Patients with AKI had significantly higher post-ESWL mean plasma CysC levels than patients without AKI (121 ± 0.25 vs. 0.94 ± 0.22 mg/dL, respectively; P = 0.001). The mean serum CRP levels after ESWL were significantly higher in patients who developed AKI compared with those who did not (4.36 ± 1.63 vs. 2.64 ± 0.95 mg/dL, respectively; P = 0.001). Conclusions In patients with renal stone disease, serum creatinine, serum CRP, and plasma CysC can be used as markers of acute renal injury after ESWL.

Covered Endovascular Reconstruction of Aortic Bifurcation Facilitated by Intravascular Lithotripsy With Shockwave Balloon: A Case Report.

Aortoiliac occlusive disease (AIOD) is a specific form of peripheral artery disease (PAD) that affects the infrarenal aorta and iliac arteries. Patients with PAD commonly suffer from intermittent claudication (IC), a condition characterized by cramping pain during or after exercise that is relieved by rest. The first-line therapy for IC involves medical management, foot care, and structured exercise programs while revascularization therapy, which can be endovascular, surgical, or a combination of both, is generally reserved for patients with claudication who do not respond adequately to initial therapies. We present the clinical case of a 58-year-old female with hypertension, dyslipidemia, and a smoking habit who was referred to our hospital (Misericordia Hospital, Grosseto, Italy) due to bilateral IC of the buttocks and thighs. Computed tomography (CT) angiography revealed a 90% tight stenosis of the infrarenal abdominal aorta just above the iliac bifurcation with diffuse calcifications. After a careful evaluation of the patient's condition and anatomical characteristics of the atherosclerotic disease, the vascular team decided to perform covered endovascular reconstruction of aortic bifurcation (CERAB) with previous intravascular lithotripsy (IVL) with shockwave balloon using intravascular ultrasound (IVUS) as guidance, because of severe aortic luminal calcifications. We performed successful CERAB, and the patient was discharged in good clinical condition on the fifth day of hospitalization with an indication to follow optimal medical therapy. At the one-month clinical follow-up, the patient reported the disappearance of claudication with marked improvement in quality of life. This first described case of IVUS-guided IVL-facilitated CERAB demonstrates the efficacy and safety of IVL in calcific aortic disease and shows the usefulness of IVUS as guidance in peripheral calcium debulking procedures.

Microenergy shockwave therapies for female stress urinary incontinence.

Stress urinary incontinence (SUI) is one of the pelvic floor disorders affecting tens of million of women worldwide. In general, non-surgical options have relatively limited efficacy. The most effective treatment is mid-urethral sling surgery which carries substantial risks of perioperative and postoperative complications. Regenerative therapy with the injection of several types of stem cells and stem cell products is promising but further investigation is needed before clinical implementation can be considered. In recent years, the application of microenergy therapy as a non-invasive treatment for SUI has received increasing attention. Preclinical animal studies of these models have demonstrated that low-intensity extracorporeal shockwave therapy (Li-ESWT) and microenergy acoustic pulse (MAP) therapy are capable of regenerating urethral sphincter tissue and pelvic floor muscles leading to improved urinary continence. One pilot clinical trial with Li-ESWT also reported improved quality of life in women with SUI as well as the symptoms. The objective of this review is to summarize the potential mechanisms associated with Li-ESWT and MAP therapies of SUI: (I) activation of tissue-resident stem cells; (II) regeneration of musculature in the urethra and pelvic floor; (III) improvement in biomechanical property of pelvic floor muscles; (IV) modulation of cellular signaling pathways. Further studies of the molecular mechanisms, optimal treatment dosage and schedule, and potential long-term side effects are needed to provide this non-invasive regenerative therapy for millions of women with SUI.

Extracorporeal shockwave therapy for degenerative meniscal tears results in a decreased T2 relaxation time and pain relief: An exploratory randomized clinical trial.

PURPOSE: The optimal management of degenerative meniscal tears remains controversial. Extracorporeal shockwave therapy (ESWT) has been shown to promote tissue repair in both preclinical and clinical studies; however, its effect on degenerative meniscal tears remains unknown. This study aimed to examine whether ESWT improves meniscal degeneration. METHODS: This randomized trial was conducted between 2020 and 2022 and involved patients with degenerative medial meniscal tears. Patients were allocated to receive either focused ESWT (0.25 mJ/mm2, 2000 impulses, 3 sessions with a 1-week interval) or sham treatment. Patients were evaluated using magnetic resonance imaging (MRI) before treatment and at 12 months after treatment. The primary endpoint was improvement in meniscal degeneration, as assessed by the change in T2 relaxation time from baseline on MRI T2 mapping. Knee pain and clinical outcomes were also examined at the same time. RESULTS: Of 29 randomized patients, 27 patients (mean age 63.9 ± 8.7 years; females 37%; ESWT group 14 patients; control group 13 patients) were included in the final analysis. At 12 months postintervention, patients in the ESWT group showed a greater decrease in the T2 relaxation time (ESWT group -2.9 ± 1.7 ms vs. control group 1.0 ± 1.9 ms; p < 0.001) and had less knee pain (p = 0.04). The clinical outcomes at 12 months post-treatment were not statistically significant. No adverse events were reported. CONCLUSION: ESWT decreased the T2 relaxation time in the meniscus at 12 months post-treatment. ESWT also provided pain relief, but no differences were observed in clinical outcomes. LEVEL OF EVIDENCE: Level II.

Evidence of restorative therapies in the treatment of Peyronie disease: A narrative review.

OBJECTIVE: To describe the evidence of Platelet Rich Plasma (PRP), Stem cells therapy (SCT) and Extracorporeal shockwave therapy (ESWL) for the treatment of Peyronies disease (PD), including information from the main urological society guidelines. MATERIALS AND METHODS: A literature review of PubMed articles published between 2000 and 2023 was conducted, utilizing keywords such as "Peyronie's Disease", "Penile curvature", "Platelet Rich Plasma", "Stem cells", and "Extracorporeal shockwave therapy". Only full-text articles in English were included, excluding case reports and opinions. RESULTS: A considerable number of clinical trials were conducted using PRP penile injections for therapy of PD, showing reduction of curvature, plaque size and improvement in quality of life. Preclinical studies in rats have shown the potential benefit of adipose-derived stem cells, with improvements in erectile function and fibrosis. Human studies with mesenchymal stem cells demonstrated promising results, with reduction of curvature and plaque size. ESWL effects on PD were investigated in randomized clinical trials and demonstrated no significant impact in curvature or plaque size, but reasonable effect on pain control. CONCLUSION: Restorative therapies has emerged as an innovative treatment option for PD and the results from current studies appear to be promising and demonstrated good safety profile. Unfortunately, due to scarce evidence, PRP and SCT are still considered experimental by American Urological Association (AUA) and European Association of Urology (EAU) guidelines. ESWT is recommended, by the same guidelines, for pain control only. More high-quality studies with long-term follow-up outcomes are needed to evaluate efficacy and reproducibility of those therapies.

Effect of extracorporeal shockwave therapy on plantar fascia thickness in plantar fasciitis: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Extracorporeal shockwave therapy (ESWT) has been used as a therapeutic option for plantar fasciitis. The objective was to investigate the effect of ESWT over the plantar fascia thickness. METHODS: MEDLINE, Embase, Web of Science, and SCOPUS databases were searched for randomized controlled trials evaluating the effect of ESWT in patients with plantar fasciitis, comparing ESWT with another treatment. Meta-analysis was conducted using a random-effects model and the generic inverse variance method. Meta-regression and subgroup analyses were also carried out. RESULTS: A total of 14 studies (867 participants) were included. ESWT significantly decreased plantar fascia thickness (weighted mean difference [WMD], -0.21 mm [95% CI -0.39, -0.02]; p = 0.03). No significant improvement in pain was observed (WMD, -0.51 cm [95% CI -1.04, 0.01]; p = 0.06) compared with non-surgical interventions. CONCLUSIONS: Our results suggest that plantar fascia thickness is significantly decreased after ESWT intervention in patients with plantar fasciitis. However, pain relief was not significantly improved compared to other non-surgical interventions.

Radial extracorporeal shockwave promotes osteogenesis-angiogenesis coupling of bone marrow stromal cells from senile osteoporosis via activating the Piezo1/CaMKII/CREB axis.

Radial extracorporeal shockwave (r-ESW) and bone marrow stromal cells (BMSCs) have been reported to alleviate senile osteoporosis (SOP), but its regulatory mechanism remains unclear. In this study, we firstly isolated human BMSCs from bone marrow samples and treated with varying r-ESW doses. And we found that r-ESW could enhance the proliferation of SOP-BMSCs in a dose-dependent manner by EdU assay. Subsequently, the impact of r-ESW on the proliferation, apoptosis and multipotency of BMSCs was assessed. And the outcomes of flow cytometry, Alizarin red S (ARS), and tube formation test demonstrated that the optimal shockwave obviously boosted SOP-BMSCs osteogenesis and angiogenesis but exhibited no significant impact on cell apoptosis. Additionally, the signaling of Piezo1 and CaMKII/CREB was examined by Western blotting, qPCR and immunofluorescence. And the results showed that r-ESW promoted the expression of Piezo1, increased intracellular Ca2+ and activated the CaMKII/CREB signaling pathway. Then, the application of Piezo1 siRNA hindered the r-ESW-induced enhancement ability of osteogenesis coupling with angiogenesis of SOP-BMSCs. The use of the CaMKII/CREB signaling pathway inhibitor KN93 suppressed the Piezo1-induced increase in osteogenesis and angiogenesis in SOP-BMSCs. Finally, we also found that r-ESW might alleviate SOP in the senescence-accelerated mouse prone 6 (SAMP6) model by activating Piezo1. In conclusion, our research offers experimental evidence and an elucidated underlying molecular mechanism to support the use of r-ESW as a credible rehabilitative treatment for senile osteoporosis.

The Effects of Shock Wave Therapy on the Symptoms and Function of Individuals With Dupuytren Disease: A Systematic Review.

OBJECTIVE: To systematically evaluate the effects of extracorporeal shockwave therapy (ESWT) on pain, clinical and functional outcomes, and satisfaction of patients with Dupuytren disease. DATA SOURCES: A thorough search for all the study types published in English was conducted in PubMed, Scopus, Web of Science, and Embase from inception to August 31, 2022. STUDY SELECTION: Title and abstract and then full-text screening against eligibility criteria was performed independently by 2 reviewers, and a third reviewer achieved consensus. DATA EXTRACTION: Reviewers identified 26 studies, of which 6 were included in the analysis (145 cases). The methodological quality was assessed using the National Heart, Lung, and Blood Institute and the Joanna Briggs Institute checklists. The certainty of evidence was evaluated using the Grading of Recommendation Assessment, Development, and Evaluation. DATA SYNTHESIS: Assessments represented a remarkable improvement in the pain and function through the measurements including the visual analog scale, the Disabilities of Arm Shoulder and Hand Questionnaire, the Michigan Hand Outcome Questionnaire, and Mayo Wrist Score. Patients' satisfaction was also favorable using the Roles and Maudsley score. The hand grip strength improvement was noted in one study measured via a Jamar dynamometer. In addition, the ultrasonographic assessment of the nodules revealed a decrease in the size of the nodules in a patient with multiple bilateral nodules after the treatment. The quality of the included studies was good for all studies except for one that was fair. The certainty of evidence was moderate for pain and function and was low for patients' satisfaction and ultrasonographic findings. CONCLUSIONS: ESWT can lead to significant pain improvement, functional rehabilitation, and patient satisfaction with no adverse effect in the management of Dupuytren disease. Pain may return over time, but not to that severity before the intervention. ESWT-related characteristics and the need for continuation of treatment remain to be fully elucidated in future large clinical trials.

Multimodal treatments based on Tadalafil during acute phase of Peyronie's disease: experience at two referral academic centers.

AIM: The purpose of this study is to identify the clinical outcomes of patients during acute phase of Peyronie's disease (PD) treated with daily Tadalafil 5 mg associated with non-surgical treatments such as intra-plaque verapamil injections (IVI), vacuum erection devices (VED) or extra corporeal shockwave therapy (ESWT). METHODS: 445 patients with PD in acute stage were treated as it follows: Group 1(G1) 117 men with only Tadalafil 5 mg once a day for 3 months; Group 2(G2) 106 men with IVI plus Tadalafil 5 mg for a period of 12 weeks; Group 3(G3) 124 men that received ESWT for 6 weeks plus Tadalafil with the same protocol of G1; Group 4(G4) 98 men with VED plus Tadalafil 5 mg for 3 months. There were assessed at baseline and follow-up: Erectile dysfunction (ED), presence and severity of painful erections, penile plaque size and penile curvature degree. The results were evaluated at baseline and 3,6,12 months. RESULTS: Not statistically significant differences emerged between the two groups at baseline, except for higher presence of patients with ED in in G3(7.4%) vs other groups(p < 0.001). Three months after the treatment in G3 men had a significant reduction of penile curvature degrees after 1 year by treatments, whereas pain in an erection or during intercourse was resolved completely in 75% of the patients. CONCLUSIONS: Our study highlights that multimodal therapy has beneficial long-term effects not only in the decrease of ED symptoms, but also in the relief of the penile curvature and the quality of life.

Cardiac shockwave therapy in addition to coronary bypass surgery improves myocardial function in ischaemic heart failure: the CAST-HF trial.

BACKGROUND AND AIMS: In chronic ischaemic heart failure, revascularisation strategies control symptoms but are less effective in improving left ventricular ejection fraction (LVEF). The aim of this trial is to investigate the safety of cardiac shockwave therapy (SWT) as a novel treatment option and its efficacy in increasing cardiac function by inducing angiogenesis and regeneration in hibernating myocardium. METHODS: In this single-blind, parallel-group, sham-controlled trial (cardiac shockwave therapy for ischemic heart failure, CAST-HF; NCT03859466) patients with LVEF ≤40% requiring surgical revascularisation were enrolled. Patients were randomly assigned to undergo direct cardiac SWT or sham treatment in addition to coronary bypass surgery. The primary efficacy endpoint was the improvement in LVEF measured by cardiac magnetic resonance imaging from baseline to 360 days. RESULTS: Overall, 63 patients were randomized, out of which 30 patients of the SWT group and 28 patients of the Sham group attained 1-year follow-up of the primary endpoint. Greater improvement in LVEF was observed in the SWT group (Δ from baseline to 360 days: SWT 11.3%, SD 8.8; Sham 6.3%, SD 7.4, P = .0146). Secondary endpoints included the 6-minute walking test, where patients randomized in the SWT group showed a greater Δ from baseline to 360 days (127.5 m, SD 110.6) than patients in the Sham group (43.6 m, SD 172.1) (P = .028) and Minnesota Living with Heart Failure Questionnaire score on day 360, which was 11.0 points (SD 19.1) for the SWT group and 17.3 points (SD 15.1) for the Sham group (P = .15). Two patients in the treatment group died for non-device-related reasons. CONCLUSIONS: In conclusion, the CAST-HF trial indicates that direct cardiac SWT, in addition to coronary bypass surgery improves LVEF and physical capacity in patients with ischaemic heart failure.

Study Protocol for a Randomized Controlled Trial of Low Intensity Shockwave Therapy for the Treatment of Post-Radical Prostatectomy Erectile Dysfunction: "SHARP-ED TRIAL".

Introduction: Erectile Dysfunction (ED) is a common challenge post Radical Prostatectomy (RALP), affecting men's sexual health after undergoing definitive cancer therapy. Despite employing nerve-sparing techniques, ED remains a prevalent issue in this population. Studies indicate that approximately 70%-85% of men experience varying degrees of ED following RALP. The existing treatment landscape for post-RALP-ED presents limitations, and a discernible knowledge gap persists. To address this, our study aims to investigate the efficacy of Shockwave Therapy (SWT) as a potential intervention for managing ED after RALP. Methods: This prospective, randomized, sham-controlled clinical trial aims to recruit 189 eligible patients post-RP and assess the effects of SWT. Comprehensive screening, including medical history, physical examinations, and biochemical evaluations, will be conducted to confirm eligibility. The intervention involves utilizing a device to administer focal shockwaves targeted at cavernosal tissue. Safety measures include continuous monitoring for adverse events and rigorous reporting protocols. The primary endpoint assesses changes in participants' ability to engage in penetrative intercourse from baseline to study completion, while secondary endpoints encompass various measures of erectile function, including questionnaire-based assessments, ultrasound parameters, and clinical outcomes. Results: Statistical analysis, encompassing ANOVA for continuous variables and Fisher's exact test for categorical ones, will evaluate demographic characteristics, baseline data, and primary as well as secondary outcomes for statistical significance. Detailed analysis of trends, subgroup comparisons, and treatment effects will provide a comprehensive understanding of the impact of SWT on post-RP ED. Conclusion: This study protocol represents a rigorous investigation into the potential therapeutic role of SWT in managing post-RP ED. The outcomes from this study aim to contribute valuable insights into the efficacy, safety, and potential improvements in erectile function following SWT, providing significant guidance for future interventions aimed at addressing this challenging condition affecting men's health and quality of life.

Percutaneous balloon mitral valvuloplasty with shockwave lithotripsy for the treatment of calcific mitral valve stenosis.

BACKGROUND: Calcific mitral stenosis (calcific MS) presents a challenge for surgical treatment and is a contraindication for most contemporary transcatheter mitral valve replacement devices (TMVR), rendering patients with very limited therapeutic options. AIMS: This study aims to assess the clinical and hemodynamic follow-up after mitral valve lithotripsy (MVL). METHODS: All consecutive patients who underwent MVL to treat symptomatic calcific MS at St Michael's Hospital, Toronto, Canada, were included. Patients were deemed unsuitable for mitral surgery or TMVR after heart team assessment. Patients with rheumatic MS or ≥moderate mitral regurgitation (MR) were excluded. The primary endpoint was a reduction in the invasive mitral gradient by ≥50% without significant (≥moderate) MR. RESULTS: Fifteen patients underwent MVL between 2021 and 2023 with a mean age of 74 ± 9 years; 53% were female, with a mean STS score of 10% ± 0.1%. Following MVL, there was a reduction in the invasively measured mean trans-mitral gradient compared to baseline (14 mmHg vs. 6 mmHg; p < 0.05). The primary endpoint was achieved in 8 patients (53%) with no major procedural complications. At follow-up (median 90 days, IQR 58-115 days), 14 (93%) patients reported improved symptoms from New York Heart Association (NYHA) Class III-IV to NYHA Class I-II (p < 0.01) with stable echo-derived mean gradient (7.7 mmHg ± 2 mmHg vs. 8.4 mmHg ± 2.9 mmHg (p = 0.7). CONCLUSIONS: In selected patients with symptomatic inoperable calcific MS, MVL was safe and associated with significant short-term clinical and hemodynamic improvement. MVL may represent a new compassionate therapy for this challenging cohort. Further studies are needed to determine the long-term outcomes and help define the role of IVL technology in treating calcific valvular conditions.

Current treatment options for erectile dysfunction in kidney transplant recipients.

INTRODUCTION: Erectile dysfunction (ED) and kidney dysfunction share common risk factors linked to conditions involving endothelial impairment, such as coronary artery disease, dyslipidemia, diabetes mellitus, hypertension, smoking, and obesity. Men with chronic kidney disease experience a high incidence and prevalence of ED. While a functional renal graft can alleviate the issue for some patients, a significant portion of recipients still experience ED (20%-50%). OBJECTIVES: This narrative review describes the variety of current treatments modalities on ED in kidney transplant recipients (KTRs) and their clinical outcomes. METHODS: MEDLINE, Web of Science, PubMed, and Google Scholar were used to find eligible articles pertaining to the treatment options of ED in KTRs. A total of 64 articles were evaluated. RESULTS: In KTRs, ED stems from a multifaceted etiology: anxiety, drug side effects, interference with penile vascularity, or the response of cavernosal muscle to neurotransmitters, along with changes in the endocrine milieu. A diverse range of treatments to restore erectile function has proven to be safe and effective for KTRs. Options include drug therapy, surgical interventions, intracavernosal injection therapies, vacuum erection devices, and extracorporeal shockwave therapy. CONCLUSION: The initial treatment approach may involve the use of a phosphodiesterase type 5 inhibitors at a low dosage, especially if testosterone-circulating levels align with the diagnosis of hypogonadism. The consideration of a combination therapy involving testosterone and phosphodiesterase type 5 inhibitors should be contemplated due to the associated beneficial effects. Extracorporeal shockwave therapy has shown positive short-term clinical and physiological effects on erectile function in patients who did not respond to first-line treatments, resulting in spontaneous erections sufficient for sexual penetration in 50% of cases. Penile implants should be considered as third-line options based on specific patient needs and compliance with clinical conditions.

Extension of interval between adjacent pulse delivery cycles to deal with myocardial ischemia by intravascular lithotripsy: case report.

BACKGROUND: Intravascular lithotripsy (IVL) represents a novel approach in the management of coronary calcification. This technique employs acoustic pressure waves, generated by a shockwave balloon, to effectively fracture both superficial and deep calcification in situ. The efficacy and safety of IVL have been convincingly demonstrated through the Disrupt CAD I-IV studies. While IVL is associated with the occurrence of atrial and ventricular arrhythmias, there is no evidence to indicate it causes myocardial ischemia. CASE DESCRIPTION: A 71-year-old man was admitted presenting with chest pain. His previous coronary angiography revealed stenosis and calcification in the left anterior descending branch. An attempt to predilate the lesion using two Lacrosse non-slip element balloons was unsuccessful. Ventricular premature beats and transient ST-segment depression were captured during the utilization of IVL. The operator gradually extended the pulse emission interval across two consecutive cycles to mitigate myocardial ischemia. Notably, when the interval reached 30s, the patient had no chest pain or ST-segment changes. Subsequent images of intravascular ultrasound confirmed calcification ruptures. Therapeutic intervention included the placement of a stent and the application of a drug-coated balloon in the left anterior descending branch. A telephonic follow-up six months later indicated the patient had no discomfort. CONCLUSIONS: This case underscores the effectiveness of gradually extending the pulse emission interval as a strategic complement to the clinical application of IVL. In certain clinical scenarios, it may become imperative to suspend the pulse delivery to improve myocardial blood supply.

Prospective Evaluation of Extracorporeal Shockwave Lithotripsy in Renal and Upper Ureteric Stone Treatment: Clinical Assessment and Results.

INTRODUCTION: Extracorporeal shockwave lithotripsy (ESWL) is a widely accepted non-invasive treatment for renal and upper ureteric stones smaller than 2 cm due to its safety and efficacy. Despite advancements in minimally invasive techniques, extracorporeal shockwave lithotripsy remains an important modality. AIMS AND OBJECTIVE: This prospective observational study aimed to evaluate the outcomes of ESWL in managing renal and upper ureteric stones measuring less than 2 cm in terms of stone clearance. MATERIAL AND METHODS: In a study conducted at a university-affiliated tertiary care hospital, 119 patients with renal and upper ureteric stones underwent extracorporeal shockwave lithotripsy over a 12-month period. Data on patient demographics, stone characteristics, treatment procedures, and complications were collected. Follow-up assessments were performed at two-week intervals for up to two months post-treatment. RESULTS: The mean age of patients was 39.78 years, with a mean stone size of 1.2 cm. Right kidney stones were more prevalent (61.3% [n=76]). Complications included fever (19.3% [n=23]), gross haematuria (24.3% [n=29]), and steinstrasse (21.8% [n=26]). The success rate of extracorporeal shockwave lithotripsy was 81.5% (n=97), with 18.5% (n=22) of patients requiring surgical intervention due to incomplete fragmentation or residual fragments >4 mm. Stone size and density played significant roles in treatment success. CONCLUSION: Despite advancements in minimally invasive techniques, ESWL retains its significance as a noninvasive and effective treatment option for renal and upper ureteric stones smaller than 2 cm. Its success depends on various factors, including the stone site, size, and composition. ESWL offers advantages such as minimal morbidity, shorter hospital stays, and better patient compliance. Complications such as steinstrasse are manageable with conservative measures or ancillary procedures. While ESWL may be losing ground in some cases, its noninvasive nature and favourable outcomes make it a valuable option in the armamentarium for stone management.