Female erectile tissues and sexual dysfunction after pelvic radiotherapy: A scoping review.

Sexual function is a vital aspect of human health and is recognized as a critical component of cancer survivorship. Understanding and evaluating the impacts of radiotherapy on female sexual function requires precise knowledge of the organs involved in sexual function and the relationship between radiotherapy exposure and sexual tissue function. Although substantial evidence exists describing the impact of radiotherapy on male erectile tissues and related clinical sexual outcomes, there is very little research in this area in females. The lack of biomedical data in female patients makes it difficult to design studies aimed at optimizing sexual function postradiotherapy for female pelvic malignancies. This scoping review identifies and categorizes current research on the impacts of radiotherapy on normal female erectile tissues, including damage to normal functioning, clinical outcomes of radiation-related female erectile tissue damage, and techniques to spare erectile tissues or therapies to treat such damage. An evaluation of the evidence was performed, and a summary of findings was generated according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Extension for Scoping Reviews guidelines. Articles were included in the review that involved normal female erectile tissues and radiotherapy side effects. The results show that little scientific investigation into the impacts of radiotherapy on female erectile tissues has been performed. Collaborative scientific investigations by clinical, basic, and behavioral scientists in oncology and radiotherapy are needed to generate radiobiologic and clinical evidence to advance prospective evaluation, prevention, and mitigation strategies that may improve sexual outcomes in female patients.

Can nerve monitoring during radical prostatectomy improve functional outcomes? A randomised trial.

OBJECTIVE: To explore how the use of the ProPep® Nerve Monitoring System (ProPep Surgical, Austin, TX, USA) for intraoperative specific sparing of the pudendal nerve fibres influences postoperative functional outcomes after unilateral nerve-sparing (UNS) or non-nerve-sparing (NNS) robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: We randomised 100 men undergoing UNS or NNS RARP to ProPep nerve monitoring during RARP (intervention) or standard of care RARP (control). Functional outcomes were assessed at 3, 6, and 12 months using the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), the International Prostate Symptom Score, the Danish Prostate Symptom Score, the International Index of Erectile Function, the Erection Hardness Scale, and 24-h pad tests. The primary outcome was the difference in ICIQ-SF score between the groups at 12 months. Secondary outcomes included differences in the remaining outcome measures and continence rates at all time points. Continence was defined as the use of no pads and the answer 'Never' to the question: 'How often do you experience urinary incontinence?' or a urine loss of <8 g on the 24-h pad test. RESULTS: A total of 82 patients were included in the per-protocol analysis at 12 months with 41 in each group. At 12 months the mean ICIQ-SF scores were 5.37 (95% confidence interval [CI] 3.71-7.03) and 5.66 (95% CI 4.05-7.27) for the intervention and control groups, respectively (P = 0.8). There were no statistically significant differences in any of the remaining outcomes. However, the continence rate was higher in the intervention group at 6 months (63% vs 44%, P = 0.09). CONCLUSIONS: Intraoperative nerve monitoring did not result in better functional outcomes following UNS or NNS RARP. Larger studies are needed to explore if ProPep can reduce the time to continence after RARP.

Tadalafil versus tamsulosin as combination therapy with 5-alpha reductase inhibitors in benign prostatic hyperplasia, urinary and sexual outcomes.

PURPOSE: To compare the urological and sexual outcomes of using either tamsulosin/finateride or tadalafil/finasteride as combination therapies in patients with large prostate. PATIENTS AND METHODS: Selection criteria included prostate volume > 40 ml and IPSS > 7. Patients with severe erectile dysfunction (IIEF-erectile functions ≤ 10) were excluded. Patients were randomized into group I (tamsulosin/finasteride) and group II (tadalafil/finasteride). The primary endpoint was to define urinary and sexual function changes (IPSS, IPSS-quality of life, urinary flow rates and IIEF domains) within each group. The secondary endpoint was to compare the treatment induced changes between both groups. RESULTS: At 4th and 12th weeks, 131 and 127 patients were available in both groups, respectively. Both groups showed significant LUTS improvement (IPSS changes: - 4.9 ± 2.7 and - 4.3 ± 2.9 at 4th week and - 6.1 ± 3 and - 5.4 ± 2.8 points by the 12th week in both groups, respectively). Group I had better average flow rates at both follow-up visits. Meanwhile, maximum flow rates were comparable in both groups at 12th week (13.5 ± 3.9vs. 12.6 ± 3.7, p > 0.05). In group I, all IIEF domains were significantly lowered at both visits (p < 0.05). Group II showed significant increase in IIEF-erectile function scores (1.3 ± 1.1 and 1.8 ± 1.2 at the 4th and 12th weeks) with a transient significant reduction of IIEF-orgasm and sexual desire noted only by the 4th week (- 0.8 ± 0.4 and - 0.6 ± 0.4, respectively). CONCLUSION: Within three months, both combinations are comparably effective in improving BPH related LUTS. Tamsulosin/finasteride provided significantly better Qmax only at 4th week. Tadalafil/finasteride had the advantage of improving sexual performance over the other combination.

Postoperative functional and cancer control evaluation of conventional and Retzius-sparing robot-assisted radical prostatectomy: Comparison of selected cases by propensity score matching.

AIM: Although many reports have shown that Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) is effective for postoperative urinary continence, the postoperative voiding status and sexual function associated with this technique have not yet been adequately compared with those associated with conventional RARP (C-RARP). In this study, the lower urinary tract function, erectile function, and cancer control after C-RARP and RS-RARP were compared chronologically. MATERIALS AND METHODS: We selected 50 cases of C-RARP and RS-RARP each by propensity score matching and evaluated them over time using various questionnaires. Urinary continence recovery rates and biochemical recurrence (BCR)-free survival rates were calculated using the Kaplan-Meier method and compared between the two groups using the log-rank test. RESULTS: When urinary continence was defined as 0 pads per day, 0 pads per day + 1 security linear, or ≤1 pad per day, the postoperative improvement in urinary continence was better with RS-RARP over the course of up to 1 year for all definitions. The International Consultation on Incontinence Questionnaire-Short Form total scores and the Overactive Bladder Symptom Scores were better in the postoperative RS-RARP group. There were no significant differences in the International Prostate Symptom Score total score, QOL score, and erectile hardness score between the two groups during the observation period. The BCR-free survival did not differ significantly between the two groups CONCLUSIONS: Postoperative urinary continence was better in the RS-RARP group than in the C-RARP group; however, the voiding function, erectile function, and cancer control did not differ significantly.

Analysis of Repair Type and Hypogastric Artery Antegrade Perfusion and Erectile Function following Repair of Abdominal Aortic Aneurysms.

BACKGROUND: Published reports suggest that exclusion of antegrade hypogastric artery flow may have deleterious effects on erectile function after abdominal aortic aneurysm (AAA) repair. Off-label and open surgical hybrid procedures and, more recently, purpose-built branched devices have been developed to maintain antegrade pelvic perfusion in patients undergoing endovascular repair. Maintaining antegrade perfusion may reduce a spectrum of risks, including buttock claudication, colorectal ischemia, and spinal cord ischemia when patients undergo subsequent thoracic aortic procedures, as well as erectile dysfunction (ED). This project specifically focuses on erectile function, and analyzes baseline associations and relationships of hypogastric artery exclusion on changes in erectile function following aneurysm repair. METHODS: Male patients in the Veterans Affairs Open Versus Endovascular Repair (CSP#498; OVER) Trial had erectile function assessed preoperatively and postoperatively by administration of the International Index of Erectile Function-5 questionnaire. Bayesian mixed-effects regression models were created with the outcome variable (erectile function) treated as a latent variable. Primary effects of differences in erectile function between groups with and without preservation of bilateral antegrade hypogastric flow were compared. RESULTS: 876 men (442 randomized to endovascular repair) were enrolled in the trial and included in the analysis comparing treatment assignment. There is significant ED in elderly men with aortic aneurysm at baseline. Over 5 years of follow-up, there is modest decrease in erectile function and the endovascular group has improved function compared to open repair (0.082; 95% credible interval (CI) 0.008 and 0.155). A fifth of patients did not have bilateral preservation of antegrade hypogastric artery perfusion, with no difference in erectile function by univariate analysis. A more detailed regression analysis was applied--and after adjustment for baseline score, age, beta blocker use, diabetes, activity level, ejection fraction, preoperative ankle-brachial indices and time--preservation of both antegrade hypogastric arteries' perfusion showed transient improvement in survey scores compared to occlusion of at least 1 hypogastric artery at 6 months and 12 months after treatment, although this was not sustained at 60 months (score change: 0.046; 95% CI: -0.123, 0.215). Retesting this model in the cohort with complete data as a sensitivity analysis did not meaningfully change the conclusions. CONCLUSIONS: In this large prospective aneurysm treatment trial with systematic measurement of erectile function with a validated instrument, endovascular repair is associated with improved erectile function. Preservation of antegrade hypogastric flow with any repair is associated with early improved erectile function; however, it is not a sustained benefit. There is limited benefit of maintaining bilateral hypogastric artery perfusion for this specific indication in unselected men undergoing AAA repair.

The erectile and ejaculatory implications of the surgical management of rectal cancer.

Colorectal cancer is a significant cause of cancer-related deaths worldwide. Although advances in surgical technology and technique have decreased mortality rates, surviving patients often experience sexual dysfunction as a common complication. The development of the lower anterior resection has greatly decreased the use of the radical abdominoperineal resection surgery, but even the less radical surgery can result in sexual dysfunction, including erectile and ejaculatory dysfunction. Improving the knowledge of the underlying causes of sexual dysfunction in this context and developing effective strategies for preventing and treating these adverse effects are essential to improving the quality of life for postoperative rectal cancer patients. This article aims to provide a comprehensive evaluation of erectile and ejaculatory dysfunction in postoperative rectal cancer patients, including their pathophysiology and time course and strategies for prevention and treatment.

Association of nerve-sparing grading in robotic radical prostatectomy and trifecta outcome.

PURPOSE: To evaluate the neurovascular bundle preservation grades during robotic-assisted radical prostatectomy and compared to the trifecta combined outcome (oncologic control, continence, and sexual function) twelve months after the surgery. METHODS: Cohort of patients who underwent nerve-sparing robotic-assisted radical prostatectomy had the neurovascular bundle preservation retrospectively graded from 0 to 8 according to the Hopkins subjective visual classification. Patients then were divided into two groups, according to the median of nerve-sparing grading: those with score six or high and those with score less than six. Main outcome was the trifecta combined outcome and secondary outcomes was the individual trifecta criteria (prospective analysis). A secondary analysis with groups divided according to pre-operatory SHIM score was made. RESULTS: One hundred robotic-assisted nerve-sparing radical prostatectomy were performed, of which 83 were included. There were 53 patients with grading greater than or equal to six (group 1) and 30 patients less than six (group 2). 66.6% patients (35/53) in group 1 had a trifecta combined outcome of compared to 33.3% (10/30) in group 2 (p = 0.017). Individually, the erectile function was higher in group 1 (73.6%) compared to group 2 (46.7%) (p = 0.014). Both the results of the combined endpoint trifecta and erection were also maintained in the group with preoperative SHIM ≥ 17. CONCLUSIONS: The grading of preservation of the neurovascular bundle in radical prostatectomy is related to a better combined trifecta outcome one year after surgery.

Prevention of Penile Prosthesis Infection.

INTRODUCTION: Management protocols for treatment of severe erectile dysfunction have changed little in the last 20 years. Most algorithms consider penile prostheses as the last option of treatment in patients who have failed medical management. Despite multiple advances in current devices, prosthetic infection remains the most feared complication by implanting surgeons and patients. This report tries to make a compilation of the factors that can be impacted to prevent penile implant infections, and to make penile implantation a safer and more reliable way to solve an erection deficit. PURPOSE OF REVIEW: List events related to the surgical act (pre-operative, intra-operative, and post-operative) that are related to the risk of infection to contextualize possible actions/measures used to avoid prosthetic infection. RECENT FINDINGS: The impact of coated implants on reduction of infection rates. The recommendation to use chlorhexidine-based solutions over iodine solution for preoperative skin preps. Appears to be no difference in infection rates according to the approach chosen by the surgeon (infrapubic vs penoscrotal). The change in the microbial colonies that are colonizing implants in recent years are dramatic. Lack of evidence of which solutions to use for salvage or revision washout surgery: Chemical eradication or mechanical lavage cleansing?. Despite the importance of metabolic control in the literature, there is a disparity in exact glycemic values ​prior to the intervention in our literature. Factors such as preparation of the operative site, presence of comorbidities or previous surgeries, surgical time, or additional maneuvers during surgery can negatively impact the final result of penile prosthetic surgery.

Supplementation with Spirulina platensis Prevents Damage to Rat Erections in a Model of Erectile Dysfunction Promoted by Hypercaloric Diet-Induced Obesity.

Erectile dysfunction (ED) is the inability to achieve and/or maintain a penile erection sufficient for sexual satisfaction. Currently, many patients do not respond to the pharmacotherapy. The effects of a supplementation with Spirulina platensis, were evaluated in a model of ED induced by hypercaloric diet consumption. Wistar rats were divided into groups fed with standard diet (SD) or hypercaloric diet (HD) and supplemented with this alga at doses of 25, 50 or 100 mg/kg. Experimental adiposity parameters and erectile function were analyzed. In SD groups, Spirulina platensis reduced food intake, final body mass and adiposity index, and increased the total antioxidant capacity (TAC) of adipose tissue. However, no change was observed in erectile function. In the HD group, without Spirulina supplementation, a decrease in food intake was observed, in addition to an increase of final body mass, weight gain, adipose reserves, and adiposity index. Additionally, reduction in the number and increase in the latency of penile erection and adipose malondialdehyde levels, as well as a reduction in TCA was noted. Furthermore, cavernous contractility was increased, and the relaxing response was decreased. Interestingly, these deleterious effects were prevented by the algae at doses of 25, 50 and/or 100 mg/kg. Therefore, the supplementation with S. platensis prevents damages associated to a hypercaloric diet consumption and emerges as an adjuvant the prevention of ED.

Neurovascular bundle preservation in robotic-assisted radical prostatectomy: How I do it after 15.000 cases.

Despite the neuroanatomy knowledge of the prostate described initially in the 1980's and the robotic surgery advantages in terms of operative view magnification, potency outcomes following robotic-assisted radical prostatectomy still challenge surgeons and patients due to its multifactorial etiology. Recent studies performed in our center have described that, in addition to the surgical technique, some important factors are associated with erectile dysfunction (ED) following robotic-assisted radical prostatectomy (RARP). These include preoperative Sexual Health Inventory for Men (SHIM) score, age, preoperative Gleason score, and Charlson Comorbidity Index (CCI). After performing 15,000 cases, in this article we described our current Robotic-assisted Radical Prostatectomy technique with details and considerations regarding the optimal approach to neurovascular bundle preservation.

[Preventive and therapeutic effects of Icariside â ¡ on radiation injury-induced erectile dysfunction in rats].

OBJECTIVE: To explore the preventive and therapeutic effects of Icariside Ⅱ (ICAⅡ) on radiation injury-induced ED (Ri-ED) in rats. METHODS: Twenty-four 10-week-old male SD rats received exposure of the prostate to single X-ray irradiation of 20 Gy, and were randomly equally divided into an Ri-ED group (6 survived and 6 died) and a treatment group treated with ICAⅡ at 4.5 mg/kg/d (9 survived and 3 died). Another 6 SD rats were taken as negative controls. After 4 weeks of continuous intragastric administration and 2 weeks of drug elution, the erectile function of the rats was evaluated by measurement of the maximum intracavernous pressure / mean arterial pressure (ICPmax/MAP), and the penile tissues were subjected to immunofluorescence staining, immunohistochemistry, Masson's trichrome staining, Western blot and detection of oxidative stress indicators. RESULTS: Compared with the negative controls, the rats in the Ri-ED group showed significant decreases in ICPmax/MAP (0.76 ± 0.09 vs 0.42 ± 0.06, P < 0.01), the number of nNOS-positive nerve fibers in the corpus cavernosum (10.17 ± 2.64 vs 3.17 ± 1.72, P < 0.01), the content of endothelial cells (1.39 ± 0.30 vs 0.35 ± 0.12, P < 0.01), the expressions of nNOS (0.42 ± 0.08 vs 0.08 ± 0.01, P < 0.01) and eNOS (0.99 ± 0.24 vs 0.12 ± 0.08, P < 0.01) and the activity of superoxide dismutase (SOD) (ï¼»343.73 ± 58.57ï¼½ vs ï¼»153.50 ± 34.06ï¼½ U/mg prot, P < 0.01), but an increase in the malondialdehyde (MDA) level (ï¼»1.80 ± 0.31ï¼½ vs ï¼»3.25 ± 0.21ï¼½ nmol/mg prot, P < 0.01). In comparison with the Ri-ED group, the animals treated with ICAⅡ exhibited remarkably increased ICP/MAP (0.42 ± 0.06 vs 0.66 ± 0.07, P < 0.01), number of nNOS-positive nerve fibers (3.17 ± 1.72 vs 7.33 ± 1.75, P < 0.05), content of endothelial cells (0.35 ± 0.12 vs 1.07 ± 0.36, P < 0.01), and expressions of nNOS (0.08 ± 0.01 vs 0.16 ± 0.05, P < 0.05) and eNOS (0.12 ± 0.08 vs 0.86 ± 0.30, P < 0.01) in the corpus cavernosum, but a decreased level of MDA (ï¼»3.25 ± 0.21ï¼½ vs ï¼»2.17 ± 0.55ï¼½ nmol/mg prot, P < 0.05). In addition, ICAⅡ effectively reduced radiation injury-induced mortality of the rats. CONCLUSION: IcarisideⅡ can significantly improve ED and pathological changes and reduce mortality caused by radiation injury in rats, which may be related to its ability of improving radiation-induced oxidative stress.

Renal Transplantation Improves Erectile Function in Patients with End-Stage Renal Disease: A Systematic Review and Meta-Analysis.

PURPOSE: Erectile dysfunction has a lower prevalence in renal transplant recipients compared to dialysis patients. Despite this observation, the effect of renal transplantation on erectile function remains unknown. We aimed to assess the role of renal transplantation on erectile function and to determine potential factors improving or deteriorating erectile dysfunction. MATERIALS AND METHODS: We conducted a systematic review and random effects meta-analysis of observational studies comparing erectile function preoperatively and postoperatively in renal transplant recipients (PROSPERO ID: CRD42020189580). Records reporting relevant outcomes were identified through search of PubMed®, Embase®, Cochrane Library and Scopus® databases from inception to September 2020. Judgment of the strength of evidence was performed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: We included 20 studies with 1,695 renal transplant recipients. At postoperative evaluation the number of patients with erectile dysfunction was reduced (RR 1.21, 95% CI 1.02-1.45, I2=88%). Renal transplant recipients reported an improvement in erectile function (RR 2.53, 95% CI 1.44-4.44, I2=90%) and the mean International Index of Erectile Function score increased by 3.04 points (95% CI 0.63-5.45, I2=96%) after renal transplantation. These effects were not demonstrated in the sensitivity analysis. In individuals reporting severe erectile dysfunction, no favorable effect of renal transplantation was observed (RR 1.51, 95% CI 0.85-2.68, I2=33%). For all outcomes the strength of evidence was considered low or very low due to methodological concerns and high heterogeneity among the included studies. CONCLUSIONS: Renal transplantation improves erectile function and the risk of erectile dysfunction reduces postoperatively compared to preoperatively. However, evidence on the matter is mostly based on low quality data. More studies with standardized outcomes are needed to validate and strengthen our findings.

Performance Feedback May Not Improve Radical Prostatectomy Outcomes: The Surgical Report Card (SuRep) Study.

PURPOSE: Oncologic, urinary, and sexual outcomes are important to patients receiving prostate cancer surgery. The objective of this study was to determine if providing surgical report cards (SuReps) to surgeons resulted in improved patient outcomes. MATERIALS AND METHODS: A prospective before-and-after study was conducted at The Ottawa Hospital. A total of 422 consecutive patients undergoing radical prostatectomy were enrolled. The intervention was provision of report cards to surgeons. The control cohort was patients treated before report card feedback (pre-SuRep), and the intervention cohort was patients treated after report card feedback (post-SuRep). The primary outcomes were postoperative erectile function, urinary continence, and positive surgical margins. RESULTS: Baseline characteristics were similar between groups. Almost all patients (99%) were continent and the majority (59%) were potent prior to surgery. Complete 1-year followup was available for 400 patients (95%). Nerve sparing surgery increased from 70% pre-SuRep to 82% post-SuRep (p=0.01). There was a nonstatistically significant increase in the proportion of patients with a positive surgical margin post-SuRep (31% pre-SuRep vs 39% post-SuRep, p=0.08). There was no difference in postoperative erectile function (17% vs 18%, p=0.7) and a decrease in continence (75% vs 65%, p=0.02) at 1 year postoperatively. CONCLUSIONS: The SuRep platform allows accurate reporting of surgical outcomes that can be used for patient counseling. However, the provision of surgical report cards did not improve functional or oncologic outcomes. Longer durations of feedback, report card modifications, or targeted interventions are likely necessary to improve outcomes.

Retzius-Sparing versus Standard Robot-Assisted Radical Prostatectomy: A Comparative Prospective Study of Nearly 500 Patients.

PURPOSE: We compared standard robot-assisted radical prostatectomy and Retzius-sparing robot-assisted radical prostatectomy in a multicenter study using prospective patient reported outcome measures of functional recovery and quality of life plus standard pentafecta outcomes. MATERIALS AND METHODS: Patient and physician reported data on 483 patients who underwent robot-assisted radical prostatectomy and Retzius-sparing robot-assisted radical prostatectomy from August 2017 to April 2020 by 3 experienced surgeons had been prospectively collected. Perioperative and pentafecta outcomes were analyzed using SPSS software. Patient reported outcome measures for urinary function, erectile function and quality of life were reported at baseline and at 7 days and 1, 3, 6, 9 and 12 months postoperatively. RESULTS: A total of 201 patients underwent robot-assisted radical prostatectomy and 282 had Retzius-sparing robot-assisted radical prostatectomy. Patient and tumor characteristics were similar except for fewer low risk and more intermediate risk disease in robot-assisted radical prostatectomy vs Retzius-sparing robot-assisted radical prostatectomy (p <0.001). High risk disease was similar between groups (p=0.071). Immediate urinary continence was higher in Retzius-sparing robot-assisted radical prostatectomy group (70.4% vs 58.1%, p=0.02), with less nocturnal enuresis prevalence (p=0.011) and bother (p=0.009) with no significant differences afterwards. A better quality of life (p=0.004) was reported 1 week after surgery. No other differences in functional or quality of life outcomes, perioperative parameters, complications or margin rates were found. CONCLUSIONS: Retzius-sparing robot-assisted radical prostatectomy is associated with better immediate continence than anterior robot-assisted radical prostatectomy with no differences in longer-term functional recovery, quality of life or other important outcomes. The overall similarity in outcomes between groups lends support to the view that the surgical technique matters less than the surgeon performing it.

Acute Ischemic Priapism: An AUA/SMSNA Guideline.

PURPOSE: Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing. Acute ischemic priapism, characterized by little or no cavernous blood flow and abnormal cavernous blood gases (ie, hypoxic, hypercarbic, acidotic) represents a medical emergency and may lead to cavernosal fibrosis and subsequent erectile dysfunction. MATERIALS AND METHODS: A comprehensive search of the literature was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. Searches identified 2948 potentially relevant articles, and 2516 of these were excluded at the title or abstract level for not meeting inclusion criteria for any key question. Full texts for the remaining 432 articles were reviewed, and ultimately 137 unique articles were included in the report. RESULTS: This Guideline was developed to inform clinicians on the proper diagnosis and surgical and non-surgical treatment of patients with acute ischemic priapism. This Guideline addresses the role of imaging, adjunctive laboratory testing, early involvement of urologists when presenting to the emergency room, discussion of conservative therapies, enhanced data for patient counseling on risks of erectile dysfunction and surgical complications, specific recommendations on intracavernosal phenylephrine with or without irrigation, the inclusion of novel surgical techniques (eg, tunneling), and early penile prosthesis placement. CONCLUSIONS: All patients with priapism should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event should be provided early intervention. Treatment of the acute ischemic patient must be based on patient objectives, available resources, and clinician experience. As such, a single pathway for managing the condition is oversimplified and no longer appropriate. Using a diversified approach, some men may be treated with intracavernosal injections of phenylephrine alone, others with aspiration/irrigation or distal shunting, and some may undergo non-emergent placement of a penile prosthesis.

Impact of Focal Versus Whole Gland Ablation for Prostate Cancer on Sexual Function and Urinary Continence.

PURPOSE: Focal instead of whole gland ablation for prostate cancer has been proposed to decrease treatment morbidity. We sought to determine differences in erectile function and urinary continence after focal and whole gland ablation for prostate cancer. MATERIALS AND METHODS: From 2009 to 2018, 346 patients underwent high intensity focused ultrasound or cryotherapy for prostate cancer. Urinary continence was defined as use of no pads and sexual potency as enough erection for sexual penetration. Logistic regressions to treatment groups and covariates age, prostate specific antigen, International Society of Urological Pathology grading, prostate volume and energy modality were performed to access the effect of focal therapy in sexual potency and urinary continence after 3 and 12 months. IIEF-5 (International Index of Erectile Function) and I-PSS (International Prostate Symptom Score) questionnaires were evaluated. Propensity score matching was performed to adjust for potential baseline differences between groups. RESULTS: After exclusion, 195 post-focal therapy and 105 post-whole gland therapy patients were included in analysis. No significant difference was seen in baseline I-PSS and IIEF-5 scores. In multivariate models focal therapy was the most important factor related to sexual potency at 3 (OR 7.7) and 12 months (OR 3.9). Median IIEF-5 score at 3 months was 12 and 5 (p <0.001), and at 12 months was 13 and 9 (p=0.04) in focal therapy and whole gland therapy groups, respectively. Focal therapy was the only factor related to continence (OR 0.7, p <0.001). Results remained significant after propensity score matching. CONCLUSIONS: Focal ablation instead of whole gland therapy is the most important factor related to better sexual and urinary continence recovery after high intensity focused ultrasound and cryotherapy for prostate cancer.

Apelin-13 Protects Corpus Cavernosum Against Fibrosis Induced by High-Fat Diet in an MMP-Dependent Mechanism.

BACKGROUND: An increased fibrosis of the corpora cavernosa is a prevalent process that underlies most cases of erectile dysfunction. Apelin, an endogenous circulating peptide, has been documented as an important effector on cardiovascular homeostasis, controlling vascular function and reducing fibrosis in multiple pathological conditions. Recently, initial studies have shown that Apelin, acting through the APJ receptor, also modulates penile erection, however, the role of this system on penile structure and intracorporal collagen remodeling has not been investigated yet. AIMS: Here we sought to investigate the effect of chronic Apelin treatment on the corpus cavernosum structure of hyperchOlesterolemic mice. METHODS: Apolipoprotein gene-deleted (ApoE-/-) mice were fed with a Western diet for 11 weeks and received Apelin-13 (2 mg/kg/day) or vehicle during the last 3 weeks. Penile samples were obtained for histological and biochemical analyses to assess the intracorporal collagen content and key proteins expression. Furthermore, the effect of Apelin-13 was evaluated in cultured NIH3T3 mouse fibroblasts stimulated with TGF-ß. OUTCOME: Local expression of Apelin-13 in mouse corpus cavernosum and its protective effect against fibrosis. RESULTS: Apelin and APJ receptor were expressed (gene and protein) within the corpus cavernosum of ApoE-/- mice, indicating a local modulation of the Apelin system. Interestingly, 3 weeks of Apelin-13 treatment strongly reduced intracavernosal collagen content. In addition, Apelin-13 enhanced total matrix metalloproteinase (MMP) activity in the mice penis, which was associated with an increased protein expression of MMP-1, MMP-3, MMP-8, and MMP-9, while tissue inhibitor of metalloproteinase were unaltered. These beneficial actions were not associated with changes in nNOS or eNOS protein expression, intracavernosal reactive oxygen species content, or atherosclerotic plaque deposition. Additionally, in cultured fibroblast, Apelin-13 inhibited TGF-ß-induced fibroblast to myofibroblast differentiation and collagen production, possibly through the activation of ERK1/2 kinase. CLINICAL TRANSLATION: These results point out Apelin/APJ system as a potential target to treat intracavernosal fibrosis-related disorders. STRENGTH & LIMITATIONS: These results provide the first evidence of the Apelin system's positive role on erectile tissue structure/remodeling. Nevertheless, additional functional study addressing erectile response would bring extended validation regarding the relevance of such effect. CONCLUSION: These results suggest a local modulation of the Apelin system within the corpus cavernosum. Remarkably, Apelin-13 reduced intracavernosal fibrosis in hypercholesterolemic mice by: (i) enhancing MMPs expression and activity; and (ii) inhibiting fibroblast differentiation into myofibroblast. Altogether, these results suggest an essential protective role of Apelin, indicating Apelin/APJ system as a promising candidate for the development of fibrosis-associated erectile dysfunction treatments. Sturny M, Anguenot L Costa-Fraga FP, et al. Apelin-13 Protects Corpus Cavernosum Against Fibrosis Induced by High-Fat Diet in an MMP-Dependent Mechanism. J Sex Med 2021;18:875-888.

Comprehensive approach for preserving cavernous nerves and erectile function after radical prostatectomy in the era of robotic surgery.

A nerve-sparing procedure during robot-assisted radical prostatectomy has been considered one of the most important techniques for preserving postoperative genitourinary function. The reason is that adequate nerve-sparing procedures could preserve both erectile function and lower urinary tract function after surgery. When a nerve-sparing procedure is carried out, the cavernous nerves themselves cannot be visualized, despite the magnified viewing field during robot-assisted radical prostatectomy. Thus, nerve-sparing procedures have been considered challenging operations, even now. However, because not all surgeons have carried out a sufficient number of nerve-sparing procedures, the development of new nerve-sparing procedures or new methods for mapping the cavernous nerves is required. Recently, various new operative techniques, for example, Retzius-sparing robot-assisted radical prostatectomy, transvesical robot-assisted radical prostatectomy and retrograde release of neurovascular bundle technique during robot-assisted radical prostatectomy, have been developed. In addition, new surgical devices, for example, biological/bioengineering solutions for cavernous nerve protection and devices for identifying the cavernous nerves during radical prostatectomy, have developed to preserve the cavernous nerves. In contrast, limitations or problems in preserving cavernous nerves and postoperative erectile function have become apparent. In particular, the recovery rate of erectile function, the positive surgical margin rate at the site of nerve-sparing and the indications for nerve sparing have become obvious with the accumulation of much evidence. Furthermore, predictive factors for postoperative erectile function after nerve-sparing procedures have also been clarified. In this article, the importance of a comprehensive approach for early recovery of erectile function in the robot-assisted radical prostatectomy era is discussed.

Using Artificial Intelligence to Predict Surgical Shunts in Men with Ischemic Priapism.

PURPOSE: Ischemic priapism is a urological emergency that requires prompt intervention to preserve erectile function. Characteristics that influence escalation to surgical intervention remain unclear. We identified factors and developed machine learning models to predict which men presenting with ischemic priapism will require shunting. MATERIALS AND METHODS: We identified men with ischemic priapism admitted to the emergency department of our large county hospital between January 2010 and June 2019. We collected patient demographics, etiology, duration of priapism prior to intervention, interventions attempted and escalation to shunting. Machine learning models were trained and tested using R to predict which patients require surgical shunting. RESULTS: A total of 334 encounters of ischemic priapism were identified. The majority resolved with intracavernosal phenylephrine injection and/or cavernous aspiration (78%). Shunting was required in 10% of men. Median duration of priapism before intervention was longer for men requiring shunting than for men who did not (48 vs 7 hours, p=0.030). Patients with sickle cell disease as the etiology were less likely to require shunting compared to all other etiologies (2.2% vs 15.2%, p=0.035). CONCLUSIONS: Men with longer duration of priapism before treatment more often underwent shunting. However, phenylephrine injection and aspiration remained effective for priapism lasting more than 36 hours. Having sickle cell disease as the etiology of priapism was protective against requiring shunting. We developed artificial intelligence models that performed with 87.2% accuracy and created an online probability calculator to determine which patients with ischemic priapism may require shunting.

Ejaculatory Hood Sparing versus Standard Laser Photoselective Vaporization of the Prostate: Sexual and Urodynamic Assessment through a Double Blinded, Randomized Trial.

PURPOSE: In a preliminary clinical trial we assessed the efficacy of ejaculatory hood sparing GreenLight™ Laser prostate photoselective vaporization to preserve antegrade ejaculation and urodynamic relief of obstruction compared to standard GreenLight prostate photoselective vaporization. MATERIALS AND METHODS: Standard prostate photoselective vaporization was classically performed in 24 patients. Ejaculatory hood sparing vaporization was performed with preservation of the paracollicular and supracollicular tissue proximal to the verumontanum in 25 patients. Patients were assessed at baseline, and 1, 3, 6 and 12 months postoperatively using the Ej-MSHQ (Ejaculatory Domain of Male Sexual Health Questionnaire) and the IIEF-15 (International Index of Erectile Function-15). The I-PSS (International Prostate Symptom Score), uroflowmetry and post-void residual urine volume were reported at each followup visit. A standard urodynamic study was performed at 6 months. RESULTS: Antegrade ejaculation was reported in 85% and 31.6% of patients after hood sparing and standard prostate vaporization, respectively (p=0.001). A significant reduction in the EJ-MSHQ score was reported after standard vaporization at 6 and 12 months (each p <0.001) with no significant difference after hood sparing vaporization (p=0.18 and 0.078, respectively). The median EJ-MSHQ score was 28.5 (range 1 to 33) and 27 (range 1 to 33) for hood sparing vaporization, and 9.5 (range 1 to 35) and 9 (range 0 to 33) for standard vaporization at 6 (p=0.005) and 12 months (p <0.001), respectively. Each group showed a decline in the mean total IIEF-15 score at 1 year but it was statistically significant only after standard vaporization (p=0.001). All urinary outcome measures revealed comparable significant improvement at all followups. Postoperative urodynamic assessment demonstrated a significant comparable decrease in the Bladder Outlet Obstruction Index from a median of 64 (range 21 to 207) to 23.5 (range 10 to 53) after hood sparing vaporization (p=0.005) and from 87 (range 38 to 186) to 19.5 (range 7 to 51) after standard vaporization (p=0.001). At 1 year the overall re-treatment rate was comparable in the 2 groups (p=0.26). CONCLUSIONS: In well informed, sexually interested patients ejaculatory hood sparing GreenLight prostate photoselective vaporization is feasible and effective treatment of small to moderate sized benign prostatic hyperplasia with a superior sexual function related outcome. Short-term relief of obstruction is objectively comparable to that of standard prostate photoselective vaporization.