A preliminary investigation of a novel method to manipulate penis length to measure female sexual satisfaction: a single-case experimental design.

OBJECTIVES: To investigate a novel methodology and explore whether artificially reducing the depth of penetration during intercourse matters to women. STUDY DESIGN AND METHODS: A study with a single-case experimental design ('n of 1'), in which a heterosexual couple act as their own control and the study is then replicated in subsequent couples, was conducted. Thirty-five couples were assessed for eligibility to participate. Twenty-nine couples without any sexual problems were randomized and 12 submitted sufficient data to analyse. As a proxy for reducing penis length, we artificially reduced the depth of penetration by using different sizes of silicone rings around the base of the man's erect penis. The main outcome measures were provided by the female partner on a scale of 0-100 and comprised: degree of (i) overall sexual pleasure; (ii) sexual pleasure from intercourse alone; and (iii) emotional connection to the male partner. The female partner was also asked before the experiment began to rate the degree of positive or negative change that would be personally meaningful for her. RESULTS: On average, reducing the depth of penetration led to a statistically significant 18% reduction of overall sexual pleasure with an average 15% reduction in length of the penis. The longer the erect penis, the less likely the rings were to have an impact on sexual pleasure. There was a range of individual responses, however, with a minority of women reporting that reducing the depth of penetration was more pleasurable on some occasions. CONCLUSIONS: Size may matter in women in a healthy stable relationship when there is penile shortening. Because of the small number of couples and the inclusion of men with an apparently long penis, our results are preliminary, and we welcome replication in a larger sample with a more diverse range of penile lengths. Our results should not be misinterpreted as meaning that increasing penile length will increase sexual pleasure in women.

Nephrometry scores: a validation of three systems for peri-operative outcomes in retroperitoneal robot-assisted partial nephrectomy.

OBJECTIVE: To externally validate the RENAL, PADUA and SPARE nephrometry scoring systems for use in retroperitoneal robot-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS: Nephrometry scores were calculated for 322 consecutive patients receiving retroperitoneal RAPN at a tertiary referral centre from 2017. Patients with multiple tumours were excluded. Scores were correlated with peri-operative outcomes, including the trifecta (warm ischaemia time <25 min, no peri-operative complications and a negative surgical margin), both as continuous and categorical variables. Comparisons were performed using Spearman correlation and ability to predict the trifecta was assessed using binomial logistical regression. RESULTS: All three scoring systems correlated significantly with the main variables (operating time, warm ischaemia time and estimated blood loss), both as continuous and categorical variables. Only PADUA and SPARE were able to predict achievement of the trifecta (PADUA area under the curve [AUC] 0.623, 95% confidence interval [CI] 0.559-0.668; SPARE AUC 0.612, 95% CI 0.548-0.677). CONCLUSION: This study validates the RENAL, PADUA and SPARE scoring systems to predict key intra-operative outcomes in retroperitoneal RAPN. Only PADUA and SPARE were able to predict achievement of the trifecta. As a simplified version of the PADUA scoring system with comparable outcomes, we recommend using the SPARE system.

Penile length is preserved after implant surgery.

OBJECTIVE: To investigate if there is a correlation between penile size measured preoperatively and erect penis after penile implant surgery (PI). A common cause of patient dissatisfaction after PI is caused by patients complaining that surgery has shortened the penis. It has been suggested that stretched penile length preoperatively is almost the same after surgery when the prosthesis is in erect status. However, no comprehensive data supports this theory. This prospective study was done to investigate this theory. PATIENTS AND METHODS: Standardised measurements of stretched penile length and girth were performed in theatre before PI implantation then re-measured at the end of the procedure with the penis in the erect position. We recorded type of PI, cylinder lengths and malleable rod diameters. All patients had data recorded on body mass index (BMI), hypertension (HTN), glycated haemoglobin (HbA1c ), and Peyronie's disease (PD). RESULTS: In all, 133 patients were assessed; 88 (66.2%) had a malleable penile prosthesis (MPP) and 45 (33.8%) an inflatable penile prosthesis (IPP). The median age and BMI were 56 years and 30 kg/m2 , respectively. In all, 40 (30.1%) patients had HTN, 37 (27.8%) had PD, and 89 (66.9%) were diabetic. The mean (SD) pre-implant stretched length was 12.8 (1.8) cm. The mean (SD) flaccid girth was 10.3 (1.2) cm. Postoperatively, the mean (SD) erect length and girth were 13.1 (1.7) cm and 11.3 (1.3) cm, respectively. Overall, there was a significant (P < 0.05) increase in both the mean (SD) length at +0.36 (0.63) cm, and girth at +1.04 (1.02) cm. Patients who had an IPP, had a greater increase in both length (mean [SD] 0.62 [0.72] cm) and girth (mean [SD] 1.7 [1.0] cm) compared to those who had a MPP (mean [SD] 0.22 [0.53] cm and 0.7 [0.87] cm, respectively) (P < 0.05). We investigated correlations between pre- and postoperative outcomes related to BMI, HTN, diabetes, and PD. None of these variables affected outcome. CONCLUSIONS: PI surgery does not significantly decrease penile size compared to the preoperative assessment. The outcome was not affected by co-morbidities. The preoperative length and girth correlated well with the immediate postoperative erect penis, although girth was not necessarily comparable in this series of patients measured under anaesthesia. Recording penile dimensions in the clinic and agreeing these with patients' preoperatively may be a way of improving satisfaction levels with this surgery.

Clomiphene citrate and human chorionic gonadotropin are both effective in restoring testosterone in hypogonadism: a short-course randomized study.

OBJECTIVES: To compare serum testosterone response and symptom improvement in men with hypogonadism in response to treatment with clomiphene citrate (CC), human chorionic gonadotropin (hCG), or a combination of both therapies. PATIENTS AND METHODS: A total of 282 men with hypogonadism, wishing to preserve their fertility, were randomized to one of three treatment arms: CC 50 mg (n = 95); 5000 IU hCG injections twice weekly (n = 94); or a combination of both therapies (CC + hCG; n = 94). All participants had complete medical history and had undergone thorough physical examination, including body mass index (BMI) assessment. Laboratory tests included serum total testosterone and glycated haemoglobin (HbA1c) measurements. Quantitative Androgen Deficiency in the Aging Male (qADAM) questionnaire scores were also recorded. Morning samples of total serum testosterone levels were assessed at three time points: baseline, 1 and 3 months. RESULTS: Testosterone levels increased at 1 and 3 months in all three groups. The mean baseline testosterone level was 2.31 ± 0.66 nmol/L, BMI was 30.8 ± 6.2 kg/m2 , and qADAM score was 20.5 ± 3.8. Testosterone levels increased in all groups at all time points, with a final mean value of 5.17 ± 1.77 nmol/L (223% increase) with no statistically significant difference among the groups. qADAM scores had increased in all groups at 1 month (CC group: 6.36; hCG group: 5.08; CC + hCG group: 7.26) and at 3 months (CC group: 12.73; hCG group: 11.82; CC + hCG group: 15.13) with a significant difference in intergroup analysis for the CC + hCG group compared with the other two groups (P < 0.01). CONCLUSIONS: All three treatments were equally effective in restoring testosterone levels. Single-agent CC is simple, cheap and may be used as treatment for hypogonadism when maintenance of fertility is desired. This approach seems to be as effective as either hCG alone or a combination of hCG and CC.

Predictors of Satisfaction in Men After Penile Implant Surgery.

INTRODUCTION: Despite the high satisfaction with penile implant (PI) surgery reported in the literature, a significant proportion of patients remain dissatisfied. AIM: To evaluate satisfaction after PI surgery, using a single question and a scoring system. Furthermore, we attempted to define factors that predicted high patient satisfaction. METHODS: The study population consisted of all patients undergoing PI surgery between 2009 and 2015. Comorbidity, demographic, and implant information were recorded. Complications recorded included: minor (requiring no re-operation) such as penile or scrotal hematoma, superficial wound breakdown; major (requiring hospitalization or re-operation) such as device infection, erosion, and mechanical malfunction. Patient satisfaction was defined using a single question posed to the patient 6 months after surgery using a 5-point Likert scale (5 being the most satisfied). Descriptive statistics were used to define complication rates and multivariable analysis (MVA) was performed to define predictors of high satisfaction (score ≥ 4), including presence and degree of complications, Peyronie's disease (PD), diabetes mellitus (DM), number of vascular comorbidities, body mass index (BMI) > 30, and patient age. MAIN OUTCOME MEASURE: Patients with a major complication, with or without an additional minor complication, had a higher likelihood of being dissatisfied (25%) compared to patients with no complication or only minor complication 1.9% (no complications) and 3.7% (only minor complications), P < .001. RESULTS: 902 patients were analysed. Mean age was 56.6 ± 10.6 years. Mean BMI was 30 ± 5. Comorbidity profile was diabetes 75%, dyslipidaemia 44%, hypertension 33%, cigarette smoking 32%, and PD 34%. 76% had a malleable implant (MPP) and 24% an inflatable implant (IPP). 31% had a minor complication and 9% a major complication. 93% had high satisfaction (score ≥4). Patients with any complication had a reduced rate of high satisfaction (97.5% vs 87.7%; P < .001) and even more pronounced with a major complication (96.7% vs 64.2%; P < .001). On MVA, only the absence of a major complication was a significant predictor of high satisfaction (OR 20, 95% CI 9-50, P < .001). CONCLUSION: A high percentage of men are satisfied after penile implant surgery. Only the presence of a major complication is linked to a lower likelihood of achieving high satisfaction. Habous M, Tal R, Tealab A, et al. Predictors of Satisfaction in Men After Penile Implant Surgery. J Sex Med 2018;15:1180-1186.

Urologists' attitudes to sexual complications of LUTS/BPH treatments.

INTRODUCTION: Many LUTS/BPH treatments currently available may affect sexual function (SD). We wished to assess urologists' attitude and practice in this area. METHODS: Attendees of an international meeting were randomly selected, interviewed and stratified by professional status and LUTS/BPH cases seen per month. There were four questions: treatment options offered, frequency of discussing erectile dysfunction (ED) with each treatment, frequency of discussing ejaculatory dysfunction (EjD) with each treatment, and offering alternative treatment based on the risks of sexual dysfunction. RESULTS: 199 of the 245 interviewed (81%) were urologists. The most common treatments offered were α-blockers (99.5%), 5-ARI (95.0%) and TURP (92.5%). About 70% of the specialists discuss ED before α-blockers (not known to cause ED). Regarding EjD, 70% discuss this prior to prescribing α-blockers, 60% before 5-ARI therapy, while 80% before TURP. A significant minority fails to discuss this complication in all areas. Many respondents do not routinely discuss alternative therapies on the risk of SD. The higher the caseload, the less likely was a urologist to offer alternative therapies, with 37% of urologists seeing over 30 LUTS/BPH patients per month stating they would "Not at all often" offer alternative therapies for this reason. CONCLUSIONS: There is a significant discrepancy in attitudes to counselling patients on SD related to LUTS/BPH treatments. This may, in some cases, affect the validity of consent to the treatment. Most urologists do not discuss alternative treatments with patients based on the risks of different outcomes and complications, and this seems more marked in those with the busier practices. This may sit ill with the concept of personalised healthcare.

Ureteric stent associated spondylodiscitis.

This case report describes a clinical presentation of spondylodiscitis, following an emergency ureteric stent placement for an infected and obstructed kidney in a woman in her late 70s who presented with right flank pain, raised inflammatory markers and an acute kidney injury. Non-contrast CT kidney, ureters and bladder (KUB) revealed a 9 mm obstructing stone and prompt decompression with a JJ stent was performed. Although the urine culture showed no growth at first, an extended spectrum beta-lactamase Escherichia coli was found in a subsequent urine culture after discharge. Postoperatively, the patient described a novel, worsening lower back pain and had persistently elevated inflammatory markers. An MRI revealed spondylodiscitis of L5/S1, for which she was treated with a 6-week course of antibiotics, and she has made a good but slow recovery. This case shows the unusual finding of spondylodiscitis postureteric stent placement and clinicians should be aware of this rare complication.

Prostate minimally invasive procedures: complications and normal vs. abnormal findings on multiparametric magnetic resonance imaging (mpMRI).

Minimally invasive alternatives to traditional prostate surgery are increasingly utilized to treat benign prostatic hyperplasia and localized prostate cancer in select patients. Advantages of these treatments over prostatectomy include lower risk of complication, shorter length of hospital stay, and a more favorable safety profile. Multiparametric magnetic resonance imaging (mpMRI) has become a widely accepted imaging modality for evaluation of the prostate gland and provides both anatomical and functional information. As prostate mpMRI and minimally invasive prostate procedure volumes increase, it is important for radiologists to be familiar with normal post-procedure imaging findings and potential complications. This paper reviews the indications, procedural concepts, common post-procedure imaging findings, and potential complications of prostatic artery embolization, prostatic urethral lift, irreversible electroporation, photodynamic therapy, high-intensity focused ultrasound, focal cryotherapy, and focal laser ablation.

Prostate cancer treated with irreversible electroporation: MRI-based volumetric analysis and oncological outcome.

BACKGROUND: To assess multiparametric magnetic resonance imaging (mpMRI) characteristics in prostate cancer (PCa) before and after irreversible electroporation (IRE) and to investigate their correlation with the presence of post-operative recurrence of PCa. METHODS: MpMRI was performed in 30 men with PCa prior to treatment, after 10 days and at 6 months. An additional scan at 1 year was available for 18 men. Two radiologists assessed retrospectively the following parameters by planimetry: tumour volume, necrotic volume (early post-treatment scan) and residual fibrosis. Residual tumour/recurrence were defined as a suspicious area within the treatment field scored ≥ 4 on a 1-to-5 scale. Oncological outcome was also assessed. RESULTS: The median follow-up of the entire study was 16 months. Six men were undertreated and showed mpMRI recurrence after 6 months. At 1-year, three additional men had recurrence. Overall, four of these 9 men (44%) were retreated. The other five men did not receive any further treatment. Median time to re-treatment was 15 months. Median pre-treatment lesion volume was 0.65 cc, 0.66 cc and 0.43 cc on the different mpMRI sequences (T2-weighted, diffusion-weighted and dynamic contrast enhanced imaging). Median necrotic volume was 10.77 cc. Median overall residual fibrosis volumes were 0.84 cc and 0.95 cc at 6-month and 1-year mpMRI. Pre-treatment, necrotic and residual fibrosis volumes were significantly different (p < 0.001). Pre-treatment tumour volumes on diffusion-weighted imaging and necrotic volumes were correlated (r = 0.18; p = 0.02). CONCLUSIONS: MpMRI is able to visualise the IRE ablation effects in men with PCa. MpMRI-derived parameters - such as tumour, necrotic and fibrosis volumes - can be measured and are potentially useful for assessing efficacy in the medium term, as with other ablative techniques.

Malleable Penile Implant Is an Effective Therapeutic Option in Men With Peyronie's Disease and Erectile Dysfunction.

BACKGROUND: The inflatable penile prosthesis (IPP) is typically the preferred implant for Peyronie's disease (PD) and malleable penile prostheses (MPPs) have been discouraged. AIMS: To evaluate the effectiveness and patient satisfaction of the MPP vs IPP in patients with PD. METHODS: Men with PD and erectile dysfunction who elected for penile implant surgery constituted the study population. Preoperatively, demographic and comorbidity parameters were recorded. Curvature was measured with a goniometer at maximum rigidity after intracavernosal injection of a vasoactive agent. Postoperatively, overall satisfaction was measured at 3, 6, 12, and 24 months on 5-point Likert scale from 1 (dissatisfied) to 5 (very satisfied). RESULTS: 166 men with a mean age of 59 ± 10 years were analyzed. The mean preoperative curvature in the entire cohort was 65° (range = 30-130°). 94% of patients with MPP had total resolution of their curvature at the end of the operation, whereas 8 patients (6%) had residual curvature (25-40°). In the IPP group 25 of 30 (83.3%) had a straight penis at the end of surgery, whereas 5 of 30 (16.7%) had residual curvature, with the mean magnitude being 33° in the MPP group and 30° in the IPP group. 86% of all patients had diabetes. There were no differences between the 2 implant groups in age, hemoglobin A1c, body mass index, or smoking status. The mean patient satisfaction was 4.42 ± 0.70 (range = 2-5) and there was no difference between the 2 groups. The mean follow-up period was 23.4 months (range = 6-29 months). CONCLUSION: We found that the MPP is as effective as the IPP in curvature correction in patients with PD, with similar patient satisfaction for the 2 groups. Habous M, Farag M, Tealab A, et al. Malleable Penile Implant Is an Effective Therapeutic Option in Men With Peyronie's Disease and Erectile Dysfunction. Sex Med 2018;6:24-29.

Natural history of surgically treated high-risk prostate cancer.

BACKGROUND: No data exist on the patterns of biochemical recurrence (BCR) and their effect on survival in patients with high-risk prostate cancer (PCa) treated with surgery. The aim of our investigation was to evaluate the natural history of PCa in patients treated with radical prostatectomy (RP) alone. MATERIALS AND METHODS: Overall, 2,065 patients with high-risk PCa treated with RP at 7 tertiary referral centers between 1991 and 2011 were identified. First, we calculated the probability of experiencing BCR after surgery. Particularly, we relied on conditional survival estimates for BCR after RP. Competing-risks regression analyses were then used to evaluate the effect of time to BCR on the risk of cancer-specific mortality (CSM). RESULTS: Median follow-up was 70 months. Overall, the 5-year BCR-free survival rate was 55.2%. Given the BCR-free survivorship at 1, 2, 3, 4, and 5 years, the BCR-free survival rates improved by+7.6%,+4.1%,+4.8%,+3.2%, and+3.7%, respectively. Overall, the 10-year CSM rate was 14.8%. When patients were stratified according to time to BCR, patients experiencing BCR within 36 months from surgery had higher 10-year CSM rates compared with those experiencing late BCR (19.1% vs. 4.4%; P<0.001). At multivariate analyses, time to BCR represented an independent predictor of CSM (P<0.001). CONCLUSIONS: Increasing time from surgery is associated with a reduction of the risk of subsequent BCR. Additionally, time to BCR represents a predictor of CSM in these patients. These results might help provide clinicians with better follow-up strategies and more aggressive treatments for early BCR.

Two cases of retroperitoneal metastasis from a completely regressed burned-out testicular cancer.

INTRODUCTION: Primary extragonadal germ cell tumors (EGCT) are rare and it is still a matter of debate if they have to be considered as primary extragonadal issues or metastases from a primary testicular neoplasm. We describe two cases of the so-called burned-out seminoma, a primary testicular germ-cell tumor that spontaneously regressed after demonstration of retroperitoneal metastases. CASES PRESENTATION: Two patients (35 and 50 years old, respectively) presented with CT findings of retroperitoneal masses. In both cases physical examination of the testis was not suspicious, and only scrotal ultrasound (SUS) showed parenchymal alterations such as scarring, calcifications and nodular lesions. Left orchiectomy and chemotherapy were then performed in both cases. Currently, they are both free of disease. CONCLUSIONS: Although primary germ cell tumors may be of retroperitoneal origin, the likelihood of metastasis from a testicular primary origin should always be carefully considered in order to avoid misdiagnosis and to apply the best treatment schedule for the patients. Therefore, a testicular ultrasonography is mandatory in patients presenting CT findings of retroperitoneal adenopathy, even if patients are completely asymptomatic and their physical examination appears normal.

Innovations in the endoscopic management of bladder cancer: is the era of white light cystoscopy over.

Bladder cancer is the most common tumor of the urinary tract, with a worldwide incidence of 8.6 x 100000 in men and 2.6 x 100000 in women (1). The majority of patients (75-85%) present as non-muscle invasive bladder cancer (NMIBC); within this category the most represented stage is Ta (70%), followed by T1 (20%) and, less frequently, carcinoma in situ (CIS) (10%) (2). The diagnosis of NMIBC and, more generally, of bladder cancer, depends on urine cytology and endoscopic examination with histological evaluation of the resected tissue. Clearly, an optimal cystoscopy with accurate transurethral resection (TUR) is of great importance in order to improve the detection rate and to reduce the probability of recurrence and progression. Today the cystoscopy is routinely performed with the white light technique (WLC), the same of about 80 years ago (3). Several studies have demonstrated that an initial TUR with WLC can miss small papillary lesions and, particularly, flat lesions such as CIS. Moreover, recurrence rates of non-muscle invasive bladder cancer (NMIBC) are directly related to the possibility of achieving a complete resection: residual cancer is present in a large percentage of re-TUR, showing a not so good performance of resection with this method. For these reasons new methodologies have been investigated in order to improve the sensitivity and specificity of WLC, such as photodynamic diagnosis (PDD), narrow band imaging (NBI), optical coherence tomography (OCT) and CT virtual cystoscopy. Some of them have been well established and supported by consistent literature while others are still to be viewed as experimental. The purpose of this review is to investigate the state of the art of these new techniques.

Impact of age and comorbidities on long-term survival of patients with high-risk prostate cancer treated with radical prostatectomy: a multi-institutional competing-risks analysis.

BACKGROUND: Survival after surgical treatment using competing-risk analysis has been previously examined in patients with prostate cancer (PCa). However, the combined effect of age and comorbidities has not been assessed in patients with high-risk PCa who might have heterogeneous rates of competing mortality despite the presence of aggressive disease. OBJECTIVE: To examine the risk of 10-yr cancer-specific mortality (CSM) and other-cause mortality (OCM) according to clinical and pathologic characteristics of patients treated with radical prostatectomy (RP) for high-risk PCa. DESIGN, SETTING, AND PARTICIPANTS: Within a multi-institutional cohort, 3828 men treated with RP for high-risk PCa (defined as the presence of at least one of these risk factors: prostate-specific antigen >20 ng/ml, biopsy Gleason score 8-10, clinical stage ≥ T3) were identified. INTERVENTION: All patients underwent RP and pelvic lymph node dissection. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Competing-risk Poisson regression analyses were performed to simultaneously assess the 10-yr CSM and OCM rates after RP. The same analyses were also conducted after stratification of patients according to age at surgery, comorbidity status assessed by the Charlson Comorbidity Index (CCI), and number of risk factors (one vs two or more). RESULTS AND LIMITATIONS: Overall, 229 patients (5.9%) died from PCa; 549 (14.3%) died from other causes. The 10-yr CSM and OCM rates ranged from 5.1% to 12.8% and from 4.3% to 37.4%, respectively. Age and CCI were the major determinants of OCM; their impact on CSM was minimal. OCM was the leading cause of death in all patient groups except in young men (≤ 59 yr) with no comorbidities, regardless of the number of risk factors (10-yr CSM and OCM 6.9-12.8% and 5.5-6.3%, respectively). The main limitation was the lack of patients managed conservatively. CONCLUSIONS: Even in the context of high-risk PCa, long-term CSM after RP is modest and represents the leading cause of death only in young, healthy patients. Conversely, older and sicker patients with multiple risk factors are at the highest risk of dying from OCM while sharing very low CSM rates.

Laparoscopic management of sacral neurinoma causing hydronephrosis.

We report the case of a sacral neurinoma, which presented with mild hydronephrosis, due to compression of the right ureter, in a 71-yr old woman admitted to our hospital with recurrent urinary tract infections. CT and MRI detected a 4 x 4 cm mass pressing on the right ureter at the sacral level, in continuity with the second sacral foramen. Given this finding, the mass was thought to be of presumable neurogenic origin. In order to both reach a conclusive diagnosis and relieve the compression of the ureter, a laparoscopic resection of the mass was performed. Surgery was successful and the pathologic examination revealed a sacral Antoni A neurinoma. Neurinomas, also called Schwannomas, are uncommon benign nerve sheath tumors arising from Schwann cells. Their diagnosis can be extremely difficult due to their aspecific symptoms and the lack of pathognomonic characteristics on imaging exams. Therefore, histopathologic evaluation is essential in establishing the diagnosis. Surgical resection seems to be the best approach, both for diagnostic and therapeutic purposes.