Surgical outcomes from limiting the use of nonabsorbable suture in tunica albuginea plication for Peyronie's disease.

Tunica albuginea plication (TAP) surgery for Peyronie's disease (PD) is classically described using nonabsorbable suture. Many patients are aware of nodularity at the suture sites (50-88%), and some find them painful (10-33%). We explore whether limiting permanent sutures provides a durable correction of curve and report the incidence of bothersome nodules. Beginning in 2007, we modified our TAP procedure to limit the use of permanent sutures. We reviewed all patients who underwent TAP procedures from 2007 to 2014 at our institution. Patients were contacted to complete a previously published survey regarding postoperative satisfaction. In total, 142 PD patients underwent the TAP procedure and 81/142 (57%) completed the postoperative survey. Mean office follow-up and survey follow-up were 17.3 and 56.3 months, respectively. Of the surveyed patients, 6.2% complained of a bothersome residual curve, 19.8% experienced nodularity and 4.9% reported bothersome nodules. Men with dorsal curves experienced less painful nodularity than those with ventral (P=0.047) or lateral curves (P=0.017). In total, 4/142 (2.8%) of men underwent repeat intervention. At long-term follow-up, limiting permanent sutures during TAP procedures for PD is durable with respect to curvature correction and has encouragingly low levels of nodularity and bother at suture sites.

Review of non-surgical treatment options for Peyronie's disease.

Non-surgical treatment of Peyronie's disease (PD) has come a long way since it was first described in 1743. A myriad of treatment options are currently available, including oral, intralesional and external energy therapies. The purpose of this article is to review the contemporary literature on non-surgical therapies for PD, and where possible, focus on randomized, placebo-controlled trials, as well as review the latest guidelines for the management of PD from the International Committee on Sexual Medicine, which conveyed its findings in July 2009. At this time, it appears that a combination of oral agents and/or intralesional injection with traction therapy may provide a synergy between the chemical effects of the drugs and the mechanical effects of traction. Until a reliable treatment emerges, it does appear that some of the non-surgical treatments discussed can be used to stabilize the scarring process and may result in some reduction of deformity with improved sexual function.

Randomized, double-blind, placebo-controlled study of postoperative nightly sildenafil citrate for the prevention of erectile dysfunction after bilateral nerve-sparing radical prostatectomy.

Four weeks after bilateral nerve-sparing radical retropubic prostatectomy, men with normal erectile function before surgery were randomized to double-blind sildenafil (50 or 100 mg) or placebo nightly for 36 weeks, followed by an 8-week drug-free period before assessment of erectile function. Enrollment was prematurely ceased and only 76 men completed because, assuming a placebo response rate similar to the published literature (for example, 34% in meta-analysis), the 25% response at blinded interim review suggested a lack of treatment effect. On the contrary, spontaneous erectile function (a combined score of >or=8 for questions 3 and 4 of the International Index of Erectile Function and a positive response to 'Were erections good enough for satisfactory sexual activity?') occurred in only 4% of the placebo group (n=1 of 25) versus 27% (n=14 of 51, P=0.0156, Fisher's exact test) of the sildenafil group. Nightly sildenafil administration for 36 weeks after surgery markedly increased the return of normal spontaneous erections.

Establishing a standardized evaluation of the man with Peyronie's disease.

The goal of this article is to encourage development of a standardized approach to the evaluation of the man with Peyronie's disease. An additional aim is to identify those subjective and objective measures of change occurring as a result of treatment which would allow uniform reporting of treatment outcome. Systematic review of current clinical parameters used in assessing the man with Peyronie's disease including demographic data, physical findings, objective measures of penile deformity and erectile function as well as questionnaires employed to gain more reliable subjective data. As there is no accepted standard approach or previously published analysis of existing approaches, a survey of 68 recently published articles is included to query current outcome reporting on Peyronie's disease therapy. Results were as follows. An algorithm is suggested as an initial format for evaluation and outcome analysis. The pros and cons of subjective and objective measures of penile deformity is presented and a standardized questionnaire and penile duplex ultrasound report form is included for current use. The literature survey revealed the broad unscientific approach to outcome reporting making assessment of treatment quite difficult. In conclusion, it is clear that it is time to establish a standardized and globally acceptable evaluation and outcome reporting algorithm. There is interest to develop and validate a specific Peyronie's disease index questionnaire. In the meantime, this article presents specific recommendations to obtaining meaningful objective measures and methods to report them.

Review of current nonsurgical management of Peyronie's disease.

The current nonsurgical treatment options for men with Peyronie's disease is reviewed. The treatments currently employed and published in the English literature are discussed. A wide variety of nonsurgical treatment options are available to the practicing physician, including oral and topical medications, intralesional injection therapy, as well as employing external energy sources to drive medicine into the tunica albuginea by iontophoresis or direct stimulation of plaque change by shock wave therapy. Nonsurgical treatment of Peyronie's disease clearly has a place in the armamentarium of the practicing urologist. Oral therapy appears to have little therapeutic benefit. Injection and topical approaches deserve further attention. Yet, no single treatment stands out as the most effective remedy for all men with Peyronie's disease. Further controlled, large-scale studies are necessary to establish the benefits of these nonsurgical approaches. In the meantime, combination therapy appears to make sense in the nonsurgical treatment of men with Peyronie's disease.

Treatment of erectile dysfunction in patients with Peyronie's disease using sildenafil citrate.

Erectile dysfunction (ED) has frequently been associated with Peyronie's Disease (PD) and may further compromise coitus. This is a retrospective analysis of ED in patients with PD since the release of sildenafil citrate (SC) focusing specifically on our patients' responses to SC. One-hundred seventy six patients with PD were evaluated between April 1998 and May 2001. All patients received a complete medical and sexual history, physical exam, penile duplex ultrasound (PDU, with 30-90 mg of papaverine) to assess penile vascular integrity, plaque dimensions, and erect penile deformity. Based on these findings, appropriate treatment options were offered for their PD and their ED including SC, which was offered to 73 men. Patient response to SC was specifically assessed during patient office interview and via a mailed EDITS (Erectile Dysfunction Inventory of Treatment Satisfaction) questionnaire. Seventy (39.8%) and 104 (59.1%) patients complained of decreased erectile capacity (ie rigidity) occurring before and after the onset of PD, respectively. Only two patients reported no change of erectile capacity. In all, 103 (58.5%) patients complained of significant reduction in sexual function due to diminished rigidity and sought treatment for their ED. Of the ED treatment options available, 73 (70.9%) patients were given a prescription for SC. Forty-eight (75.0%) patients returned the EDITS questionnaire while four of 73 (5.5%) patients did not fill their prescription and five of 73 (6.8%) did not engage in sexual activity following an initial trial of SC due to side effects (flushing, headaches). Based upon the EDITS response, 34 of 48 (70.8%) patients reported that they were either very satisfied or somewhat satisfied, five of 48 (10.4%) patients were neither satisfied nor dissatisfied, and nine of 48 (18.8%) patients were somewhat dissatisfied or very dissatisfied with the effectiveness of SC in enhancing their erectile response. No patient reported worsening of PD deformity or an increase in penile pain. The 30 patients who were not prescribed SC chose the following options to enhance rigidity: eight (7.8%) underwent prosthesis placement, four (3.9%) opted for vacuum constriction device (VCD), four (3.9%) chose intracorporal injections, and 14 (13.6%) used no adjunctive therapy. Erectile dysfunction is a problem associated with PD and all typical treatment options are acceptable. However, to our knowledge, there is no published study reviewing the efficacy of SC in patients with ED associated with PD. There appears to be no contraindication to using SC as being the least invasive and most convenient treatment option for ED with PD. Although the potential risk of coital trauma to the erect penis with PD is present, there is no evidence from this study that erections and coitus enhanced specifically by SC resulted in worsening deformity or progression of the PD. EDITS questionnaire results reveal that SC is an agent that allowed successful coitus in 70.8% of males with PD.

Intralesional verapamil for the treatment of Peyronie's disease: a review.

Multiple treatment options have been used for Peyronie's disease (PD) including intralesional injection of the calcium antagonist verapamil. The use of verapamil is based on its capacity to alter fibroblast function at several levels, including cell proliferation, extracellular matrix protein synthesis and secretion, as well as collagen degradation. Consequently, calcium antagonists may have the capacity to slow, prevent, or even reverse plaque formation and the progression of PD. The multicenter international experience with intralesional verapamil injection suggests that the majority of men with PD that receive treatment demonstrate durable reduction in pain, decrease in curvature, and improved sexual function. We review the scientific rationale, published literature, clinical experience, and technique of intralesional injection of verapamil.

Effect of multislice CT technology on scanner productivity.

OBJECTIVE: In this study we analyzed the impact of multislice CT technology on scanner productivity in a tertiary care medical center. MATERIALS AND METHODS: We compared the productivity of two diagnostic CT scanners during the periods January 1 to August 31, 1999 (when both scanners had single-slice CT capability) and January 1 to August 31, 2000 (when one of these scanners was replaced with a multislice CT scanner). The scanners were used primarily for outpatients during the day shift and for inpatients during the evening shift; the demand for CT services was stable. For this analysis, we queried the hospital's radiology information system and identified the number of CT examinations performed during the two analysis periods. We also determined the examination mix, including proportion of enhanced and unenhanced examinations and the anatomic region examined, to ensure comparable patient populations. Statistical analysis was performed. RESULTS: The number of CT studies performed on the two scanners increased by 1772 (13.1%) from 13,548 (before multislice CT) to 15,320 (when multislice CT was available). The number of examinations enhanced with contrast media increased from 52% to 65%. Between 9:00 A.M. and 5:00 P.M., the number of CT examinations was similar on the single-slice scanners in the two periods (p > 0.05). However, in the period when multislice CT was available, the number of studies performed on the multislice scanner (5919) was 51.9% higher than those performed using the single-slice scanner (3896) (p < 0.0006). CONCLUSION: Using a multislice CT scanner leads to an increase in CT productivity, even though multislice studies are performed using more complicated protocols than are used on a single-slice CT scanner.

Mechanical reliability and safety of, and patient satisfaction with the Ambicor inflatable penile prosthesis: results of a 2 center study.

PURPOSE: We reviewed the experience with the 2-piece Ambicor penile prosthesis (American Medical Systems, Minnetonka, Minnesota) at 2 medical centers to investigate its mechanical reliability and complication rates as well as patient and partner satisfaction with the device. MATERIALS AND METHODS: From 1995 through 1999, 131 men underwent implantation of an Ambicor penile prosthesis at 2 medical centers. We performed a 3-part study consisting of a retrospective clinical record review, mailed patient and partner questionnaire, and mailed modified patient and partner Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire. Mean followup was 43.4 months (range 12 to 73). RESULTS: All 131 men had a history consistent with an organic etiology of erectile dysfunction, including vascular disease in 62%, radical retropubic prostatectomy in 17%, Peyronie's disease in 15%, neophallus construction in 4% and radical pelvic surgery in 2%. Mean patient age was 56.8 years (range 22 to 76) at implantation. Overall there were complications in 10 cases (7.6%), including infection, hematoma and mechanical failure in 6 (4.6%), 1 (0.7%) and 3 (2.3%), respectively. A total of 112 men (85%) and 91 partners completed the questionnaire. All patient respondents still had an Ambicor prosthesis implanted and 96.4% had erection suitable for coitus. Overall patient and partner satisfaction was 96.4% and 91.2%, respectively. Of the respondents 92.9% of patients and 90.1% of partners would recommend the device to others. Of the 85 men (65%) and 46 partners who completed the modified Erectile Dysfunction Inventory of Treatment Satisfaction survey 90.6% and 82.6%, respectively, were satisfied or very satisfied overall with the penile prosthesis. CONCLUSIONS: The Ambicor penile prosthesis is associated with a low complication rate and reliable mechanical function. High satisfaction was reported by patients and partners.

Vacuum constriction and external erection devices in erectile dysfunction.

The development of external erection devices has evolved as the social stigma surrounding the treatment of erectile dysfunction has gradually disappeared during the late twentieth century. Although the success of surgical and medical therapy for erectile dysfunction has been documented, especially since the introduction of sildenafil citrate, patient demand for an effective, noninvasive, drug-free management of erectile dysfunction has remained. As the population continues to age, acquiring the comorbidities commonly associated with erectile dysfunction, such as hypertension, diabetes mellitus, and atherosclerotic vascular disease, the demand for such treatment should persist. This article examines the development, mechanism of action, efficacy, and patient satisfaction with regard to vacuum constriction and external erection devices.

Microsurgical denervation of the spermatic cord as primary surgical treatment of chronic orchialgia.

PURPOSE: We evaluate the effectiveness of microsurgical denervation of the spermatic cord for treatment of chronic orchialgia. MATERIALS AND METHODS: Patients referred to our clinic diagnosed with chronic orchialgia are evaluated with a thorough medical and psychiatric history, physical examination and scrotal ultrasound when indicated. A total of 27 patients with chronic orchialgia refractory to nonsurgical management who had temporary pain relief after undergoing outpatient cord block were candidates for denervation. There were 6 patients who had bilateral pain, therefore, 33 testicular units were denervated. Followup ranged from 1 to 74 months (mean 20). RESULTS: Complete pain relief was noted in 25 (76%) testicular units, partial relief in 3 (9.1%) and no relief in the remaining 5 (15%), with a mean followup of 19, 24 and 10 months, respectively. There was no significant difference in outcome when evaluated by the etiology of orchialgia. CONCLUSIONS: When conservative treatment fails, microsurgical denervation of the spermatic cord should be considered first rate surgical therapy for patients with chronic orchialgia.

Preoperative semen analysis as a predictor of seminal improvement following varicocelectomy.

OBJECTIVE: To determine the predictive role of preoperative semen analysis on both seminal improvement and pregnancy rates following varicocelectomy. DESIGN: Retrospective data analysis. SETTING: Two academic medical center infertility clinics. PATIENT(S): One hundred ten consecutive patients who underwent varicocelectomies. Seminal improvement data were available for 84 patients, and pregnancy data were available for 58 patients. INTERVENTION(S): Stratification of patients based on preoperative total motile sperm count (TM). Varicocelectomy was performed on all patients. MAIN OUTCOME MEASURE(S): TMs, pregnancy rates, and conception techniques following varicocelectomy of each preoperative group. RESULT(S): Men with mild to moderate oligoasthenospermia (TM >5 million) had significantly better seminal improvement following varicocelectomy. While preoperative stratification showed no difference in pregnancy rates (when assisted reproductive techniques were included), men who achieved a postoperative TM >20 million were more likely to achieve conception by less invasive techniques (natural and intrauterine insemination vs. in vitro fertilization [IVF]). CONCLUSION(S): Varicocelectomy may be the most cost-effective initial intervention in males with TM >5 million. Patients with TM <5 million and concomitant female factor infertility may be better initial candidates for IVF.

Technical cost of CT examinations.

PURPOSE: To measure the technical cost of different categories of computed tomographic (CT) examinations. MATERIALS AND METHODS: For fiscal year 1997, the technical costs of performing CT examinations in a tertiary care academic medical center were measured. Costs were divided into labor and nonlabor categories. Indirect departmental costs were fully allocated according to activity-based methods. Hospital overhead costs were set at 85% of the departmental budget. Physician costs, including those related to image interpretation were not included. The technical cost of CT was determined on a per technical relative value unit (RVU) basis and on a per examination basis. For the latter, the technical cost of nonenhanced CT, contrast material-enhanced diagnostic CT, and interventional CT procedures were determined. RESULTS: In fiscal year 1997, 45,599 examinations (22,158 [48.6%] abdominal and/or pelvic, 12,115 [26.6%] head and neck, 6,572 [14.4%] thoracic, 1,593 [3.5%] interventional, and 3,161 [6.9%] other) were performed with five CT scanners for a technical RVU output of 254,461. Of 45,599 examinations, 31,007 (68%) were performed with intravenously administered contrast medium. Overall labor costs were $1,744,653, and nonlabor costs were $2,912,282. The cost of a hypothetical CT examination with a mean technical RVU of 5.58 was $189. The overall cost per examination was $150 for nonenhanced CT, $237 for contrast-enhanced CT, and $462 for interventional CT. CONCLUSION: Although CT is based on sophisticated technology, the mean technical cost of a diagnostic CT examination is less than $200.

Report of the American Foundation for Urologic Disease (AFUD) Thought Leader Panel for evaluation and treatment of priapism.

PURPOSE: Patients with priapism often develop permanent erectile dysfunction and personal sexual distress. This report is intended to help educate the public by reviewing the varied definitions and classifications of priapism and limited literature reports of pathophysiology, diagnosis and treatment outcomes of priapism. The AUA priapism guidelines committee is responsible for creating consensus as to appropriate individual patient management of priapism by physicians. MATERIALS AND METHODS: A multidisciplinary panel, consisting of 19 thought leaders in priapism, was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease to address pertinent issues concerning the role of the urologist, primary care providers and other health care professionals in the education of the public regarding management of men with priapism. The panel utilized a modified Delphi method and built upon the peer review literature on priapism. RESULTS: The Thought Leader Panel recommended adoption of the definition of priapism as a pathological condition of a penile erection that persists beyond or is unrelated to sexual stimulation. Priapism is stressed to be an important medical condition that requires evaluation and may require emergency management. The classification system is categorized into ischemic and non-ischemic priapism. Essential elements of the ischemic classification are the inclusion of: (i) clinical characteristics of pain and rigidity; (ii) diagnostic characteristics of absence of cavernosal arterial blood flow; (iii) pathophysiological characteristics of a closed compartment syndrome; (iv) a time limit of 4 h prior to emergent medical care; and (v) a description of the potential consequences of delayed treatment. Essential elements of the non-ischemic classification are the inclusion of: (i) clinical characteristics of absence of pain and presence of partial rigidity; (ii) diagnostic and pathophysiological characteristics of unregulated cavernosal arterial inflow; and (iii) the need for evaluation but emphasizing the lack of a medical emergency. The panel recommended adoption of a rational management algorithm for the assessment and treatment of priapism where the cornerstone of initial assessment includes a careful clinical history, a focused physical examination and selected laboratory and/or radiologic tests. The panel recommended that specific criteria and clinical profiles requiring specialist referral should be identified. The panel further recommended that patient (and partner) needs and education concerning priapism should be addressed prior to therapeutic intervention, however only in the case of chronic management or post acute presentation evaluation should this delay intervention. Treatment goals to be discussed include management of the priapism with concomitant prevention of permanent and irreversible erectile dysfunction and associated psychosocial consequences. The panel recommended that when specific therapies for priapism are required, a step-care treatment approach based upon reversibility and invasiveness should be followed. CONCLUSIONS: The Thought Leader Panel calls for research to expand our understanding of the prevalence and diagnosis of priapism and education to create awareness among the public of the potential urgency of this condition. Critical areas to be addressed include the multiple pathophysiologies of priapism as well as multi-institutional trials to objectively assess safety and efficacy in the various treatment modalities.

Importance of asking questions about erectile dysfunction.

Cardiovascular disease and erectile dysfunction share many common risk factors. In fact, recent studies have demonstrated evidence of occult coronary artery disease, undiagnosed hyperlipidemia, and hypertension in men presenting with erectile dysfunction. It is therefore incumbent upon all physicians, especially cardiologists, to query their patients about their erectile function.

A surgical algorithm for penile prosthesis placement in men with erectile failure and Peyronie's disease.

We developed an algorithm for surgical management and placement of penile prostheses in patients with erectile failure (ED) and Peyronie's disease (PD). We identified 46 men ages 40 to 77 y with PD who could not attain an adequate erection with sexual stimulation and pharmacotherapy. All men were candidates for penile straightening and inflatable prosthesis placement using the following algorithm. Manual molding was attempted initially, followed by tunica incision for insufficient straightening. For tunical defects greater than 2 cm, polytetrafluoroethylene (PTFE) patch grafting was performed to prevent prosthesis cylinder herniation and recurrent deformity from cicatrix contraction. Mean preoperative penile curvature was 53 degrees (0-90). Prosthesis implantation with manual molding, implant with plaque incision, and implant with plaque incision and PTFE grafting were successfully accomplished in 25 (54%), 12 (26%), and nine (20)% respectively. Mean follow-up was 39 months (range 1-74). Full erectile capacity with a straight phallus was achieved in all patients. Complications included temporary (< 8 months) decreased penile sensation in four (9%), mild (< 2 cm) penile shortening in three (7%), delayed ejaculation in one (2%), and infection requiring explanation in one diabetic male (2%). All of the implanted prostheses provided satisfactory rigidity with no mechanical failures or recurrent curvature. We conclude that inflatable penile prosthesis implantation is a safe and effective therapy with a high satisfaction rate in men with ED and PD. The developed algorithm helps define prosthesis placement and straightening techniques to obtain optimal results with minimal complications.

Technical cost of radiologic examinations: analysis across imaging modalities.

PURPOSE: To determine the individual technical costs of general diagnostic radiographic, ultrasonographic (US), computed tomographic (CT), magnetic resonance (MR) imaging, and scintigraphic examinations and interventional radiology. MATERIALS AND METHODS: The Radiology Cost and Productivity Benchmarking Study method of the University HealthSystem Consortium, a cooperative group of academic medical centers, was modified and extended to the six imaging modalities in a tertiary care academic setting. Hospital billing and cost records were analyzed for fiscal year 1996. Costs were divided into labor and nonlabor categories and were allocated to individual imaging modalities on the basis of resources consumed. Physician cost and hospital overhead were not included. Unit costs were analyzed per technical relative value unit (RVU) and per examination. RESULTS: The costs per technical RVU for diagnostic radiography, US, CT, MR imaging, scintigraphy, and interventional radiology were $65. 06, $28.74, $20.95, $17.69, $42.19, and $89.03, respectively. The technical costs per examination for diagnostic radiography, US, CT, MR imaging, scintigraphy, and interventional radiology were $41.92, $50.28, $112.32, $266.96, $196.88, and $692.60, respectively. CONCLUSION: The method of unit cost analysis for individual imaging modalities was successfully tested in a tertiary care setting. The method should be adopted to allow cost comparison across many institutions, which will permit the promotion of best practices.

Diagnosis and treatment of erectile dysfunction.

Up to 30 million men in the United States are affected by some degree of erectile dysfunction (ED). In the Massachusetts Male Aging Study (MMAS) 52% of men between 40 and 70 years of age were found to have some degree of ED. The MMAS and other studies also found that the likelihood of developing ED increases significantly with age. The vast majority of ED is primarily of organic and vascular cause, although psychological factors also play a role in most cases. ED has been shown to compromise overall quality of life and is associated with depression, anxiety, and loss of self-esteem. It may also signal serious underlying disease, including diabetes, hypertension, and cardiovascular disease. Therefore, questions regarding sexual functioning should be a routine part of the medical history. In the early 1990s, with the growing number of nonspecific and effective as well as less invasive tests, a new algorithm was developed that tailored evaluation to the treatment goals of the patient and his partner. This "goal-directed" approach simplifies the management of ED in the primary care setting; the availability of an effective oral agent, as well as a range of other therapeutic options, allows men with ED of all causes to receive effective treatment.

Identification of seminiferous tubule aberrations and a low incidence of testicular microliths associated with the development of azoospermia.

OBJECTIVE: To evaluate the use of percutaneous testicular sperm aspiration in the assessment of azoospermia and its association with seminiferous tubule microliths. DESIGN: Case report. SETTING: Tertiary care fertility center in a university hospital. PATIENT(S): Male undergoing infertility evaluation. INTERVENTION(S): Testicular biopsy and percutaneous testicular aspiration. MAIN OUTCOME MEASURE(S): Serum hormone analysis, sperm concentration in semen, spermatogenesis in samples from testicular biopsies and aspirations, and microlith composition. RESULT(S): A patient presented for infertility evaluation with a history of severe oligospermia that progressed to azoospermia. The serum testosterone concentration (357 ng/dL) and LH concentration (9.2 mIU/mL) were normal and the serum FSH concentration (18.3 mIU/mL) was elevated. Testicular biopsy results indicated spermatogenic hypoplasia with limited spermatozoa. Seminiferous tubules obtained by percutaneous testicular aspiration were structurally aberrant, with multiple diverticula. Microliths averaging 120 microm in diameter were observed within and blocking the seminiferous tubules. The microliths were composed of calcium phosphate (hydroxyapatite) in both the core and peripheral regions. Electron microscopy revealed a high degree of collagen-like material within the peripheral zone. CONCLUSION(S): The presence of seminiferous tubule microliths is associated with the development of azoospermia. In patients with a low incidence of seminiferous tubule microliths and aberrant seminiferous tubule architecture, percutaneous testicular aspiration may provide a diagnostic advantage over testicular biopsy.