Final 5-Year Outcomes of the Multicenter Randomized Sham-Controlled Trial of a Water Vapor Thermal Therapy for Treatment of Moderate to Severe Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia.

PURPOSE: We present final 5-year outcomes of the multicenter randomized sham-controlled trial of a water vapor therapy (Rezum™) for treatment of moderate to severe lower urinary tract symptoms due to benign prostatic hyperplasia. MATERIALS AND METHODS: A total of 197 subjects >50 years of age with International Prostate Symptom Score ≥13, maximum flow rate ≤15 ml/second and prostate volume 30 to 80 cc were randomized and followed for 5 years. From the control arm of 61 subjects, a subset of 53 subjects requalified and after 3 months received treatment as part of the crossover group and were also followed for 5 years. The total number of vapor treatments to each lobe of the prostate was determined by length of prostatic urethra and included middle lobe treatment per physician discretion. RESULTS: Significant improvement of lower urinary tract symptoms was observed at <3 months post-thermal therapy, remaining durable through 5 years in the treatment group (International Prostate Symptom Score reduced 48%, quality of life increased 45%, maximum flow rate improved 44%, Benign Prostatic Hyperplasia Impact Index decreased 48%). Surgical re-treatment rate was 4.4% with no reports of device or procedure related sexual dysfunction or sustained de novo erectile dysfunction. Results within the crossover group were similar through 5 years. CONCLUSIONS: Minimally invasive treatment with water vapor thermal therapy provides significant and durable symptom relief as well as flow rate improvements through 5 years, with low surgical re-treatment rates and without impacting sexual function. It is a versatile therapy, providing successful treatment to obstructive lateral and middle lobes.

Ureteroscopic evaluation and treatment of benign essential hematuria: a systematic review.

INTRODUCTION The advent of ureteroscopy has revolutionized the treatment many urologic diseases, including benign essential hematuria. This systematic review examines the treatment of benign essential hematuria (BEH) with ureteroscopic interventions. MATERIALS AND METHODS: We performed a systematic review of the literature from 1977 to May 2020. We included studies that evaluated the use of ureteroscopy to diagnose or treat BEH. Demographics, follow up, findings, treatment method and success rate were extracted from each identified paper. Quality analysis was performed independently by both authors. RESULTS: Our search resulted in 587 articles. Fifteen of these studies met inclusion criteria and were included in the final analysis. No randomized controlled trials were found. All 15 studies were case series. Nine studies were graded as good, five as fair, and one as poor. Follow up ranged from 2 to 108 months. A total of 307 patients underwent ureteroscopy for suspected BEH; 223 (73%) were diagnosed with a discrete lesion, 33 (11%) with a diffuse lesion, and 44 (14%) had no lesions seen on ureteroscopy. Of those diagnosed with discrete lesions, the most common was minute venous ruptures (35%), followed by hemangiomas (26%). Ureteroscopic treatment successfully relieved the hematuria and symptoms in most patients, and was more successful in those treated for discrete lesion (115/120, 96%) than diffuse (10/19, 53%). CONCLUSIONS: Ureteroscopic treatment of BEH yields excellent outcomes. In this systematic review, 96% of patients with discrete lesions and 53% of patients with diffuse lesions had resolution of their hematuria after ureteroscopic interventions.

Rural Medicare patients less likely to undergo penile prosthesis implantation following radical cystectomy.

INTRODUCTION Erectile dysfunction is common after radical cystectomy; however, research on sexual dysfunction after this procedure is relatively scarce. Our goal was to evaluate the incidence of penile prosthesis implantation after radical cystectomy, with a focus on rural/urban disparity. MATERIALS AND METHODS: We used the SEER-Medicare database to identify patients with bladder cancer diagnosed between 1991-2009 who had a radical cystectomy (ICD-9 codes 57.7, 57.71, 57.79). The outcome was placement of a penile implant (ICD-9 codes 64.95 and 64.97). Covariates extracted included rural county status, age, race, ethnicity, marital status, geographic region, socioeconomic status, Charlson comorbidity, pathologic cancer stage, and type of urinary diversion. RESULTS: A total of 95 penile implants were performed in the 11,477 cystectomy patients (0.83%). Patients who had a penile implant were mostly from urban counties (85.1%) and in the Western region of the United States (83.9%). After controlling for covariates, rural patients who underwent an ileal conduit for urinary diversion were less likely to have a penile prosthesis procedure after radical cystectomy. CONCLUSIONS: Penile prosthetic procedures are uncommon in bladder cancer patients who have undergone radical cystectomy; therefore, sexual health should be considered and discussed with patients after radical cystectomy.

Azoospermia and embryo morphokinetics: testicular sperm-derived embryos exhibit delays in early cell cycle events and increased arrest prior to compaction.

PURPOSE: Sperm play an essential role in embryonic genome activation and embryonic progression to blastocyst. In the present work, we focus on development of embryos created as a result of ICSI with testicular or epididymal sperm from azoospermic males and compare this to outcomes from normospermic males. The objective of this study was to determine if sperm origin influences clinical outcomes, the kinetics of embryo development, or the incidence of cleavage anomalies and multinucleation. METHODS: A total of 93 consecutive intracytoplasmic sperm injection cycles (ICSI) performed for 83 couples were included in this study. Observations were made on 594 fertilized oocytes cultured in the EmbryoScope using time-lapse microscopy (TLM). Epididymal sperm (n = 29) cycles or surgically retrieved sperm from the testis (TESE; n = 37 cycles) of men with either obstructive (OA) or non-obstructive azoospermia (NOA) were used to inject oocytes. A further 27 ICSI cycles were performed using ejaculated sperm from normospermic males, designated as our control sperm (CS) group. Kinetic data and cycle outcomes were retrospectively analyzed. RESULTS: The clinical pregnancy rate was not different between the three groups (TESE 51.4%, PESA 57.7%, and CS 59.3%). A non-significant decrease was observed in both implantation (30.9%) and live birth rate (43%) with TESE as compared to PESA (35.3%, 58%, respectively) and CS groups (45.1%, 56%, respectively). Failure to compact was significantly higher amongst TESE-NOA embryos (35.2%; P < 0.001) as compared to TESE-OA (4%), PESA (9%), and CS (3.8%) embryos. The two points at which TESE-derived embryos (both NOA and OA) behaved most differently from PESA and CS embryos was at cc2 (t3-t2; time to initiation of the second cell cycle) and tSB (time to start of blastulation). A significantly lower percentage of TESE embryos exhibited kinetics typically ascribed to high quality embryos with the greatest developmental potential. Finally, the incidence of direct uneven cleavage (DUC) was observed to be significantly higher after ICSI with sperm retrieved from azoospermic males. CONCLUSIONS: TLM allowed a more in depth comparison of paternal influence on embryo morphokinetics and helped to identify specific differences in cell cycle kinetics. TESE-NOA embryos exhibited a higher incidence of compaction failure.

Factors and practice patterns that affect the decision for vasoepididymostomy.

INTRODUCTION: To determine the factors used to make the decision between vasovasostomy (VV) and vasoepididymostomy (VE) by leaders performing microsurgical vasectomy reversal using a questionnaire. MATERIALS AND METHODS: An online questionnaire was sent to all members of the Society for the Study of Male Reproduction (SSMR), a male reproduction subspecialty society of the AUA, using the SurveyMonkey platform. RESULTS: Sixty-seven surgeons responded to the questionnaire (27% of SSMR members). Of which 72% of members performed less than 50 vasectomy reversals per year. Also, 71% of members stated that less than 20% of their vasectomy reversals are vasoepididymostomies. When evaluating epididymal fluid at the time of reversal, 87% would perform a VE for pasty fluid, 66% with creamy fluid without sperm heads and 55% with no or scant fluid. With respect to banking sperm, 36% take sperm or testicular tissue at the time of VE while 37% sometimes take sperm mostly depending on the couple's preference. The Berger end-to-side with intussusception VE technique is used by the majority of members (78%). The presence of intact sperm or sperm parts determined the location in the epididymis for anastomosis for 55% and 19% of members respectively. Postoperative semen testing after a VE is evaluated first between 6 weeks to 3 months for 64%. The procedure is considered a failure between 6 to 12 months for 34% and 12 to 18 months for another 48% if no sperm is seen on semen analysis. CONCLUSIONS: Most members perform a VE with pasty fluid or creamy fluid without sperm heads. Three out of four members are using the Berger end-to-side intussusception technique to perform their VE. More studies are needed to determine the optimal circumstances to perform a VE as there is significant variation in responses even among members of the SSMR.

Empiric medical therapy with hormonal agents for idiopathic male infertility.

INTRODUCTION: Infertility affects approximately 15% of all couples, and male factor contribute to up to 50% of cases. Unfortunately, the cause of male infertility is unknown in about 30% of these cases. Infertility of unknown origin is classified as idiopathic male infertility when abnormal semen parameters are present. Despite not having a definable cause, these men may respond to treatment. This review focuses on the use of empiric hormonal therapies for idiopathic male infertility. METHODS: A detailed PubMed/MEDLINE search was conducted to identify all publications pertaining to empiric use of hormonal therapies in the treatment of idiopathic male infertility using the keywords "idiopathic," "male infertility," "empiric treatment," "clomiphene," "SERM," "gonadotropin," "aromatase inhibitor," and "androgen." These manuscripts were reviewed to identify treatment modalities and results. RESULTS: Gonadotropins, androgens, aromatase inhibitors, and selective estrogen receptor modulators (SERMs) have all been used with varying results. The studies on these treatments are of variable quality. The most well-studied agents are the SERMs which show a modest increase in semen parameters and pregnancy rates. Aromatase inhibitors are most effective in non-idiopathic patients. Gonadotropin treatment is limited by their inconvenience and relative ineffectiveness in this population. Testosterone suppresses spermatogenesis and should not be used to treat infertility. CONCLUSION: Gonadotropins, SERMs, and aromatase inhibitors may improve semen parameters and hormone levels in men with idiopathic infertility with the best results from SERMs. Testosterone should never be used to treat infertility. Large multicenter randomized controlled studies are needed to better determine the success of empiric use of hormonal therapy on pregnancy rates.

Growing teratoma syndrome: clinical and radiographic characteristics.

OBJECTIVES: To present an overview of our surgical experience in the management of growing teratoma syndrome. METHODS: A retrospective analysis of all patients undergoing post-chemotherapy retroperitoneal lymphadenectomy between November 2005 and February 2012 revealed 15 patients who met the criteria for growing teratoma syndrome. Their clinical data, imaging characteristics, and surgical and oncological outcomes were reviewed. RESULTS: The median age at diagnosis was 23 years. Primary testis tumors included non-seminomatous germ cell tumor in 12 of 15 patients, seminoma in two of 15 patients and hemorrhagic mass in one patient. Mature teratoma was present in just six (40%) of the orchiectomy specimens. All patients received preoperative chemotherapy. On imaging, the median size of the largest retroperitoneal mass was 7 cm (range 3.9-24.5 cm). The median rate of linear growth was 0.5 cm/month (range 0.03-2.9), and the increase in volume was 9.2 cm(3) /month. All tumors were found to have cystic and necrotic components. Median operative time was 6.2 h (range 4.2-15.2 h). Estimated blood loss was 600 mL (range 100-7000 mL), and median length of stay was 5 days (range 3-19 days). Four patients required resection of non-retroperitoneal growing teratoma masses after post-chemotherapy retroperitoneal lymphadenectomy to achieve tumor-free status. There were two minor (Clavien I-II) and two major postoperative complications (Clavien ≥III). All patients are alive and disease free with a median duration of follow-up of 8 months (range 1-64 months). CONCLUSIONS: Growing teratoma syndrome tumors vary in their growth rate, but they all appear to have cystic features with necrosis elements on radiographic evaluation. Aggressive surgical excision is associated with excellent outcomes.

Porous Se@SiO2 nanocomposites play a potential inhibition role in hyperoxaluria associated kidney stone by exerting antioxidant effects.

Background: Nephrolithiasis seriously affects people's health with increasing prevalence and high recurrence rates. However, there is still a lack of effective interventions for the clinical prevention of kidney stones. Hyperoxaluria-induced renal tubular epithelial cell (TEC) injury is a known key factor in kidney stone formation. Thus, developing new drugs to inhibit the hyperoxaluria-induced TEC injury may be the best way. Methods: We synthesized the Se@SiO2 nanocomposites as described in Zhu's study. The size and morphology of the Se@SiO2 nanocomposites were captured by transmission electron microscopy. Cell viability was measured by a Cell Counting Kit-8 (CCK-8) assay. The mice were randomly divided into the following four groups: (I) the control group (n=6); (II) the Se@SiO2 group (n=6); (III) the glyoxylic acid monohydrate (GAM) group; and (IV) the GAM + Se@SiO2 group (n=6). The concentration of Se in the mice was quantified using inductively coupled plasma atomic emission spectroscopy. Results: The CCK-8 assays showed that Se@SiO2 nanocomposites had almost no obvious cytotoxicity on the Transformed C3H Mouse Kidney-1 (TCMK-1) cell. The mice kidney Se concentration levels in the Se@SiO2 groups (Se@SiO2 6.905±0.074 mg/kg; GAM + Se@SiO2 7.673±2.85 mg/kg) (n=6) were significantly higher than those in the control group (Control 0.727±0.072 mg/kg; GAM 0.747±0.074 mg/kg) (n=6). The Se@SiO2 nanocomposites reduced kidney injury, calcium oxalate crystal deposition, and the osteoblastic-associated proteins in the hyperoxaluria mice models. Conclusions: Se@SiO2 nanocomposites appear to protect renal TECs from hyperoxaluria by reducing reactive oxygen species production, suggesting the potential role of preventing kidney stone formation and recurrence.

A single dose of a non-steroidal anti-inflammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-controlled trial.

OBJECTIVES: To determine the incidence of severe pain after ureteric stent removal. To evaluate the efficacy of a single dose of a non-steroidal anti-inflammatory drug (NSAID) in preventing this complication. PATIENTS AND METHODS: A prospective, randomised, double-blind, placebo-controlled trial was performed at our institution. Adults with an indwelling ureteric stent after ureteroscopy were randomised to receive either a single dose of placebo or an NSAID (rofecoxib 50 mg) before ureteric stent removal. Pain was measured using a visual analogue scale (VAS) just before and 24 h after stent removal Pain medication use after ureteric stent removal was measured using morphine equivalents. RESULTS: In all, 22 patients were enrolled and randomised into the study before ending the study after interim analysis showed significant decrease in pain level in the NSAID group. The most common indication for ureteroscopy was urolithiasis (14 patients). The proportion of patients with severe pain (VAS score of ≥7) during the 24 h after ureteric stent removal was six of 11 (55%) in the placebo group and it was zero of 10 in the NSAID group (P < 0.01). There were no complications related to the use of rofecoxib. CONCLUSIONS: We found a 55% incidence of severe pain after ureteric stent removal. A single dose of a NSAID before stent removal prevents severe pain after ureteric stent removal.

Beneficial effect of roxadustat on early posttransplant anemia and iron utilization in kidney transplant recipients: a retrospective comparative cohort study.

Background: Although posttransplant anemia (PTA) is a common complication after kidney transplant, it has not been thoroughly evaluated for appropriate treatment. Roxadustat can stimulate erythropoiesis by increasing erythropoietin (EPO) production and improving the utilization of iron. However, there are currently a few case reports describing its effect on PTA in kidney transplant recipients (KTRs). Our purpose was to evaluate the efficacy and safety of roxadustat in KTRs with PTA. Methods: In this retrospective study, KTRs with early PTA were divided into a roxadustat group, erythropoiesis-stimulating agent (ESA) group, and untreated group (neither roxadustat nor ESA) according to the treatment prescribed by their physicians. We compared the levels of hemoglobin (Hb), creatinine, lipids, hepcidin, intact fibroblast growth factor 23 (iFGF23) and iron-related indices, at baseline and different time points posttransplant. Outcome was assessed at both month 3 and month 12 posttransplant. Adverse events during the treatment course were also recorded. Results: A total of 57 KTRs were included (n=22 roxadustat group, n=13 ESA group, n=22 untreated group). There was no difference in age, sex, body mass index, dialysis method and duration, donor type among three groups at baseline. The mean Hb levels at month 3 posttransplant (128.00±19.62 vs. 118.59±11.60 g/L, P=0.048) and the average change in Hb levels from week 2 to month 3 (48.05±22.53 vs. 31.45±12.96 g/L, P=0.005) in the roxadustat group were significantly higher than those in the untreated group. However, there was no significant difference in the above indices between the roxadustat and ESA groups. At month 3, the total iron binding capacity (TIBC) and levels of transferrin were significantly higher while levels of ferritin, hepcidin and iFGF23 were significantly lower in the roxadustat group than in other groups (P<0.05). No significant difference was found in creatinine or estimated glomerular filtration rate (eGFR) levels among the three groups at month 3. During the follow-up, no adverse events related to roxadustat were reported. Conclusions: Administration of roxadustat in KTRs with early PTA could elevate Hb levels effectively and safely by enhancing endogenous EPO production and improving iron utilization. Further randomized studies with larger sample size are necessary to verify our results.

The Use of Testicular Sperm for Intracytoplasmic Sperm Injection in Patients with High Sperm DNA Damage: A Systematic Review.

The advent of intracytoplasmic sperm injection (ICSI) has changed the human reproduction landscape by overcoming several limitations related to both male and female infertility factors. However, despite the development of new technologies, the live-birth rate with ICSI has not exceeded 30%. In order to improve assisted reproductive technology outcomes, advanced sperm function analysis have gained increased attention and the effects of sperm DNA fragmentation (SDF) on assisted reproduction success are being extensively studied. Utilizing ejaculated sperm with an elevated SDF has been found to result in poor ICSI outcomes. Furthermore, studies have reported that testicular sperm has lower SDF level, when compared to ejaculated sperm. This has led a number of clinicians world-wide to offer testicular sperm retrieval for ICSI in non-azoospermic males with high SDF. This practice has remained controversial due to lack of high quality evidence.

Case report: Urogenital myiasis in an adult male.

Urogenital Myiasis is rarely documented in developed countries, so epidemiological data are limited and often associated with travel to endemic regions. We report a Case of urogenital myiasis, unassociated with travel, in a 31 year old male. The patient presented to the emergency department after passing a larval fly during micturition. Pathologic examination of the initial urine sample confirmed the presence of living fly larvae and further evaluation was arranged with the urology department. The patient had no further episodes, and resolution was confirmed via urinalysis and cystoscopy. Several common risk factors were identified, including poor sanitation and hygiene.

The role of environmental factors and lifestyle on male reproductive health, the epigenome, and resulting offspring.

Many environmental and genetic variables affect male reproductive health. Some of these factors, however, interfere not only with fertility, but also the non-genomic materials within spermatozoa that can cause phenotypic changes in the offspring, and in some cases, multiple generations. This intergenerational and transgenerational inheritance is due to epigenetic modifications, which is a complex adjunct to traditional Mendelian genetics whose influence on a wide range of human diseases is an active area of research. As the epigenome is a gestalt of individual exposures to the world, ongoing research is evaluating the scope of environmental impacts on the epigenome, as well as its mechanisms for adjusting the phenotypic expression of the organism without changing the code itself. Of particular interest is how these traits are passable to subsequent generations. This article will cover the latest data concerning how the overall quality of nutrition and lifestyle of an individual has been demonstrated to have a significant effect on male reproductive health, and how the accumulation of these modifications are risk factors for the health of their offspring.

Erectile dysfunction in renal failure and transplant patients.

Erectile dysfunction (ED) is a prevalent and pertinent condition in the chronic kidney disease (CKD) population. It has a multifactorial etiology, including disruptions of the hypothalamic-pituitary-gonadal axis, the endothelial paracrine signaling system, calcium and vitamin D homeostasis, along with several other factors. Efficacy of treatment of ED in the CKD population is comparable to non-CKD patients across multiple modalities, including PDE5 inhibitors, vacuum erectile devices, intracavernosal injections and penile prostheses. Renal transplant improves the contributing comorbid conditions that lead to ED in CKD patients; thus rates of ED are improved post-transplant. It is important to note that there is a small percentage of patients with persistent ED after renal transplantation.

Testosterone and male rejuvenation.

Testosterone has long been touted as the panacea for men wishing to restore their vitality, sexuality, and masculinity to that of their youth. While the benefits of testosterone are not mythical, they are definite. In this article we will review the various benefits of testosterone as it pertains to men's health and male infertility.

Effect of Antioxidant Supplementation on the Sperm Proteome of Idiopathic Infertile Men.

Antioxidant supplementation in idiopathic male infertility has a beneficial effect on semen parameters. However, the molecular mechanism behind this effect has not been reported. The objective of this study was to evaluate the sperm proteome of idiopathic infertile men pre- and post-antioxidant supplementation. Idiopathic infertile men were provided with oral antioxidant supplementation once daily for a period of 6 months. Of the 379 differentially expressed proteins (DEPs) between pre- and post-antioxidant treatment patients, the majority of the proteins (n = 274) were overexpressed following antioxidant treatment. Bioinformatic analysis revealed the activation of oxidative phosphorylation pathway and upregulation of key proteins involved in spermatogenesis, sperm maturation, binding of sperm, fertilization and normal reproductive function. In addition, the transcriptional factors associated with antioxidant defense system (PPARGC1A) and free radical scavenging (NFE2L2) were predicted to be functionally activated post-treatment. Key DEPs, namely, NDUFS1, CCT3, PRKARA1 and SPA17 validated by Western blot showed significant overexpression post-treatment. Our novel proteomic findings suggest that antioxidant supplementation in idiopathic infertile men improves sperm function at the molecular level by modulating proteins involved in CREM signaling, mitochondrial function and protein oxidation. Further, activation of TRiC complex helped in nuclear compaction, maintenance of telomere length, flagella function, and expression of zona pellucida receptors for sperm-oocyte interaction.

Reduction in Opioid Prescribing Using a Postoperative Pain Management Protocol following Scrotal and Subinguinal Surgery.

INTRODUCTION: Excess prescribing of opioid pain medication increases medical costs and the potential for abuse by patients and others. We sought to improve our understanding of postoperative pain and opioid use after scrotal and subinguinal urological surgery to develop a protocol for pain management. METHODS: We retrospectively analyzed opioid prescribing and usage in 20 patients undergoing scrotal or subinguinal surgery. Collected data were used to develop a standardized postoperative protocol. This protocol included enhanced pain management education and limiting outpatient opioid prescriptions. Outcomes analysis was then performed for 60 consecutive patients via questionnaire. Statistical analysis was performed using the Wilcoxon rank sum test and ANOVA. Linear regression was performed comparing age and narcotic use. RESULTS: Comparison of preprotocol and postprotocol implementation opioid prescriptions and consumption showed a statistically significant decrease in the number of tablets prescribed but no difference in opioid usage. Preprotocol and postprotocol opioid prescription usage was 20 and 10 tablets, respectively, while median usage was 3.5 and 3 tablets, respectively. CONCLUSIONS: Evaluation of postoperative pain management revealed excessive prescribing of opioid medications compared to actual usage. Our protocol resulted in a significant decrease in opioid prescribing without compromising management of postoperative pain. Adjunct treatments for pain, including scrotal support, ice packs, elevation and nonsteroidal anti-inflammatory drugs, may improve postoperative pain control without increasing opioid usage. The combination of enhanced patient education and reduced opioid prescribing may result in decreased opioid use, opioid abuse and medication costs.

Utility of trigger point injection as an adjunct to physical therapy in men with chronic prostatitis/chronic pelvic pain syndrome.

BACKGROUND: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is often associated with pelvic floor muscle spasm. While pelvic floor physical therapy (PFPT) is effective, some men are unable to resolve their symptoms and have residual trigger points (TPs). TP injection has been used for treatment in several neuromuscular pain syndromes. The objective of this study was to examine the efficacy and side effects of TP injection in men with CP/CPPS and pelvic floor spasm refractory to PT. METHODS: Using an IRB approved Men's Health Registry we reviewed the records of all men with a diagnosis of CP/CPPS who received at least 1 TP injection. Patients were phenotyped with UPOINT (all had the "T" domain for tenderness of muscle) and symptoms measured with the NIH Chronic Prostatitis Symptom Index (CPSI). Response was measured by a 5-point Global Response Assessment (GRA) and change in CPSI (paired t-test). For pelvic TPs, a pudendal block was done in lithotomy position and then each TP was identified transrectally by palpation. A nerve block needle was passed through the perineum into the TP confirmed by palpation. Between 0.5-1 cc was injected into each TP of a local anesthetic mixture (30:70 of 2% lidocaine and 0.25% bupivacaine). For anterior TPs, an ultrasound guided ilioinguinal block was done first and then each TP injected by direct palpation through the abdominal skin. Men were offered up to three sets of injections separated by 6 weeks each. RESULTS: We identified 37 patients who had a total of 68 procedures. Three men had no follow-up after their first injection and were included for side effects but not included for outcome. The indication was failure to progress on PT in 33, recurrent symptoms in 1 and refusal to do PT in 3. Mean age was 43.7 years (range 21-70 years) and median UPOINT domains was 3 (range 1-5). Initial CPSI was pain 13.7±3.4, urinary 5.3±2.2, quality of life 9.8±2.1 and total 28.8±6.0. 16 men had 1 injection, 11 had 2 and 10 had 3. All had pelvic TPs injected and 9 also had anterior TPs. By GRA, 12 had significant improvement (35.3%), 10 had some improvement (29.4%), 11 had no change (32.3%) and 1 was worse (2.9%). Mean CPSI dropped from 28.8±6.0 to 21.8±7.2 (P<0.0001). 18 men had a drop of 6 or more points in CPSI (53%). Of note, none of 3 men who were noncompliant with PT had benefit. 3 men had temporary numbness in the lateral thigh after the injection (4.4%) and 1 had difficulty weight bearing on 1 leg for about 30 minutes. CONCLUSIONS: TP injection in CP/CPPS patients as an adjunct to PT is well tolerated and leads to symptom improvement in about half. Durability and long term results are yet to be determined.

Conversion of Low-Flow Priapism to High-Flow State Using T-Shunt with Tunneling.

Introduction. The three types of priapism are stuttering, arterial (high-flow, nonischemic), and venoocclusive (low-flow, ischemic). These are usually distinct entities and rarely occur in the same patient. T-shunts and other distal shunts are frequently combined with tunneling, but a seldom recognized potential complication is conversion to a high-flow state. Case Presentation. We describe 2 cases of men who presented with low-flow priapism episodes that were treated using T-shunts with tunneling that resulted with both men having recurrent erections shortly after surgery that were found to be consistent with high-flow states. Case 1 was a 33-year-old male with sickle cell anemia and case 2 was a 24-year-old male with idiopathic thrombocytopenic purpura. In both cases the men were observed over several weeks and both men returned to normal erectile function. Conclusions. Historically, proximal shunts were performed only in cases when distal shunts failed and carry a higher risk of serious complications. T-shunts and other distal shunts combined with tunneling are being used more frequently in place of proximal shunts. These cases illustrate how postoperative erections after T-shunts with tunneling can signify a conversion from low-flow to high-flow states and could potentially be misdiagnosed as an operative failure.