Search

Context The European Association of Urology (EAU) has updated its guidelines on sexual and reproductive health for 2021. Objective To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health, including advances and areas of controversy in male infertility. Evidence acquisition The panel performed a comprehensive literature review of novel data up to January 2021. The guidelines were updated and a strength rating for each recommendation was included that was based either on a systematic review of the literature or consensus opinion from the expert panel, where applicable. Evidence synthesis The male partner in infertile couples should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors causing fertility impairment. Infertile men are at a higher risk of harbouring and developing other diseases including malignancy and cardiovascular disease and should be screened for potential modifiable risk factors, such as hypogonadism. Sperm DNA fragmentation testing has emerged as a novel biomarker that can identify infertile men and provide information on the outcomes from assisted reproductive techniques. The role of hormone stimulation therapy in hypergonadotropic hypogonadal or eugonadal patients is controversial and is not recommended outside of clinical trials. Furthermore, there is insufficient evidence to support the widespread use of other empirical treatments and surgical interventions in clinical practice (such as antioxidants and surgical sperm retrieval in men without azoospermia). There is low-quality evidence to support the routine use of testicular fine-needle mapping as an alternative diagnostic and predictive tool before testicular sperm extraction (TESE) in men with nonobstructive azoospermia (NOA), and either conventional or microdissection TESE remains the surgical modality of choice for men with NOA. Conclusions All infertile men should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors. Increasing data indicate that infertile men are at higher risk of cardiovascular mortality and of developing cancers and should be screened and counselled accordingly. There is low-quality evidence supporting the use of empirical treatments and interventions currently used in clinical practice; the efficacy of these therapies needs to be validated in large-scale randomised controlled trials. Patient summary Approximately 50% of infertility will be due to problems with the male partner. Therefore, all infertile men should be assessed by a specialist with the expertise to not only help optimise their fertility but also because they are at higher risk of developing cardiovascular disease and cancer long term and therefore require appropriate counselling and management. There are many treatments and interventions for male infertility that have not been validated in high-quality studies and caution should be applied to their use in routine clinical practice.

Urologists can bridge the gender gap in life expectancy through the promotion of a holistic and streamlined approach to men's health that incorporates optimisation of lifestyle factors (smoking cessation, weight loss, diet) and comorbidities (treatment of hypertension, hypercholesterolaemia, and hypogo-nadism) and offers cancer screening.

Context Management of men with penile squamous cell carcinoma (PSCC) who have high-risk features following radical inguinal lymphadenectomy (ILND) remains controversial. European Association of Urology guidelines state that adjuvant inguinal radiotherapy (AIRT) is “not generally recommended”. Despite this, many centres continue to offer AIRT to a subset of men. Objective To undertake a systematic review of the evidence on AIRT in node-positive men with PSCC. Evidence acquisition A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with no language or date restriction. Inclusion criteria were men with PSCC, pathologically staged inguinal node positive after ILND. The intervention included ILND with AIRT compared with ILND alone. Primary outcomes were relapse-free survival and toxicity. Risk of bias assessment was undertaken. Evidence synthesis A total of 913 abstracts were identified and screened independently by two reviewers. Seven studies were eligible for inclusion: six full-text manuscripts and one conference abstract. All were retrospective series and at a high risk of bias. The selected studies included 1605 men. Indications for AIRT varied but were typically involvement of two or more inguinal nodes or extranodal extension. Regional recurrence rate following AIRT was reported at 10–91.7%. Only one study reported on toxicity. Two studies compared recurrence and survival between men who received and who did not receive AIRT, with no significant difference (p > 0.05). Conclusions The evidence indicates that men treated with AIRT do not gain benefit with respect to relapse or survival. Uncertainty remains due to the retrospective nature and high risks of bias across the evidence. Given the lack of evidence supporting AIRT, it cannot be recommended for routine practice. Patient summary Men with penile cancer who have involvement of the inguinal lymph nodes are at a high risk of cancer recurrence and death. We reviewed the literature to see if radiation treatment after removal of the nodes provided benefit. We did not find any good-quality evidence supporting this treatment, and hence it cannot be recommended.

Context: Penile cancer has high mortality once metastatic spread has occurred. Local treatment can be mutilating and devastating for the patient. Progress has been made in organ-preserving local treatment, lymph node management, and multimodal treatment of lymphatic metastases, requiring an update of the European Association of Urology guidelines. Objective: To provide an evidence-based update of treatment recommendations based on the literature published since 2008. Evidence acquisition: A PubMed search covering the period from August 2008 to November 2013 was performed, and 352 full-text papers were reviewed. Levels of evidence were assessed and recommendations graded. Because there is a lack of controlled trials or large series, the levels of evidence and grades of recommendation are low compared with those for more common diseases. Evidence synthesis: Penile squamous cell carcinoma occurs in distinct histologic variants, some of which are related to human papilloma virus infection; others are not. Primary local treatment should be organ preserving, if possible. There are no outcome differences between local treatment modes in superficial and T1 disease. Management of inguinal lymph nodes is crucial for prognosis. In impalpable nodes, invasive staging should be done depending on the risk factors of the primary tumour. Lymph node metastases should be treated by surgery and adjuvant chemotherapy in N2/N3 disease. Conclusions: Organ preservation has become the standard approach to low-stage penile cancer, whereas in lymphatic disease, it is recognised that multimodal treatment with radical inguinal node surgery and adjuvant chemotherapy improves outcome. Patient summary: Approximately 80% of penile cancer patients of all stages can be cured. With increasing experience in the management of penile cancer, it is recognized that organ-preserving treatment allows for better quality of life and sexual function and should be offered to all patients whenever feasible. Referral to centres with experience is recommended. (C) 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Background Tissue preservation by means of focal therapy offers some men with clinically significant prostate cancer an alternative to standard care that appears to confer favourable genito-urinary outcomes. The precise estimates of these outcomes have so far been based on small series. Objective This analysis pools the sexual domain related patient reported outcomes from three prospective, registered studies that represent a range of inclusion criteria. Design, setting, and participants One-hundred and eighteen men with localised prostate cancer (prostate specific antigen ≤ 15ng/ml, Gleason ≤ 4+3, stage ≤ T3aN0M0) treated in a tissue-preserving manner using high intensity focused ultrasound from three registered studies were included. Data on International Index of Erectile Function (IIEF-5) scores and use of phosphodiesterase-5-inhibitors were collected at baseline, and 1 mo, 3 mo, 6 mo, 9 mo, and 12 mo postoperatively. The IIEF-15 total and individual domain scores were used to assess overall sexual function. Urinary function was assessed with the International Prostate Symptom Score (IPSS), IPSS quality-of-life, and UCLA-Expanded Prostate Cancer Index Composite continence questionnaires. General health status was derived by means of the Charlson score. Multiple linear regression was used to assess whether age, grade, stage, qualitative scores (IIEF, IPSS, Expanded Prostate Cancer Index Composite, Charlson), or focal therapy type duration were associated with IIEF-5 and IIEF-15 scores at 12 mo. Results and limitations Median age was 63 yr (interquartile range [IQR] 52–70 yr). Median IIEF-erectile score at baseline was 23 (IQR 11–28). This declined significantly to 9 (IQR 3–22, p p =0.30) at 1 yr posttreatment. Changes in total IIEF and other IIEF domains were only significantly different from preoperative values at 1 mo and 3 mo postoperatively. In the same period, the proportion of men using phosphodiesterase-5-inhibitors was 10% preoperatively, reaching 43% and 42% at 6 mo and 9 months before declining to 37% at 1 yr. The only baseline determinants of postoperative erectile function were total IIEF and IIEF-erectile function scores ( p =0.002). The primary limitation of our study is the relatively short follow-up of 1 yr. Conclusion Men who received a range of tissue preserving therapies from the three pertinent studies experienced small decreases in total IIEF, erectile, and individual sexual domain scores that are not significantly different to those recorded at baseline. The only determinant of erectile dysfunction after tissue preserving therapy was preoperative erectile dysfunction status. Tissue preservation confers a high probability of maintaining erectile function that appears independent of all perioperative factors with the exception of baseline status. Patient summary In this report, the largest prospectively collected and published set of patients with erectile dysfunction outcomes post–focal therapy for prostate cancer, we have found a return to baseline International Index of Erectile Function–erectile and total International Index of Erectile Function scores by 6 mo post–focal therapy which was maintained at 1 yr, with the majority of patients not on any form of medical treatment for their erectile dysfunction at that point. Focal therapy may represent a suitable alternative for men of any age or comorbidity wishing to maintain erectile function.

Background Ischaemic priapism (IP), which is refractory to conventional medical and surgical intervention, results in necrosis of the corpus cavernosum smooth muscle. These patients eventually develop a variable degree of corporal smooth muscle fibrosis that presents as erectile dysfunction and penile shortening. Objectives To evaluate the long-term outcome of patients who have undergone the immediate insertion of a penile prosthesis as a treatment for an acute episode of IP refractory to medical therapy or shunt surgery. Design, setting, and participants A total of 50 patients presented with prolonged IP that was unresponsive to conventional treatment. Unsuccessful shunt surgery had been performed in 13 patients. All patients had evidence of cavernosal smooth muscle necrosis and, therefore, underwent an immediate insertion of a penile prosthesis in the acute setting. Measurements Mean age, duration of priapism in hours, intraoperative and postoperative complications, the surgical outcome, and patients' satisfaction were recorded. Results and limitations A malleable penile prosthesis was inserted in 43 patients and a three-piece inflatable implant in was inserted in 7 patients; a subsequent elective exchange of a malleable to an inflatable device was performed in 6 patients. After a median follow-up of 15.7 mo (4–60 mo), 42 patients had already resumed successful sexual intercourse. Prosthesis infection occurred in three patients (6%), which was managed by explantation and delayed reinsertion. A further six patients needed revision surgery. No patient complained of penile shortening, and the overall satisfaction rate was 96%. Conclusions The immediate insertion of a penile prosthesis for acute refractory ischaemic priapism is a simple and successful procedure that treats the acute episode as well as the inevitable erectile dysfunction that will occur with preservation of penile length.

This study assessed the management of patients requesting penile length enhancement by division of the penile suspensory ligament.From September 1998 to January 2005, 42 patients with a variety of etiologies were included; all underwent division of the penile suspensory ligament. The outcome was assessed objectively based on increase in flaccid stretched penile length (SPL) and subjectively using the rates of patient satisfaction.The mean increase in SPL was 1.3+/-0.9 cm (range, -1 to +3 cm), with the addition of a silicone spacer placed between the pubis and penis giving a better outcome (p0.05). The overall patient satisfaction rate was 35% but lower in the group with penile dysmorphic disorder at 27%.Division of the penile suspensory ligament or other augmentation techniques may increase penile length but usually not to a degree that satisfies the patient. Men with penile dysmorphic disorder often have unrealistic expectations regarding the outcome of surgical intervention and should be encouraged to seek psychological help primarily, with surgery reserved as the last resort.

Objective: Open surgical pyeloplasty has been the gold standard for the correction of ureteropelvic junction obstruction (UPJO). Endourological management of UPJO has gained increased acceptance, with reported success rates of 57–87%. It has been suggested that Acucise ® endopyelotomy (AE) should be the procedure of choice for patients with UPJO. The aim of this study was to assess the effectiveness of AE in the treatment of UPJO and the factors contributing to surgical outcome. Materials and Methods: Forty-two patients (34 primary, 8 secondary UPJO) underwent AE between June 1995 and December 1999. Presenting symptoms were; pain 34 (80.9%), UTI 10 (23.8%) and haematuria 5 (11.9%). Pre-operative evaluation included ultrasound and/or intravenous urogram with diuretic renography. Hydronephrosis was graded in 36 patients. Of these 4, 14, 9 and 9 had grade I, II, III and IV hydronephrosis, respectively. Twenty-four patients were stented prior to endopyelotomy and one required nephrostomy. Overall (true) success was defined as clinically pain free and radiologically no evidence of obstruction on diuretic scan. Results: The average operating time was 45min and mean hospital stay was 2.7 days. Mean follow-up was 27 months (range 6–55). The objective success rate was 52% and the subjective success rate was 64%. A total of 19 patients (45.2%) had long lasting clinical and radiographic treatment success. Three (7%) patients required nephrectomy and five (12%) underwent open pyeloplasty. Success rate for grade I/II hydronephrosis was 55.5% and only 27.7% with grade III/IV hydronephrosis. Normal renograms were found in 12 (48%) of those with perioperative extravasation compared to three (25%) without. Only one of the eight patients with secondary UPJO had a normal post-operative renogram. Size or type of stent used had no effect on surgical outcome. The substandard results were noted in patients with grade III/IV hydronephrosis, poor pre-operative renal function, secondary UPJO and without perioperative extravasation. Conclusions: Acucise ® endopyelotomy is a safe and minimally invasive procedure for the management of UPJO. Although the results of AE are suboptimal, its lower degree of invasiveness makes it reasonable choice for first-line treatment. Careful selection of patients will improve the results of AE, although multicentre randomized trials are needed to make a valued comparison with other techniques.