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Context: Penile shaft sparing (PSS) surgery for localised penile cancer (PeCa) aims to balance oncological and functional outcomes., Objective: To summarise the published evidence on different PSS approaches., Evidence Acquisition: We performed a systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The systematic search was performed on PubMed, EMBASE, and Scopus databases up to February 14, 2023. The inclusion criteria encompassed retrospective or prospective studies including patients ≥18 yr of age with localised PeCa treated with different PSS approaches, classified as laser ablation, circumcision, wide local excision, glansectomy with or without split skin graft, glans resurfacing, and mixed technique excision. The risk of bias was assessed using the Newcastle-Ottawa scale. A quantitative synthesis was not performed due to anticipated data heterogeneity and a lack of comparative studies., Evidence Synthesis: Out of 4343 articles identified, 47 met our inclusion criteria, including 10 847 patients. The year of publication ranged between 1983 and 2021. Nine studies were prospective case series, while the remaining studies were retrospective. No comparative studies were identified. Most of the cases included in these studies were Ta and T1. The oncological outcomes were good for all the approaches, with cancer-specific mortality ranging between 0% and 18%. Sexual and cosmetic outcomes, despite being under-reported, were good for all the approaches, with almost all patients being satisfied with their quality of life after surgery. The Newcastle and Ottawa scale revealed a high or severely high risk of bias in all the included studies., Conclusions: PSS approaches were safe and had good functional outcomes, considering however the overall low quality of the studies on this issue., Patient Summary: The perioperative, function, and oncological outcomes of penile shaft sparing approaches are good. However, high-quality studies are needed to determine whether these approaches benefit patients with localised penile cancer., (Copyright © 2024 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Sleep quality and duration have been investigated for their association with health. Insomnia affects up to one-third of adults and may impact male erectile function. In addition, medical treatments for insomnia (many of which are sedatives) may also affect erectile quality., Objective: To investigate the association of erectile dysfunction (ED) in patients diagnosed with and treated for insomnia., Design, Setting, and Participants: We utilized the IBM MarketScan (2007-2016) Commercial and Medicare Supplemental Databases (v 2.0). Age- and enrollment-matched controls were selected among patients without insomnia diagnosis or treatment., Outcome Measurements and Statistical Analysis: Cox proportional hazard models were used to estimate the risk of incident ED (ie, diagnosis alone, or diagnosis and treatment with phosphodiesterase-5 inhibitors [PDE5i], intracavernous injection (ICI)/urethral suppositories, and penile prosthesis) after the diagnosis or treatment of insomnia while adjusting for relevant comorbidities., Results and Limitations: In total, 539 109 men with an insomnia diagnosis were identified. Of these men, 356 575 were also medically treated for insomnia. The mean (±standard deviation) follow-up times for patients diagnosed with insomnia and those diagnosed with and treated for insomnia were 2.8 ± 1.6 and 3.1 ± 1.8 yr, respectively. Men with insomnia were more commonly smokers and had a higher number of office visits and comorbidities than controls (p < 0.001). On an adjusted analysis, both untreated and treated insomnia were associated with increased risks of ED diagnosis (hazard ratio or HR [95% confidence interval {CI}]: 1.58 [1.54-1.62] and 1.66 [1.64-1.69], respectively; p < 0.001). Similarly, men with treated insomnia had a higher risk of having ED treated with PDE5i (HR [95% CI]: 1.52 [1.49-1.55]; p < 0.001) and ICI (HR [95% CI]: 1.32 [1.14-1.54]; p < 0.001) when compared with controls. A limitation of this study was that a lack of granularity regarding patient clinical characteristics (eg, severity of disease, laboratory data, etc.) is inherent to insurance claims data. In addition, the follow-up was limited and may affect associations at longer time points., Conclusions: In the current report, a consistent association between insomnia and ED diagnosis was identified. Men diagnosed with insomnia only were found to have a higher risk of developing ED. Moreover, men with pharmacological insomnia treatments were more often prescribed treatments for ED. Given the prevalence of insomnia, future studies are warranted to delineate the association of insomnia and its treatment with erectile function., Patient Summary: Insomnia affects up to one-third of adults and impact male erectile function. Men only diagnosed with insomnia were found to have a higher risk of developing erectile dysfunction (ED). Moreover, men with pharmacological insomnia treatments were more often prescribed treatments for ED., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: Male infertility has been associated with increased morbidity and mortality., Objective: To perform a systematic review and meta-analysis to provide the most critical evidence on the association between infertility and the risk of incident comorbidities in males., Evidence Acquisition: A systematic review and meta-analysis was performed according to the Meta-analysis of Observational Studies in Epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and registered on PROSPERO. All published studies on infertile versus fertile men regarding overall mortality and risks of cancer, diabetes, and cardiovascular events were selected from a database search on PubMed, EMBASE, Google Scholar, and Cochrane. Forest plot and quasi-individual patient data meta-analysis were used for pooled analyses. A risk of bias was assessed using the ROBINS-E tool., Evidence Synthesis: Overall, an increased risk of death from any cause was found for infertile men (hazard risk [HR] 1.37, [95% confidence interval {CI} 1.04-1.81], p = 0.027), and a 30-yr survival probability of 91.0% (95% CI 89.6-92.4%) was found for infertile versus 95.9% (95% CI 95.3-96.4%) for fertile men (p < 0.001). An increased risk emerged of being diagnosed with testis cancer (relative risk [RR] 1.86 [95% CI 1.41-2.45], p < 0.001), melanoma (RR 1.30 [95% CI 1.08-1.56], p = 0.006), and prostate cancer (RR 1.66 [95% CI 1.06-2.61], p < 0.001). As well, an increased risk of diabetes (HR 1.39 [95% CI 1.09-1.71], p = 0.008), with a 30-yr probability of diabetes of 25.0% (95% CI 21.1-26.9%) for infertile versus 17.1% (95% CI 16.1-18.1%) for fertile men (p < 0.001), and an increased risk of cardiovascular events (HR 1.20 [95% CI 1.00-1.44], p = 0.049), with a probability of major cardiovascular events of 13.9% (95% CI 13.3-14.6%) for fertile versus 15.7% (95% CI 14.3-16.9%) for infertile men (p = 0.008), emerged., Conclusions: There is statistical evidence that a diagnosis of male infertility is associated with increased risks of death and incident comorbidities. Owing to the overall high risk of bias, results should be interpreted carefully., Patient Summary: Male fertility is a proxy of general men's health and as such should be seen as an opportunity to improve preventive strategies for overall men's health beyond the immediate reproductive goals., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Holmium laser enucleation of the prostate (HoLEP) is considered a challenging procedure even for surgeons who have completed the learning curve., Objectives: To assess outcomes and complications following HoLEP performed by a highly experienced surgeon., Design, Setting, and Participants: This was a single-institution prospective study (NCT03583034) performed at a tertiary referral centre that included 243 consecutive patients with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE) treated with HoLEP by a single experienced surgeon (>1600 cases)., Outcome Measurements and Statistical Analysis: Patients were assessed using validated questionnaires and uroflowmetry at baseline and several follow-up dates. Intraoperative and postoperative complications were recorded. Kaplan-Meier analysis was used to estimate recovery rates for urinary continence and erectile function. Logistic regression models were constructed to assess predictors of postoperative complications., Results and Limitations: Of the 243 patients, 78 (32.1%) had an indwelling urethral catheter. The median prostate volume (PV) was 87 cm 3 (interquartile range 60-115) and 146 patients (59.8%) had PV >80 cm 3 . At 3-mo follow-up, 219 patients (90.1%) had a peak flow rate >20 ml/s and 182 (74.9%) had no postvoid residual urine. The improvement in subjective symptoms was significant at 1-mo follow-up and was maintained until 12 mo after surgery. Urinary continence recovery was slow, with an estimated rate of 68% (95% confidence interval [CI] 62-74%) at 1 mo and 94% (95% CI 91-97%) at 12 mo after HoLEP. The recovery rate for erectile function was 53% (95% CI 46-61%) at 1 mo and 85% (95% CI 77-90%) at 12 mo. Postoperative complications occurred in 36 patients (14.8%) during their hospital stay, in 34 (14%) within 1 mo following discharge from hospital, and in ten (4.1%) at later follow-up dates. Clinically significant complications (Clavien-Dindo ≥2) were observed in 44 cases (18%) and were more common for patients with an indwelling catheter at baseline (odds ratio 5.05; p = 0.006)., Conclusions: HoLEP is an effective procedure for treating LUTS due to BPE, although it is not devoid of complications and sequelae, even in the hands of a highly experienced surgeon., Patient Summary: Holmium laser treatment of the prostate to reduce its size has positive results for urinary function when performed by an experienced surgeon, even in complex cases, although there can be complications., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: The outcomes and morbidity following treatment for persistent or varicocele recurrence remain controversial., Objective: To conduct a systematic review relating to the outcomes following treatment (any surgical or radiological) for varicocele persistence/recurrence., Evidence Acquisition: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Prospective and retrospective observational or interventional studies were included until March 2022. Outcomes were pregnancy rate, improvements in semen parameters after treatment compared with those at baseline, pain control, complication rates, and repeat treatment approach. Men of any age with any-grade persistent/recurrent varicoceles were included., Evidence Synthesis: Of 913 articles identified, 18 with 1073 patients were eligible for inclusion. The mean time between the first and repeat treatment ranged between 5.3 and 73.3 months. The indication for repeat treatment was infertility in eight and pain control in six out of 18 studies, whereas four did not provide details for the indication. Of the patients with recurrent/persistent varicoceles initially treated using a radiological intervention, 83.8% underwent another radiological procedure, whereas 16.2% underwent a surgical procedure. Of those initially treated with a surgical procedure, 77.8% underwent a further surgical procedure, whereas 22.2% underwent a radiological procedure. The rate of success of repeat treatment was 60-100%. The reported complications were as follows: hydrocele (up to 16%), testicular atrophy (up to 2%), scrotal hematoma (up to 1.6%), wound infection (up to 6.6%), chronic pain (up to 2.9%), injury to other organs (up to 10%), and thrombophlebitis (up to 5.8%). The rate of symptom resolution was >90% for pain control. Pregnancy rates were 17-58% at 12-month follow-up. Semen parameters improved after repeat treatment compared with that at baseline in 87.5% of studies. The main limitations are the high risk of bias according to the Newcastle and Ottawa Scale, heterogeneity of the included studies, and small simple size., Conclusions: Treating any grade of persistent/recurrent varicoceles has a good rate of success, pregnancy, and pain control, but there is still a risk of complications. Repeat treatment with the same interventional modality is feasible. The level of evidence is overall low., Patient Summary: In this systematic review on persistent or recurrent varicoceles, we showed that repeat treatment with radiological or surgical procedures was feasible, with good success, pregnancy, and pain control rates at follow-up. However, repeat treatment was associated with a higher risk of complications than reported in the published literature relating to patients having their first intervention., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: A dynamic sentinel lymph node biopsy (DSNB) is used for inguinal lymph node staging in patients presenting with primary penile cancer with clinically impalpable inguinal lymph nodes (cN0). Further completion radical inguinal lymph node dissection (RLND) is offered to patients diagnosed with metastatic inguinal nodes following a DSNB., Objective: To identify the diagnostic accuracy of a DSNB and RLND to detect lymph node metastasis., Evidence Acquisition: A systematic literature search was performed on PubMed Medscape, EMBASE, Google Scholar, and Cochrane database for relevant studies between January 1, 2000 and April 30, 2022. Studies were included if a DSNB was offered to cN0 patients and if RLND was offered to patients with positive histology at the DSNB. Risk of bias and confounding assessments were performed. Diagnostic odds ratio, pooled sensitivity/specificity, and heterogeneity analyses were displayed., Evidence Synthesis: Overall, 2893 patients in the 28 studies analysed underwent a DSNB. Twenty-one studies reported patients undergoing RLND for a positive DSNB. A DSNB showed pooled weighted sensitivity of 0.87 (95% confidence interval [CI]: 0.82-0.91) and pooled log diagnostic odds ratio of 6.17 (95% CI: 5.47-6.87). A DSNB showed pooled weighted sensitivity of 0.50 (95% CI: 0.24-0.59), specificity of 0.82 (95% CI: 0.78-0.87), and a log diagnostic odds ratio of 1.18 (95% CI: 0.29-2.97) for detecting further positive lymph nodes at RLND. High heterogeneity, mostly caused by study design, characteristics of the included patients, DSNB technique used, surgical experience/centre case volumes, and follow-up schedule, represents the main limitation of this meta-analysis. Several sensitivity analyses to address these issues support our findings., Conclusions: A positive DSNB is poorly able to discriminate which patients will have further metastatic involvement at completion RLND. Better stratification of these patients would avoid unnecessary overtreatment and possible postoperative comorbidities., Patient Summary: This analysis of the data from the published literature provides evidence that the diagnostic accuracy of a dynamic sentinel lymph node biopsy (DSNB) requires further improvement. Moreover, a high proportion of patients with a positive DSNB undergo unnecessary radical lymph node dissection; better stratification of these patients might help determine avoidable overtreatment and postoperative comorbidities., (Copyright © 2022. Published by Elsevier B.V.)

Current noninvasive treatments for erectile dysfunction (ED) include oral medications, intracavernosal injections, and vacuum-assisted devices. Although these therapies work well for many, some patients experience side effects or are unsatisfied with these therapeutic modalities. Restorative therapies are the newest frontier for ED treatments and are focused on regenerating injured tissue and delivering a possible "cure". Stem cell therapy is a regenerative treatment aimed at restoring normal erectile physiology and curing ED. It is promising in cell-based and animal studies and has now been studied in humans. Although the clinical results are not robust, future research may shed more light on the efficacy of this treatment for ED. PATIENT SUMMARY: Stem cell therapy is a promising regenerative treatment for erectile dysfunction, but the clinical results are not robust. It is currently considered an experimental treatment and should not be used outside a clinical trial setting., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Context: The benefits and harms of varicocele treatment versus observation in adult infertile males are still controversial., Objective: To systematically pool the evidence on outcomes of varicocele treatment (any surgical or radiological) versus observation in adult infertile men., Evidence Acquisition: A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Only prospective randomized and nonrandomized studies were included until November 2021. The primary outcome was pregnancy rate; the secondary outcomes were improvements in sperm concentration, normal morphology, and progressive sperm motility after treatment compared to baseline. Men ≥18 yr of age with any-grade varicoceles were included., Evidence Synthesis: Of 557 articles identified, 12 were eligible for inclusion, involving 1357 patients. Varicoceles were treated surgically in ten and radiologically in four studies. Varicocele treatment improved pregnancy rates (odds ratio 1.29; 95% confidence interval [CI] 1.00-1.65; p = 0.048) and sperm concentration (mean difference 12.34 million/ml, 95% CI 3.49-21.18; p = 0.006) compared with observation. Proportions of spermatozoa with normal morphology and progressive motility were not statistically different from those with observation. However, considering treatment arm only, sperm concentration, progressive motility, and normal sperm morphology were improved compared with baseline. A subgroup analysis showed that the benefit of varicocele treatment is evident in men with an abnormal semen analysis. The main limitation is represented by the heterogeneity of the included studies, mostly in terms of study population, fertility of the partner, outcome evaluation, lack of long-term outcomes, and intermediate/high risk of bias., Conclusions: Treatment of any-grade varicoceles may improve pregnancy rates and sperm concentration in adult infertile men, while benefits in sperm motility and normal morphology are less clear., Patient Summary: In this systematic review and meta-analysis of all published prospective trials on varicocele treatment, significant evidence emerged on its benefit in terms of improved pregnancy rates and sperm concentration, while benefits in sperm motility and morphology are less clear., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Discrepancies exist between patient-reported storage phase symptoms severity and International Prostate Symptom Score (IPSS) scores., Objective: To investigate whether the Overactive Bladder questionnaire (OABq) can detect further storage phase lower urinary tract symptoms (LUTS) among patients complaining solely of voiding LUTS based on the IPSS questionnaire, and to address the real-life impact of voiding LUTS towards patients' quality of life (QoL)., Design, Setting, and Participants: Data from 233 consecutive men seeking medical help for LUTS/benign prostate enlargement for the first time were analysed. All patients completed both the OABq and the IPSS questionnaire. In order to investigate patients with predominantly voiding phase symptoms, men with storage phase symptoms at IPSS were eventually excluded from the analysis. Patients with an OABq score of ≥40 were considered as those having moderate-to-severe storage LUTS., Outcome Measurements and Statistical Analysis: Descriptive statistics and linear regression models tested the associations between OABq scores, IPSS, and IPSS-QoL., Results and Limitations: OABq scores were higher in men with severe voiding symptoms than in men with mild voiding symptoms (p < 0.001). More than half of patients with predominant voiding symptoms, according to the IPSS questionnaire, depicted a pathologic OABq score. A higher rate of pathologic OABq scores was found in men with moderate/severe voiding symptoms than in those with mild scores (67.4% vs 49.6%, p < 0.001). At multivariable analysis, younger age (beta -0.1, p < 0.01), IPSS voiding subscore (beta 0.3, p < 0.001), and OABq score ≥40 (beta 1.1, p < 0.001) emerged as independent predictors of IPSS-QoL after accounting for prostate volume and flow max., Conclusions: The OABq can detect the presence of further storage phase LUTS in patients presenting solely with voiding LUTS and IPSS suggestive of voiding phase symptoms. In addition, the OABq was associated with worse patient QoL regardless of the severity of voiding symptoms., Patient Summary: The Overactive Bladder questionnaire (OABq) is able to detect the presence of additional storage lower urinary tract symptoms (LUTS) in patients presenting solely with voiding LUTS according to the IPSS questionnaire. Moreover, the OABq is associated with worse quality of life in these patients regardless of the severity of voiding symptoms., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Scarce data are available about long-term follow-up (FU) in men undergoing holmium laser enucleation of the prostate (HoLEP)., Objective: To investigate the risk of being symptomatic at 10-yr FU after HoLEP., Design, Setting, and Participants: Perioperative data from 125 patients submitted to HoLEP in 2007-2010 by a single, highly experienced surgeon were analyzed. Patients were assessed by International Prostate Symptoms Score (IPSS), prostate-specific antigen (PSA), and uroflowmetry at 6-mo and 10-yr FU., Outcome Measurements and Statistical Analysis: Logistic regression models tested the association between clinically significant predictors and the risk of being symptomatic at long-term FU (defined as IPSS≥8 and/or peak flow rate [PFR]<15ml/s and/or postvoid residual volume [PVR]>20ml, need for symptomatic medical treatment, or redo surgery)., Results and Limitations: At surgery, median (interquartile range) age was 66 years (61, 69), prostate volume was 78ml (56, 105), and PFR was 9ml/s (7, 12). All patients showed favorable outcomes (ie, IPSS and uroflowmetry parameters) 6 months after surgery. At median 126-month FU, PFR was 16ml/s (13, 23), PVR was 10ml (5, 15), total IPSS was 5 (1-7), and PSA was 0.7 ng/ml (0.4, 1.3). Of all, 32 patients (26%) were symptomatic at long-term FU, seven (5.7%) reported urinary incontinence, and six (4.7%) underwent redo surgery throughout the FU period due to either bladder neck contracture or urethral stricture. Older patients at surgery (odds ratio [OR]: 1.12; 95% confidence interval [CI]: 1.03-1.22; p=0.006) and patients who never recovered full continence postoperatively (OR: 0.49; 95% CI: 0.01-0.27; p=0.001) were at a higher risk of being symptomatic at very long-term FU, after adjusting for baseline clinical characteristics., Conclusions: HoLEP ensures a durable relief of urinary symptoms in almost 75% of patients up to 10 years after surgery. Older patients and those who do not recover from incontinence after surgery should be counseled carefully regarding a higher risk of symptom recurrence at long-term assessment., Patient Summary: Consistent symptom relief is preserved even 10 years after holmium laser enucleation of the prostate in almost 75% of patients. Older age and incomplete continence recovery after surgery were the two most relevant risk factors for being symptomatic at long-term follow-up. Postoperative functional outcomes are kept in three out of four patients at 10-yr follow-up after holmium laser enucleation of the prostate. Conversely, the older the patient at surgery and the presence of incomplete continence recovery throughout the postoperative period, the greater the probability of being symptomatic at long-term follow-up., (Copyright © 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.)