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We measured the skeletal effects of Herbst appliance treatment in a retrospective sample of 25 boys (aged 10.7-14.5 years) and 25 girls (aged 10.7-14.3 years). Selection criteria were (1) a pretreatment full Class II molar relationship (ANB angle: average, 6.7 degrees; range, 2.5-10.5 degrees) and (2) a posttreatment full Class I or overcorrected Class I molar relationship within 6-8 months. A first t-test was used to evaluate variations between pre- and posttreatment cephalometric measures. Then, compared with the appropriate age- and sex-matched European norm, every pre- and posttreatment value was transformed into a z-score on the distribution of the norm value and a second t-test was performed. The second t-test was to study variations between pre- and posttreatment z-scores in order to neutralize the effect of natural growth. Posttreatment, the mandible showed a remarkable forward repositioning without opening of the gonial angle, particularly in males. Only ANB and Xi-CF-PTV angles were significantly different when the effect of normal growth was excluded. In males, ramus height and mandibular basal length were significantly increased when total variation was considered (ie, not excluding the effect of normal growth). In females, only the mandibular ramus height was significantly increased. In conclusion, even short-term Herbst therapy can be efficacious, with the most frequent effect being mandibular forward repositioning followed by mandibular ramus elongation. The statistical procedure used counteracts the effect of growth and sex on the results. Moreover, z-scores are adimensional measures with which any kind of parameter may be compared and scaled to each other in the perspective of a more reliable mutivariated interpretation of cephalometric variables.

Risk factors for Peyronie's disease (PD) are serum lipid abnormalities, hypertension and type 2 diabetes mellitus (T2DM). Oxidative stress and inflammation are key-players in the pathogenesis of arterial diseases, leading to insulin resistance (IR), which is a major determinant of non-alcoholic fatty liver disease (NAFLD). We studied the potential relationship between PD, IR, and NAFLD. Forty-nine male patients were enrolled, fulfilling the well-accepted diagnostic criteria of stable PD. Fifty male individuals without PD, well-matched for age and BMI, were selected as the control group. Comorbidities (T2DM and hypertension), as well as the lipid profile and the glucometabolic asset, were evaluated. The triglycerides/HDL ratio (TG/HDL-C ratio) with a cut-off of ≥3 and the triglycerides-glucose index (TyG) with an optimal cut-point of 8.5 were used for diagnosis of IR and NAFLD, respectively. NAFLD diagnosis was confirmed by the presence of bright liver at ultrasonography. Hypertension was found more frequently in PD patients than in no-PD subjects (P=0.017), independently of age (P=0.99). Both IR and NAFLD were significantly associated with the presence of PD in our population of men (P=0.043 and 0.0001, respectively), no matter how old (P=0.11 and 0.74, respectively). At logistic regression, NAFLD was the only predictor of the PD presence (p=0.021). The AUROC of TyG to predict PD was 0.7437 (sensitivity 67.35% and specificity 80%) with a percentage of correctly classified patients of 73.74%. Oxidative stress markers were significantly associated with NAFLD. Testosterone level was significantly low in the subjects with NAFLD in cross-sectional analyses. Both factors, i.e., oxidative stress and hypogonadism, are central to PD pathogenesis. In conclusion, NAFLD and IR are strongly associated with PD. The pathogenic link between these conditions and the underlying mechanisms are only hypothetical and thoroughly summarized in the discussion.

Background The effects of kidney transplantation on male sexual function are controversial. Aim To evaluate the impact of kidney transplantation on erectile and ejaculatory function and to assess a possible correlation between some selected characteristics of patients and their erectile and ejaculatory function after renal transplantation. Methods An observational retrospective analysis was conducted on male patients who had undergone kidney transplantation from January 2009 to April 2019. A prospectively maintained database was used to collect all data. Patients were evaluated before kidney transplant and 6 and 12 months after kidney transplant. Male patients undergoing renal transplantation for any cause who were sexually active with a stable partner were included in the study. Outcomes The main outcome measures included the International Index of Erectile Function (IIEF-15) and the 4-item version of Male Sexual Health Quality–Ejaculation Disorders (MSHQ-EjD Short Form) questionnaires. The first 3 questions of the MSHQ-EjD Short Form were used to assess the ejaculatory function, whereas the fourth question was used to evaluate the ejaculation bother. Results A total of 95 patients were eligible in the study. The evaluation of sexual function was available in 56 patients (58.9%). Mean IIEF-15 significantly decreased at 6 months (P Clinical Implications Improvement of knowledge regarding the effects of kidney transplantation on sexual function and about the patient characteristics related to sexual health after transplantation. Strength & Limitations This is the first article that analyzes in depth the ejaculatory function in patients who had undergone kidney transplantation assessing ejaculation with a validated questionnaire. The main limitation is the retrospective design of the study. Conclusion Kidney transplantation appears to have a negative impact on sexual health, significantly worsening both erectile and ejaculatory functions. Age, diabetes, hypertension, smoking, pretransplantation testosterone levels, time for transplantation, as well as erectile and ejaculatory function before transplant were significantly related to erectile and ejaculatory functions after renal transplantation.

The present study aimed to describe and critically discuss the current evidence regarding the penile girth enhancement procedures for aesthetic purposes. We designed a narrative review of the literature. A comprehensive search in the MEDLINE database was performed. Original articles in English-language, published until March 2021, were selected. A total of 29 studies were included (3 reporting non-invasive approaches, 11 injection therapies, and 15 surgical procedures). The vast majority of articles (26, 89.7%) were not randomized controlled trials, with overall low quality and limited level of evidence. Only 1 (33.3%) paper regarding non-invasive approaches reported a minimal (+0.03 cm) but a significant increase of penile girth (p = 0.034). A low rate (11.2-14.4%) of mild, temporary adverse events and poor-to-moderate patient satisfaction were found. Eight (72.7%) articles concerning injection therapies showed a significant increase in penile girth (p < 0.05). A low rate of mild complications, generally at the injection site, and a high patient satisfaction rate (75-100%) were highlighted. Nine (60%) papers on surgical treatments found a significant increase in penile girth (p < 0.05), while the other 6 (40%) studies reported a generic improvement in penile circumference. Skin necrosis or ulcers, wound infections, or need for reoperation were reported in 8 (53.3%) studies. A high patient satisfaction rate (60-100%) was reported. Our review highlighted the overall positive results of injection procedures, the poor outcomes associated with non-invasive techniques, and the good efficacy and satisfaction with a non-negligible risk of complications in patients undergoing surgical treatments. However, the adverse events are probably largely under-reported and these procedures should still be considered under investigation due to the limited evidence available and the lack of guidelines.

Introduction: Several urological conditions that share an impairment of tissue oxygenation can benefit from hyperbaric oxygen therapy; limited evidence is available of its impact on patients undergoing male-to-female gender affirmation surgery. Aim: To evaluate the efficacy and safety of hyperbaric oxygen therapy as adjuvant treatment for surgical site infections in patients undergoing male-to-female gender affirmation surgery. Methods: This research was conducted as an observational retrospective study. Patients undergoing male-to-female gender affirmation surgery at the principal investigators’ institution from January 2009 to September 2019, with a discharge diagnosis of complicated superficial or deep wound infections, were included. All patients underwent standard management of wound infection. Subjects received/not-received hyperbaric oxygen therapy at the surgeon's discretion and were assigned to the hyperbaric oxygen therapy versus non-hyperbaric oxygen therapy group accordingly. Complete wound healing rate (primary outcome), duration of antibiotic therapy, perineal drain time, bladder catheter time, and hospital stay were recorded. All adverse events that occurred during the study period were described. Results: A total of 156 patients underwent male-to-female gender affirmation surgery in the study period. Thirty-three patients were enrolled. Fifteen subjects belonged to the hyperbaric oxygen therapy group, the other 18 to the non-hyperbaric oxygen therapy group. No statistically significant differences were found between the two groups at baseline. Penile inversion vaginoplasty and intestinal vaginoplasty were performed in nine (60%) and six (40%) patients of the hyperbaric oxygen therapy group. Only penile inversion vaginoplasty was performed in subjects of the non-hyperbaric oxygen therapy group. Complete wound healing was obtained in 15 patients (100%) of the hyperbaric oxygen therapy group and 17 patients (94.4%) of the non-hyperbaric oxygen therapy group (p=0.35). Duration of antibiotic therapy, perineal drain time, bladder catheter time, and hospital stay were significantly lower in the hyperbaric oxygen therapy group (p&nbsp

Context: Several sexual side effects, including erectile, ejaculatory, and orgasmic dysfunction, were reported with the majority of surgical procedures for benign prostatic obstruction (BPO). Objective: To systematically review current evidence regarding the impact of benign prostatic hyperplasia (BPH) surgery on sexual function. Evidence acquisition: A comprehensive bibliographic search on the MEDLINE, Cochrane Library, Embase, Web of Science, and Google Scholar databases was conducted in July 2021. The population, intervention, comparator, and outcome (PICO) model was used to define study eligibility. Studies were Included if they assessed patients with BPO and related lower urinary tract symptoms (P) undergoing BPH surgery (I) with or without a comparison between surgical treatments (C) evaluating the impact on sexual function (O). Retrospective and prospective primary studies were included. A pooled analysis was conducted on studies including the postoperative assessment of International Index of Erectile Function (IIEF)-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD; Function and/or Bother), or retrograde ejaculation (RE) rate (PROSPERO database ID: CRD42020177907). Evidence synthesis: A total of 151 studies investigating 20 531 patients were included. Forty-eight randomized controlled trials evaluating 5045 individuals were eligible for the meta-analysis. In most studies (122, 80.8%), only erectile and/or ejaculatory function was evaluated. A substantial number of articles (67, 44.4%) also used nonvalidated tools to evaluate erectile and/or ejaculatory function. The pooled analysis showed no statistically significant changes in IIEF-5 score compared with baseline for the transurethral resection of the prostate (TURP; weighted mean difference [WMD] 0.76 pts; 95% confidence interval [CI] –0.1, 1.62; p = 0.08), laser procedure (WMD 0.33 pts; 95% CI –0.1, 0.77; p = 0.13), and minimally invasive treatment (WMD –1.37 pts; 95% CI –3.19, 0.44; p = 0.14) groups. A statistically significantly higher rate of RE was found after TURP (risk ratio [RR] 13.31; 95% CI 8.37, 21.17; p < 0.00001), other electrosurgical procedures (RR 34.77; 95% CI 10.58, 127.82; p < 0.00001), and the entire laser group (RR 17.37; 95% CI 5.93, 50.81; p < 0.00001). No statistically significant increase in RE rate was described after most of the minimally invasive procedures (p > 0.05). The pooled analysis of MSHQ-EjD scores was possible only for prostatic urethral lift, showing no statistically significant difference between baseline and post-treatment MSHQ-EjD Function scores (WMD –0.80 pts; 95% CI –2.41, 0.81; p = 0.33), but postoperative MSHQ-EjD Bother scores were significantly higher (WMD 0.76 pts; 95% CI 0.22, 1.30; p = 0.006). Conclusions: Erectile function appears to be unaffected by most surgical procedures for BPO. RE is a very common adverse event of BPH surgery, although emerging minimally invasive surgical procedures could be associated with a lower risk. Patient summary: Benign prostatic hyperplasia surgery can have an impact on sexual function, mainly involving ejaculatory function.

Background A xenograft consisting of equine collagen coated with human fibrinogen and thrombin (TachoSil; Baxter, CA) has recently been introduced in grafting procedures for Peyronie’s disease (PD). Aim To describe the results of a multicenter prospective registry on patients with PD undergoing plaque incision or and grafting (PIG) or plaque excision and grafting (PEG) with collagen fleece TachoSil, to evaluate the efficacy and safety of this procedure. Methods A prospective non-controlled multicenter study of patients with PD was performed between May 2016 and March 2018. Patients from 10 centers with stable PD for at least 3 months, difficulties in sexual intercourse, normal erectile function with or without pharmacological treatment, curvature >45°, and/or penile shortening and/or complex deformities were included. All patients underwent PIG/PEG with collagen fleece TachoSil. Outcomes The main outcome measure of this study were penile curvature correction (intraoperative), penile shortening (intraoperative), erectile function with the 5-item version of the International Index of Erectile Function (IIEF-5) and the Erection Hardness Score, subjective patient outcomes with non-validated questionnaires, and complications. Results A total of 52 patients were enrolled in the study. The mean (SD) preoperative penile curvature was 72.8° (17.0). PIG was the preferred technique (80.8%). Intraoperatively, complete curvature correction was achieved in 92.3%, and no significant penile shortening was recorded in 80.8% of subjects. Subjective penile shortening was reported in 83.3% of patients at 6 months. No objective measurement of penile curvature and length was recorded during follow-up. No statistically significant difference from the baseline was found in IIEF-5 and Erection Hardness Score at 3 or at 6 months, although 16.7% of men experienced a worsening of IIEF-5 scores and 14.3% required de novo phosphodiesterase type 5 inhibitor use. 6 months after surgery, 78.5% of men were satisfied with intervention. Swelling and ecchymosis/hematoma were the most common perioperative complications (40.4%). 2 cases (3.8%) of wound infection were recorded. At 6 months, 35.7% of patients reported mild penile hypesthesia. Clinical implications Our results confirm the high success rate of grafting with TachoSil, and the surgeon perceived low percentage of penile shortening. Strength & Limitations This is the first multicentre study on patients with PD undergoing grafting with TachoSil without concomitant placement of penile prosthesis. The main limitations are the short follow-up and the relatively small sample size. Conclusion Grafting with TachoSil after PIG/PEG in patients with PD is an effective and safe procedure. Among the main advantages of this technique, there are ease of use of the graft and reduced operative time.

Background and Objectives: Multiparametric magnetic resonance imaging (mpMRI) of the prostate and prostate-specific membrane antigen positron emission tomography (PSMA PET) are some examples of how the advancement of imaging techniques have revolutionized the diagnosis, staging, and consequently management of patients with prostate cancer (PCa). Although with less striking results, novel radiological modalities have also been proposed for bladder cancer (BCa) in recent years. Micro-ultrasound (MUS) is an imaging examination characterized by high real-time spatial resolution, recently introduced in the urological field. This article aimed to describe the current evidence regarding the application of MUS for the diagnosis and staging of PCa and BCa. Materials and Methods: We designed a narrative review. A comprehensive search in the MEDLINE, Scopus, and Cochrane Library databases was performed. Articles in English-language and published until July 2022 were deemed eligible. Retrospective and prospective primary clinical studies, as well as meta-analyses, were included. Results: MUS-guided prostate biopsy showed high sensitivity (0.91, 95% CI, 0.79–0.97) in the diagnosis of clinically significant PCa (csPCa). It was associated with a higher detection rate of csPCa than a systematic biopsy (1.18, 95% CI 0.83–1.68). No significant difference was found between MUS and mpMRI-guided biopsy in the total detection of PCa (p = 0.89) and in the detection of Grade Groups ≥ 2 (p = 0.92). The use of MUS to distinguish between non-muscle-invasive and muscle-invasive BCa was described, highlighting an up-staging with MUS only in a minority of cases (28.6%). Conclusions: Promising findings have emerged regarding the feasibility and accuracy of MUS in the diagnosis and staging of PCa and BCa. However, the available evidence is limited and should be considered preliminary.

Purpose: To evaluate the efficacy and safety of Escherichia coli Nissle 1917 (EcN) in association with levofloxacin in patients with chronic bacterial prostatitis (CBP). Methods: Patients with CBP referred to our clinic from September 2017 to July 2019 were enrolled. At baseline, the symptomatology was assessed with the NIH-Chronic Prostatitis Symptom Index (NIH-CPSI), while the Meares–Stamey test was used to diagnose the infection. Patients were randomized (1:1) in two groups (A and B). All subjects underwent oral administration of Levoxacin® 500mg once daily for 4weeks. Only the patients in Group B underwent oral administration of EcN® 320mg, twice daily for 4weeks and then once daily for 8weeks. After 3months, each patient repeated the NIH-CPSI questionnaire, while the Meares–Stamey test was repeated at 3 and 6months in patients who reported persistent symptoms. All adverse events (AEs) were recorded. Results: A total of 110 patients were enrolled. After 3months patients in Group B reported a significantly lower NIH-CPSI score (5.85 ± 3.07 vs. 7.64 ± 3.86; p = 0.009) and biological recurrences rate (9.8 vs. 26.9%; p = 0.043). At 6months the biological recurrences rate was significantly lower in Group B (8.7 vs. 28.9%; p = 0.038). Only three patients in Group A and six in Group B (p = 0.25) complained mild AEs. Conclusions: Combination therapy with EcN and levofloxacin allows a better control of symptoms and biological recurrences in patients with CBP, without worsening the safety of the treatment.

The growing demand for glans penis augmentation (GPA) makes it a hot topic in the field of andrological surgery, albeit still widely debated. The lack of high supporting evidence and its technically challenging aspects are the main concerns. The aim of this study was to review the current literature about GPA in order to provide an easy and comprehensive overview of the topic. GPA is suitable for managing both cosmetic and functional issues. Counseling should be the cornerstone of the decision-making process. A thorough understanding of the glans anatomy and treatment strategies remain essential to safely and effectively address the patient’s needs. GPA can be performed using injectable fillers or surgical grafting. Glans-shaft penis asymmetries, small glans size, and loss of glans tumescence can be managed by both injectable fillers and surgery. On the other hand, patients with lifelong premature ejaculation can mainly benefit from using injectable fillers. Currently, available studies show promising results but are limited by small sample’s size and non-randomized design. Furthermore, treatment-related complications are poorly reported. The long-term efficacy and safety profiles of GPA techniques should be further investigated.

Resumen Introduccion La suspension de la mayoria de las cirugias electivas durante la pandemia por COVID-19 ha aumentado las listas de espera de cirugia urologica. El objetivo de este estudio es evaluar el impacto de la pandemia COVID-19 en la lista de espera de cirugia urologica en un hospital de alto volumen. Metodos Se diseno un estudio descriptivo observacional. Se analizaron todos los pacientes incluidos en la lista de espera de cirugia urologica de nuestro centro de alto volumen el 1 de mayo de 2020 (46 dias despues de la suspension de la cirugia electiva). Se registraron las caracteristicas basales, prioridad en la lista de espera, enfermedad urologica principal, tipo de cirugia programada y tiempo de espera. Otras variables registradas fueron la presencia de cateter urinario, el numero de visitas al servicio de urgencias, evidencia de infeccion por COVID-19, el numero de muertes y su causa. El tiempo de espera de cada enfermedad se comparo con el tiempo de espera para la cirugia en 2019. Resultados Un total de 350 pacientes fueron incluidos en el estudio. El tiempo medio (DE) en la lista de espera fue de 97,33 (55,47) dias. Los pacientes de prioridad 1, que normalmente deben ser operados en un plazo de 30 dias, estuvieron en la lista de espera por un tiempo medio de 60,51 (20,14) dias. Eran principalmente pacientes con litiasis ureteral (25,6%), cancer de vejiga de alto riesgo o musculo-invasivo (20,9%) y cancer de prostata de alto riesgo (13,9%). El tiempo medio de espera superaba significativamente el tiempo medio (DE) de espera para cistectomia radical (p = 0,04) y URS (p = 0,003) en 2019. Conclusiones La suspension de la mayoria de las cirugias electivas debido a la pandemia por COVID-19 tuvo un impacto significativo en la lista de espera de cirugia urologica de nuestro centro de alto volumen, especialmente en el grupo de prioridad 1.

Background Several studies reported high satisfaction rates (> 90%) for patients and their partners after penile prosthesis (PP) implantation. Aim To describe and critically discuss the current evidence regarding the assessment of patient and partner satisfaction after penile implant surgery. Methods A critical narrative review of the studies investigating the patient and partner satisfaction after PP implantation was designed. Papers in English-language published until January 2021 were included. Outcomes The main outcome investigated was patient and partner satisfaction after penile implant surgery. Results The International Index of Erectile Function , the Erectile Dysfunction Inventory of Treatment Satisfaction , the Treatment Satisfaction Scale , and the Quality of Life and Sexuality with Penile Prosthesis are the best-known validated tools used to assess satisfaction after PP implantation. Except for Quality of Life and Sexuality with Penile Prosthesis , they were not validated in patients undergoing penile implant surgery. The lack of an “ad hoc” tool has led to the widespread of nonvalidated questionnaires. Several tools can be useful in the preimplantation counseling, such as the mnemonic Compulsive/obsessive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial, and Psychiatric , the Minnesota Multiphasic Personality Inventory, the Brief Sexual Symptom Checklist for Men , the Attitude towards Penile Implant , and the Attitude Attributed to the Partner towards Penile Implant . Clinical Implications Improvement of knowledge regarding the available tools to evaluate the satisfaction after penile implant surgery. Strengths & Limitations Comprehensive and thorough review of all the main validated questionnaires available to assess satisfaction in patients with PP. Lack of a systematic approach and quantitative data analysis. Conclusion Despite the high satisfaction rate reported in the literature, most of the studies used suboptimal or non-validated questionnaires to assess patients undergoing penile implant surgery. Future research is needed to develop and validate a specific, complete and easy-to-use questionnaire. Manfredi C, Fortier E, Faix A, et al. Penile Implant Surgery Satisfaction Assessment. J Sex Med 2021;18:868–874.

Most cancers are related to lifestyle and environmental risk factors, including smoking, alcohol consumption, dietary habits, and environment (occupational exposures). A growing interest in the association between sexual activity (SA) and the development of different types of tumors in both men and women has been recorded in recent years. The aim of the present systematic review is to describe and critically discuss the current evidence regarding the association between SA and male genital cancers (prostatic, penile, and testicular), and to analyze the different theories and biological mechanisms reported in the literature. A comprehensive bibliographic search in the MEDLINE, Scopus, and Web of Science databases was performed in July 2021. Papers in the English language without chronological restrictions were selected. Retrospective and prospective primary clinical studies, in addition to previous systematic reviews and meta-analyses, were included. A total of 19 studies, including 953,704 patients were selected. Case reports, conference abstracts, and editorial comments were excluded. Men with more than 20 sexual partners in their lifetime, and those reporting more than 21 ejaculations per month, reported a decreased risk of overall and less aggressive prostate cancer (PCa). About 40% of penile cancers (PCs) were HPV-associated, with HPV 16 being the dominant genotype. Data regarding the risk of HPV in circumcised patients are conflicting, although circumcision appears to have a protective role against PC. Viral infections and epididymo-orchitis are among the main sex-related risk factors studied for testicular cancer (TC); however, data in the literature are limited. Testicular trauma can allow the identification of pre-existing TC. SA is closely associated with the development of PC through high-risk HPV transmission; in this context, phimosis appears to be a favoring factor. Sexual behaviors appear to play a significant role in PCa pathogenesis, probably through inflammatory mechanisms; however, protective sexual habits have also been described. A direct correlation between SA and TC has not yet been proven, although infections remain the most studied sex-related factor.

The intraplaque injection of collagenase from Clostridium Histolyticum (CCH) was established as an effective therapeutic alternative for selected patients with Peyronie's disease (PD). There is no consensus on the use of pre-procedure anaesthesia. The aim of this pilot study was to assess the efficacy and safety of dorsal penile block before CCH injections in reducing procedure related pain. The treatment protocol described in the IMPRESS trials was adopted. The first injection of the first cycle was given without anaesthesia, while the second after penile block. After the administration of each injection, the pain related to the procedure was evaluated with the Wong-Baker-FACES(R)-Pain-Rating-Scale. Thirty patients were included. Mean age 56.7 (SD: 9.61) years. Mean basal penile curvature 59.37o (SD: 18.26). The mean pain value related to the procedure measured after the first injection of the first cycle (without anaesthesia) was 5.4 (SD: 2.13), while after the second injection (with anaesthesia) was 2.5 (SD: 1.92), (p < .001). The treatment was more painful in patients with dorsal plaques (mean:6.2) than in patients with lateral plaques (mean: 4.35) (p = .01). We can conclude that penile block before CCH injection in patients with PD seems an effective and safe measure to decrease the pain related to the procedure.

The penoscrotal (PS), infrapubic (IP), and subcoronal (SC) incisions are used for inserting an inflatable penile prosthesis (IPP). Each surgical approach has its advantages and disadvantages and experts continue to debate which technique has the best outcomes. We performed a critical review of the published English-language studies up to April 2020 investigating the PS, IP, or SC approach for IPP placement. The PS approach is the most frequently used incision. The available data do not suggest a difference between PS and IP approach in size of the implanted prostheses, achieved penile length, patient satisfaction, infection rate, and risk of urethral injury. The risk of dorsal nerve injury, even if low, seems to be greater for IP approach. IP technique is associated with shorter operative time and earlier use of IPP compared with PS approach. Despite limited available data it is reasonable to assume that SC approach, compared with other approaches, has longer operative time and similar infection rate. The time to device activation with SC technique could be similar to the IP approach, but there is only minimal data that can confirm this hypothesis.

Background Some studies showed encouraging results on the efficacy and safety of penile traction therapy after Peyronie's disease (PD) surgery. The early traction therapy (ETT) could be an effective and safe approach to minimize penile shortening in patients undergoing PD surgery. Aim To evaluate the feasibility, efficacy, and safety of a novel penile splint as ETT in patients with PD undergoing grafting techniques. Methods Patients with PD underwent plaque incision and grafting technique; at the end of the procedure, a novel penile splint (ETT) was applied to all patient. The device consisted of 2 10CH intubating stylets, self-adapted to each patient, that kept the penis stretched with the aid of non-absorbable sutures. The total expense for the materials needed to build each penile splint was less than 15 euros. This active traction was maintained for 1–3 weeks; then, we removed the stitches leaving the device on-site for a passive traction. Within 3–4 weeks from surgery, the penile splint was replaced by a standard penile traction device. Outcomes The main outcomes evaluated at 6 months included stretched penile length (SPL), penile curvature, International Index of Erectile Function-erectile function (IIEF-EF) domain, patient satisfaction, and time to first satisfactory sexual intercourse. Results A total of 46 patients were enrolled. The median preoperative IIEF-EF, penile curvature, and SPL were 27 points, 70°, and 13 cm, respectively. The median follow-up was 15 months. The median postoperative IIEF-EF was 25 points (P < .001). The median residual penile curvature was 10° (P < .001). The median postoperative SPL was 13 cm (P = .269). 8 patients (17.4%) lost 1 cm of SPL; no shortening greater than 1 cm was recorded. The median time to first satisfactory sexual intercourse and patient satisfaction score was 6 weeks and 9 points, respectively. Clinical Implications Our results could pave the way for a new line of research, which in turn could lead to an improvement in the postoperative management of the patient undergoing surgery for PD. Strength & Limitations This is the first study evaluating the ETT after PD surgery. The main limitation of this study is the lack of a randomized control group. Other weaknesses are the small sample size and the short follow-up time. Conclusion Our novel penile splint is inexpensive, easy to assemble, and adaptable to the patient. ETT using this novel device, followed by standard traction therapy, seems to be feasible, effective, and safe.

The purpose of this study was to evaluate the effectiveness and safety of the second cycle of Collagenase Clostridium histolyticum injections using the modified shortened protocol. We performed a retrospective analysis on patients who had already undergone the first cycle of injections using the modified shortened protocol and requested more injections to improve the remaining curvature. The International Index of Erectile Function, the Peyronie's Disease Questionnaire and the Global Assessment of Peyronie's Disease questionnaire were self-administered to all patients. All the parameters were recorded at baseline, after the first cycle and after the second cycle of injections. All adverse events were recorded. Seventeen patients completed two cycles of injections. All patients had a reduction of the initial curvature after the first cycle, with a mean improvement of 17.4° (27.4%). After the second cycle, the reduction of the curvature was 7.9° (17.1%), and 29.4% of patients had no further improvement. No severe side effect was recorded. The results of the present study confirm the effectiveness and safety of the modified shortened protocol of Collagenase C.histolyticum injections for Peyronie's disease. However, the second cycle of three injections may be less effective, and patients may not be completely satisfied.

PURPOSE: To perform a cumulative analysis of the current evidence on the surgical and functional outcomes of bipolar endoscopic enucleation of the prostate (b-EEP) versus bipolar transurethral resection of the prostate (b-TURP). METHODS: A systematic review of the literature was performed on PubMed, Ovid®, and Scopus® according to Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA Statement). The meta-analysis was conducted using the Review Manager 5.3 software. Parameters of interest were surgical and functional outcomes. Weighted mean difference, and odds ratio with 95% confidence interval were calculated for continuous and binary variables, respectively. Pooled estimates were calculated using the random-effect model. RESULTS: Fourteen comparative studies were included. No statistically significant difference in terms of overall baseline characteristics was found. b-EEP had higher amount of resected tissue (p

No study has yet been done to evaluate topical alprostadil as a less invasive alternative vasoactive agent for Penile Dynamic Duplex Ultrasonography (PDDU) in the diagnosis of erectile dysfunction. The main aim of our study was to evaluate the usability and reliability of topical alprostadil for PDDU compared with standard intracavernous injection. A further objective was to determine the patients' preference between these two different approaches. During session A, patients received injection while during session B, they received topical alprostadil. Each patient underwent both sessions, 1week apart from the other. A total of 80 patients were enrolled. After 20min from drug administration, no significant difference was found between the two procedures in terms of peak systolic velocity and end-diastolic velocity, while Erection Hardness Score was significantly higher with injection. Patients reported less pain/discomfort during the procedure in case of topical alprostadil use and an overall preference towards this examination modality. Topical alprostadil could represent a usable and reliable alternative to intracavernous injection for PDDU, with less discomfort and greater preference by patients.

Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been associated with multiple entities and several types of cancers. They can be assumed as markers of inflammatory imbalance. The objective of this study is to evaluate the NLR and PLR in Peyronie's disease (PD) and to establish a comparison of its values in the acute and chronic stages. We recruited patients with PD from March 2018 to March 2019. The patients enrolled underwent medical and sexual history as well as a physical examination. The values of blood count of each patient were collected both in the acute and chronic stages. Wilcoxon test was used to compare the acute and chronic stage ratios. Kruskal-Wallis test was carried out to evaluate the impact of treatments on the ratios. To identify cutoff values, we used sensibility and specificity tables and receiver operating characteristic (ROC) curves. A total of 120 patients were enrolled. Their mean age was 55.85 (range: 18-77) years and the mean penile curvature was 48.43 degrees (range: 10 degrees-100 degrees). In the acute stage, the mean NLR was 2.35 and the mean PLR was 111.22. These ratios, in the chronic stage, were 1.57 and 100.00, respectively. Statistically significant differences between acute and stable stages for both indices were found (NLR: P< 0.0001; PLR: P= 0.0202). The optimal cutoff for classification in acute or stable stage was 2 for NLR and 102 for PLR. According to our results, with an ordinary blood count, we could have important indications regarding the disease stage of the patient, and consequently on the most appropriate type of therapy to choose.

Erectile dysfunction (ED) and premature ejaculation (PE) are two forms of male sexual disorder with both psychological and physical features. While their cognitive, attentional, and affective components have been investigated separately, there is a lack of knowledge about the role played by cognitive attentional syndrome in their onset and maintenance. The aim of the present study was to investigate the possible contribution of perseverative thinking styles and thought control strategies to the development and maintenance of ED and PE. The authors hypothesized that such modes of processing might constitute a cognitive attentional syndrome specific to these disorders and sustained by particular metacognitive beliefs. A semistructured interview was administered to 11 participants with ED and 10 with PE in order to assess their metacognitive beliefs and cognitive attentional processes. The results suggest that individuals with ED and PE adopt a range of cognitive attentional strategies aimed at improving their sexual performance, and endorse both positive and negative metacognitive beliefs about these thinking responses. Overall, their cognitive and attentional patterns worsened negative internal states, reduced sexual excitement, detached them from their bodily sensations, and hindered sexual functioning. These preliminary findings suggest that perseverative thinking, thought control strategies, and metacognitive beliefs may play a key role in the onset and maintenance of male sexual dysfunction.

Structured AbstractObjectives To investigate possible changes and/or device-related impairments in phonetic habits produced by rapid maxillary expansion (RME). Materials and Methods Thirty-five patients scheduled for RME were divided into two groups: Group A (banded two-arm Hyrax) and Group B (banded four-arm Hyrax). Speech samples were collected at six time points, before, during and after RME removal. Acoustical analysis was performed using PRAAT and BioVoice analysis tools. Ten volunteers completed a questionnaire on the acceptability of patient's speech. Maxillary dimensions and palatal volume were measured on dental casts before and after expansion using a digital gauge. Results Voice analysis showed an increase in the peak frequency of fricative consonants (/s/,/ʃ/) after expansion, whereas there was no change of formant frequencies of palatal consonants (/ɲ/,/ʎ/). Vowel /i/ displayed a lowering of the first formant frequency, and an increase in the second and third formant frequencies. After bonding, Group B showed both a greater reduction in the peak frequency of fricatives and a greater increase in the formant frequencies of palatal consonants than Group A. Conclusion Rapid maxillary expansion causes a slight phonetic change in the acoustical parameters of both consonants and vowels. The two-arm Hyrax caused less speech impairment than the four-arm Hyrax during the treatment.

Background The automatic analysis of facial expressions is an evolving field that finds several clinical applications. One of these applications is the study of facial bradykinesia in Parkinson’s disease (PD), which is a major motor sign of this neurodegenerative illness. Facial bradykinesia consists in the reduction/loss of facial movements and emotional facial expressions called hypomimia. New method In this work we propose an automatic method for studying facial expressions in PD patients relying on video-based Methods 17 Parkinsonian patients and 17 healthy control subjects were asked to show basic facial expressions, upon request of the clinician and after the imitation of a visual cue on a screen. Through an existing face tracker, the Euclidean distance of the facial model from a neutral baseline was computed in order to quantify the changes in facial expressivity during the tasks. Moreover, an automatic facial expressions recognition algorithm was trained in order to study how PD expressions differed from the standard expressions. Results Results show that control subjects reported on average higher distances than PD patients along the tasks. Comparison with existing methods This confirms that control subjects show larger movements during both posed and imitated facial expressions. Moreover, our results demonstrate that anger and disgust are the two most impaired expressions in PD patients. Conclusions Contactless video-based systems can be important techniques for analyzing facial expressions also in rehabilitation, in particular speech therapy, where patients could get a definite advantage from a real-time feedback about the proper facial expressions/movements to perform.

Background and objectives: XX male syndrome is part of the disorders of sex development (DSD). The patients generally have normal external genitalia and discover their pathology in adulthood because of infertility. There are no guidelines regarding XX male syndrome, so the aim of our study was to evaluate the literature evidence in order to guide the physicians in the management of these type of patients. Materials and Methods: We performed a systematic review of the available literature in September 2018, using MEDLINE, Web of Science, Embase and Google Scholar database to search for all published studies regarding XX male syndrome according to PRISMA guidelines. The following search terms were used: “46 XX male”, “DSD”, “infertility”, “hypogonadism”. Results: After appropriate screening we selected 37 papers. Mean (SD) age was 33.14 (11.4) years. Hair distribution was normal in 29/39 patients (74.3%), gynecomastia was absent in 22/39 cases (56.4%), normal testes volume was reported in 0/14, penis size was normal in 26/32 cases (81.2%), pubic hair had a normal development in 6/7 patients (85.7%), normal erectile function was present in 27/30 cases (90%) and libido was preserved in 20/20 patients (100%). The data revealed the common presence of hypergonadotropic hypogonadism. All patients had a 46,XX karyotype. The sex-determining region Y (SRY) gene was detected in 51/57 cases. The position of the SRY was on the Xp in the 97% of the cases. Conclusions: An appropriate physical examination should include the evaluation of genitalia to detect cryptorchidism, hypospadias, penis size, and gynecomastia; it is important to use a validated questionnaire to evaluate erectile dysfunction, such as the International Index of Erectile Function (IIEF). Semen analysis is mandatory and so is the karyotype test. Abdominal ultrasound is useful in order to exclude residual Müllerian structures. Genetic and endocrine consultations are necessary to assess a possible hypergonadotropic hypogonadism. Testicular sperm extraction is not recommended, and adoption or in vitro fertilization with a sperm donor are fertility options. Background and objectives: XX male syndrome is part of the disorders of sex development (DSD). The patients generally have normal external genitalia and discover their pathology in adulthood because of infertility. There are no guidelines regarding XX male syndrome, so the aim of our study was to evaluate the literature evidence in order to guide the physicians in the management of these type of patients. Materials and Methods: We performed a systematic review of the available literature in September 2018, using MEDLINE, Web of Science, Embase and Google Scholar database to search for all published studies regarding XX male syndrome according to PRISMA guidelines. The following search terms were used: " 46 XX male", " DSD", " infertility", " hypogonadism". Results: After appropriate screening we selected 37 papers. Mean (SD) age was 33.14 (11.4) years. Hair distribution was normal in 29/39 patients (74.3%), gynecomastia was absent in 22/39 cases (56.4%), normal testes volume was reported in 0/14, penis size was normal in 26/32 cases (81.2%), pubic hair had a normal development in 6/7 patients (85.7%), normal erectile function was present in 27/30 cases (90%) and libido was preserved in 20/20 patients (100%). The data revealed the common presence of hypergonadotropic hypogonadism. All patients had a 46, XX karyotype. The sex-determining region Y (SRY) gene was detected in 51/57 cases. The position of the SRY was on the Xp in the 97% of the cases. Conclusions: An appropriate physical examination should include the evaluation of genitalia to detect cryptorchidism, hypospadias, penis size, and gynecomastia; it is important to use a validated questionnaire to evaluate erectile dysfunction, such as the International Index of Erectile Function (IIEF). Semen analysis is mandatory and so is the karyotype test. Abdominal ultrasound is useful in order to exclude residual Mullerian structures. Genetic and endocrine consultations are necessary to assess a possible hypergonadotropic hypogonadism. Testicular sperm extraction is not recommended, and adoption or in vitro fertilization with a sperm donor are fertility options.

Summary Objectives A large percentage of patients with Parkinson's disease have hypokinetic dysarthria, exhibiting reduced peak velocities of jaw and lips during speech. This limitation implies a reduction of speech intelligibility for such patients. This work aims at testing a cost-effective markerless approach for assessing kinematic parameters of hypokinetic dysarthria. Study Design Kinematic parameters of the lips are calculated during a syllable repetition task from 14 Parkinsonian patients and 14 age-matched control subjects. Methods Combining color and depth frames provided by a depth sensor (Microsoft Kinect), we computed the three-dimensional coordinates of main facial points. The peak velocities and accelerations of the lower lip during a syllable repetition task are considered to compare the two groups. Results Results show that Parkinsonian patients exhibit reduced peak velocities of the lower lip, both during the opening and the closing phase of the mouth. In addition, peak values of acceleration are reduced in Parkinsonian patients, although with significant differences only in the opening phase with respect to healthy control subjects. Conclusions The novel contribution of this work is the implementation of an entirely markerless technique capable to detect signs of hypokinetic dysarthria for the analysis of articulatory movements during speech. Although a large number of Parkinsonian patients have hypokinetic dysarthria, only a small percentage of them undergoes speech therapy to increase their articulatory movements. The system proposed here could be easily implemented in a home environment, thus, increasing the percentage of patients who can perform speech rehabilitation at home.

Summary Objectives Scientific and clinical advances in perinatology and neonatology have enhanced the chances of survival of preterm and very low weight neonates. Infant cry analysis is a suitable noninvasive complementary tool to assess the neurologic state of infants particularly important in the case of preterm neonates. This article aims at exploiting differences between full-term and preterm infant cry with robust automatic acoustical analysis and data mining techniques. Study design Twenty-two acoustical parameters are estimated in more than 3000 cry units from cry recordings of 28 full-term and 10 preterm newborns. Methods Feature extraction is performed through the BioVoice dedicated software tool, developed at the Biomedical Engineering Lab, University of Firenze, Italy. Classification and pattern recognition is based on genetic algorithms for the selection of the best attributes. Training is performed comparing four classifiers: Logistic Curve, Multilayer Perceptron, Support Vector Machine, and Random Forest and three different testing options: full training set, 10-fold cross-validation, and 66% split. Results Results show that the best feature set is made up by 10 parameters capable to assess differences between preterm and full-term newborns with about 87% of accuracy. Best results are obtained with the Random Forest method (receiver operating characteristic area, 0.94). Conclusions These 10 cry features might convey important additional information to assist the clinical specialist in the diagnosis and follow-up of possible delays or disorders in the neurologic development due to premature birth in this extremely vulnerable population of patients. The proposed approach is a first step toward an automatic infant cry recognition system for fast and proper identification of risk in preterm babies.

Summary Introduction The obvious perceptual differences between various singing styles like Western operatic and jazz rely on specific dissimilarities in vocal technique. The present study focuses on differences in vibrato acoustics and in singer's formant as analyzed by a novel software tool, named BioVoice , based on robust high-resolution and adaptive techniques that have proven its validity on synthetic voice signals. Material and Methods A total of 48 professional singers were investigated (29 females; 19 males; 29 Western operatic; and 19 jazz). They were asked to sing "a cappella," but with artistic expression, a well-known musical phrase from Gershwin's Porgy and Bess, in their own style: either operatic or jazz. A specific sustained note was extracted for detailed vibrato analysis. Beside rate (s −1 ) and extent (cents), duration (seconds) and regularity were computed. Two new concepts are introduced: vibrato jitter and vibrato shimmer, by analogy with the traditional jitter and shimmer of voice signals. For the singer's formant, on the same sustained tone, the ratio of the acoustic energy in formants 1–2 to the energy in formants 3, 4, and 5 was automatically computed, providing a quality ratio (QR). Results Vibrato rates did not differ among groups. Extent was significantly larger in operatic singers, particularly females. Vibrato jitter and vibrato shimmer were significantly smaller in operatic singers. Duration of vibrato was also significantly longer in operatic singers. QR was significantly lower in male operatic singers. Conclusions Some vibrato characteristics (extent, regularity, and duration) very clearly differentiate the Western operatic singing style from the jazz singing style. The singer's formant is typical of male operatic singers. The new software tool is well suited to provide useful feedback in a pedagogical context.

The effect of the topical application of fluoride and strontium on dental enamel has been studied. 30 subjects were split into two groups, all of whom had to have their first superior premolars extracted. One of the two premolars to be extracted was treated with three applications of APF gel in the first group, and with a series of topical applications of SrCl2 at 0.2% and EDTA at 10% in the second group. The results obtained show a significant increase in the concentration of trace elements in enamel of the treated teeth, the increase being of 0.23 and 0.05 mcg/mcm for the fluoride in the most superficial and in the deepest respectively of the observed strata. In the control teeth the average concentrations of fluoride resulted in 0.08 mcg/mcm on the surface and in depth, while the strontium showed an average concentration of 0.03 mcg/mcm. Similar behaviour was observed for the depth of biting resulting in an average of 6.8 mcm in the two groups of treated samples and of 11.4 and 9.7 mcm for the controls, respectively. The results confirm the usefulness of topical treatments and should stimulate further investigations of the problem mainly for the evaluation in the long run of the benefits and the efficacy of treatments integrating the two active principles.