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Viewing Peyronie disease as related to erectile dysfunction allows for the possibility of preventing the disease in patients with erectile insufficiency.

INTRODUCTION AND OBJECTIVE:Evaluate whether inflatable penile prosthesis (IPP) after radical cystectomy (RC) is associated with higher complication rates compared to IPP for other etiologies of ere...

Background: To determine which preoperative factors drive patient-reported quality of life (QoL) after artificial urinary sphincter (AUS) implantation. Methods: Men receiving AUS after prostate cancer treatment were identified from a prospectively collected dataset. Preoperative factors were recorded during the initial incontinence consultation. Patients underwent urodynamic testing (UDS) preoperatively at surgeon discretion. Patients were surveyed by telephone postoperatively and given the EPIC Urinary Domain (EPIC-UD) and Urinary Distress Inventory (UDI-6) questionnaires. Differences in postoperative maximum pads per day (MxPPD) and questionnaire scores were compared across preoperative factors, with P≤0.05 indicating statistical significance. Results: Telephone survey was completed by 101 of 238 patients (42%). Median age was 69 [63–75] years, BMI was 29 [26–32] kg/m 2 . MxPPD was 5 [3–9] preoperatively and 2 [1–3] postoperatively (r=0.255, P=0.011). Postoperative median EPIC-UD was 82 [67–89] and UDI-6 was 22 [11–36]. Postoperative MxPPD was lower in patients who reported being able to store urine before AUS {2 [1–2] vs . 2 [1–4], P=0.046}, and lower with urodynamically-proven detrusor overactivity (DO) {1.5 [1–2] with vs . 2 [1–4] without, P=0.050}. Detrusor pressure at maximum flow was negatively associated with QoL as measured by EPIC-UD score (r=−0.346, P=0.013) and UDI-6 score (r=0.413, P=0.003). Although 41 (41%) patients had a history of radiation, postoperative outcomes did not significantly differ with or without a history of radiation. Conclusions: Few preoperative factors predict QoL after AUS insertion.

Objective To determine whether patients with solid organ transplant (SOT) are at higher risk of developing complications after inflatable penile prosthesis (IPP) implantation. Methods We retrospectively reviewed outcomes data for all patients with SOT who underwent IPP placement at our institution. A cohort of age-matched IPP recipients without SOT were used as controls. Results We identified 26 patients who underwent SOT and IPP between 1999 and 2015, and 26 controls. Transplants included heart (3), liver (2), kidney only (17), and kidney and pancreas (4). Mean follow-up time after IPP placement was 29.5 months (SOT group) and 13.5 months (controls). Age at IPP did not significantly differ between groups (53.7 + 8.1 vs 56.4 + 9.0, P = .26), nor did body mass index (30.3 + 5.5 vs 30.2 + 4.7, P = .92), history of prostatectomy (7.7% vs 15.4%, P = .39), rectal surgery (3.9% vs 3.9%, P = 1.00), hyperlipidemia (69.2% vs 69.2%, P = 1.00), hypertension (92.3% vs 76.9%, P = .25), or heart disease (57.7% vs 30.8%, P = .093). Peripheral vascular disease was more common in transplant patients (26.9% vs 3.9%, P = .021), as were stroke (19.2% vs 0.0%, P = .05) and diabetes (84.6% vs 53.6%, P = .016). No significant differences in IPP reoperation rates existed between patients with vs without SOT (11.5% vs 11.5%, P = 1.00), nor did they differ by organ transplanted (P = 1.00). No differences in IPP reoperation rate existed between 2-piece vs 3-piece IPP models (P = .47). Conclusion Outcomes of IPP implantation in patients with SOT are similar to those of nontransplant patients. Patients with SOT should be considered suitable candidates for penile prosthesis.

Introduction: The relationship between erectile dysfunction (ED) and Peyronie’s disease (PD) has not been well understood. A better understanding of this might lead to strategies to prevent this disorder.Aim: To examine the relationship between ED and PD and develop strategies for the prevention of PD.Methods: This review was based primarily on the author’s 45 year experience in a subspecialty dealing with these two disorders. Selected references were cited to help support these views.Main Outcomes Measures and Results: A synthesis of the author’s experience was used to develop a better understanding of the relationship of ED to PD. A new term (erectile insufficiency) was proposed , and a new definition for safe sex was given. Strategies to prevent PD were developed.Conclusion: ED is a significant factor in the development of PD. Using this knowledge patients can be educated on how to reduce the chance of developing this disorder.

Introduction Men undergoing prostatectomy can have unrealistic preoperative expectations regarding sexual function after surgery and may desire more education on recovery and symptom management. Aim To present contemporary data on recovery of sexual function after prostatectomy and characterize how it is impacted by perioperative patient educational interventions. Methods A comprehensive review of the English-language literature available by PubMed search. Main Outcome Measures Rates of sexual function recovery after prostatectomy and the impact of educational interventions on these and related outcomes. Results Available studies describe heterogeneous educational and support interventions that differ by patient selection, content, method of delivery, timing, and duration. Interventions with group-based education or peer support benefitted sexual satisfaction metrics. Many studies included men and their partners in supportive interventions. However, the few randomized controlled trials directly analyzing the effect of partner attendance revealed no additional benefit to outcomes. Interventions within 6 weeks of prostatectomy variably aided measures of sexual recovery. Some studies with greater time between prostate cancer treatment and interventions revealed only temporary improvements in outcomes. Yet durable improvements in sexual satisfaction and sexual function were observed in some men enrolled years after prostate cancer treatment. At times, web-based interventions had lower completion rates, but sexual function outcomes were comparable to traditional in-person interventions within randomized trials. Conclusion Educational interventions imparted variable benefit to sexual function and satisfaction, with group-based designs mostly benefitting satisfaction outcomes. Despite standardized interventions, men reported worse-than-expected outcomes, suggesting an emphasis on counseling regarding changes in erectile function at multiple time points before surgery and during the recovery period may be helpful. Earlier interventions may help with recovery by establishing more accurate patient expectations. Regarding accessibility, future endeavors may be improved with internet-based educational content, as such interventions appeared to provide comparable benefits to in-person sessions. Faris AER, Montague DK, Gill BC. Perioperative Educational Interventions and Contemporary Sexual Function Outcomes of Radical Prostatectomy. Sex Med Rev 2019;7:293–305.

Objective To issue a consensus document on the prevention, management, and research of infection associated with penile prostheses, as neither professional associations nor governmental entities have issued guidelines that are specific to this infection. Methods Sixteen North American experts on infection of penile prostheses were identified and assembled to select and discuss certain issues related to infection of penile prostheses. After performing an extensive search of clinically important issues in published reports, the 16 experts met twice in person to finalize the selection, discuss the issues that were deemed most important, and issue pertinent recommendations. Results Although many subjects relevant to infection of penile prostheses were initially identified, the experts selected 10 issues as currently being the most important issues and for which there exists some support in the published data. The examined issues involved prevention, management, or research of infections associated with penile prostheses. Conclusion In the absence of pertinent guidelines, the consensus document issued by experts in the field of prosthetic urology is anticipated to improve the quality of patient care, streamline the prevention and management of infected penile prostheses, and stimulate collaborative research. Although this consensus document could serve as best practice recommendations, the lack of adherence to these recommendations would not indicate improper care.

Introduction. Sexual health is an integral part of overall health. Sexual dysfunction can have a major impact on quality of life and psychosocial and emotional well-being. Aim. To provide evidence-based, expert-opinion consensus guidelines for clinical management of sexual dysfunction in men. Methods. An international consultation collaborating with major urologic and sexual medicine societies convened in Paris, July 2009. More than 190 multidisciplinary experts from 33 countries were assembled into 25 consultation committees. Committee members established scope and objectives for each chapter. Following an exhaustive review of available data and publications, committees developed evidence-based guidelines in each area. Main Outcome Measures. New algorithms and guidelines for assessment and treatment of sexual dysfunctions were developed based on work of previous consultations and evidence from scientific literature published from 2003 to 2009. The Oxford system of evidence-based review was systematically applied. Expert opinion was based on systematic grading of medical literature, and cultural and ethical considerations. Results. Algorithms, recommendations, and guidelines for sexual dysfunction in men are presented. These guidelines were developed in an evidence-based, patient-centered, multidisciplinary manner. It was felt that all sexual dysfunctions should be evaluated and managed following a uniform strategy, thus the International Consultation of Sexual Medicine (ICSM-5) developed a stepwise diagnostic and treatment algorithm for sexual dysfunction. The main goal of ICSM-5 is to unmask the underlying etiology and/or indicate appropriate treatment options according to men's and women's individual needs (patient-centered medicine) using the best available data from population-based research (evidence-based medicine). Specific evaluation, treatment guidelines, and algorithms were developed for every sexual dysfunction in men, including erectile dysfunction; disorders of libido, orgasm, and ejaculation; Peyronie's disease; and priapism. Conclusions. Sexual dysfunction in men represents a group of common medical conditions that need to be managed from a multidisciplinary perspective. Montorsi F, Adaikan G, Becher E, Giuliano F, Khoury S, Lue TF, Sharlip I, Althof SE, Andersson K-E, Brock G, Broderick G, Burnett A, Buvat J, Dean J, Donatucci C, Eardley I, Fugl-Meyer KS, Goldstein I, Hackett G, Hatzichristou D, Hellstrom W, Incrocci L, Jackson G, Kadioglu A, Levine L, Lewis RW, Maggi M, McCabe M, McMahon CG, Montague D, Montorsi P, Mulhall J, Pfaus J, Porst H, Ralph D, Rosen R, Rowland D, Sadeghi-Nejad H, Shabsigh R, Stief C, Vardi Y, Wallen K, and Wasserman M. Summary of the recommendations on sexual dysfunctions in men. J Sex Med 2010;7:3572-3588.

Objective measures show the AdVance() sling provides some benefit in post-prostatectomy incontinence. To our knowledge no validated, patient determined outcomes have been used to assess this procedure. We described the patient perceived effectiveness and postoperative complications.A retrospective chart review was followed by a telephone survey consisting of the Patient Global Impression of Improvement, Patient Global Impression of Severity, and questions about recommending the surgery, daily pad use and complications. Successful outcomes were Patient Global Impression of Improvement responses of very much better or much better without further incontinence treatment. Objective success is defined as pad-free or a reduction to 2 or less pads daily.A total of 35 patients received the sling a median of 25 months after prostatectomy. Telephone surveys were administered a mean of 35 weeks after the sling procedure and 33 patients were contacted. Of the cases 18 (51.4%) and 21 (60%) were patient determined and objective successes, respectively. Of the patients with subjective treatment failure 3 would recommend the surgery to a friend and 12 were undecided or would not. Furthermore, no patients with subjective treatment failure were pad-free and 10 (58.8%) had pads that were mostly wet on changing. For the entire population a reduction in median daily pad use from 2.5 to 1 was observed as well as a strong association (p0.01) between Patient Global Impression of Improvement and Patient Global Impression of Severity responses. Three individuals pursued further treatment with bulking agents and 3 had retention that resolved.The AdVance sling is safe, and demonstrates similar subjective and objective outcomes. The procedure can benefit some individuals with post-prostatectomy incontinence and, therefore, may be another treatment option for this condition.

OBJECTIVES Some surgeons will not offer a three-piece inflatable penile prosthesis (IPP) to patients who have undergone retropubic surgery because of a perceived increase in intraoperative risk during reservoir placement into the retropubic space. METHODS Of 942 consecutive patients undergoing IPP placement from 1986 to 2006, 115 had undergone radical prostatectomy before placement of an American Medical Systems Ultrex (n = 73), CX (n = 34), or CX-M (n = 8) device. Intraoperative and follow-up data for all patients were collected in an institutional review board-approved database. RESULTS All 115 IPP placements were completed as planned and without intraoperative complications, including no injury to the bladder or iliac vessels. An increased amount of scarring often made the fascia more difficult to perforate, but blind entrance into the retropubic space was performed successfully in all cases. Three prosthetic infections (2.6%) and eight mechanical failures (7%) occurred during a median follow-up of 3.3 years. The estimated probability of no infection or mechanical failure at 3 years in this patient cohort was 97.0% and 95.5%, respectively. CONCLUSIONS Retropubic placement of the reservoir of a three-piece IPP was accomplished without intraoperative complications in 115 consecutive postprostatectomy patients, with more than 90% of devices free of mechanical failure at 5 years. Because three-piece IPPs can be placed safely and have been associated with the greatest patient and partner satisfaction rates, we do not believe that prostatectomy should be a contraindication for placement of the retropubic reservoir of a three-piece IPP through a transverse scrotal incision.

Sickle cell disease is a common genetic disorder characterized by sickling of red blood cells under conditions of reduced oxygen tension. In turn, sickling leads to intravascular hemolysis and vaso-occlusive events with subsequent tissue ischemia-reperfusion injury affecting multiple organs, including the genitourinary system. Our review of the genitourinary manifestations of sickle cell disease focuses on sickle cell nephropathy, priapism, and other genitourinary complications such as papillary necrosis and renal medullary carcinoma.

Aim Squamous cell carcinoma of the penis (PC) has traditionally been treated with partial penectomy with a 2-cm margin. More conservative resection margins have been reported to have no effect on oncologic control, but there is no consensus in the literature regarding functional outcomes after organ-preserving surgery for PC. Methods Six patients meeting inclusion criteria were retrospectively identified to have received organ-sparing surgery for PC at the Cleveland Clinic from 2003 to 2012. Patient's sexual and urinary quality of life was assessed retrospectively using the International Index of Erectile Function and the patient-reported outcome measure for urethral stricture surgery. Results Three patients (50%) report normal erections but describe intercourse as not very enjoyable and report being dissatisfied with their sex life. The remaining 50% consistently report no sexual activity and denied feeling sexual desire. All report only mild urinary symptoms, including decreased stream (18%) and feelings of incomplete voiding (67%). Eighty-three percent of patients report their sexual symptoms do not interfere with their daily lives. One hundred percent report being satisfied with their procedure. Conclusion Our study is the first to use standardized, validated questionnaires to evaluate sexual and urinary function in a North American penile cancer patient population. We report excellent overall urinary function and quality of life following penile-sparing surgery for PC, and our results depict more realistic sexual outcomes than those reported in studies using non-blinded and non-validated methods.

To investigate public restroom habits with secondary outcomes evaluating health-related quality of life (HRQoL) outcomes in our patients who underwent artificial urinary sphincter (AUS) implantation after prostatectomy. Postprostatectomy incontinence is a significant burden on patients' emotional health and ability to perform activities of daily living.Between June 2012 and January 2014, we identified 50 men who had undergone AUS placement for postprostatectomy incontinence. All 50 men completed baseline Expanded Prostate Cancer Index Composite-Urinary Domain (EPIC-UD) and Urogenital Distress Inventory Short Form (UDI-6) questionnaires preoperatively. We evaluated patients' subjective postoperative continence status using the UDI-6 and EPIC-UD scales via a telephone-administered questionnaire.Thirty-one of 50 patients (62%) were contacted and agreed to participate in the study. The pad score decreased significantly from 3 (median = 3 pads per day [ppd]; interquartile range [IQR] = 2) during minimal activity before surgery to 1 (median = 1.0 ppd; IQR = 0.5) after surgery (P.001), and from 5 pads (median =5 ppd; IQR = 5) during strenuous activity to 1 pad (median = 1 ppd; IQR = 2; P.001). QoL analysis pre- and post-AUS revealed a score increase of 16.5 points (P.007) in EPIC-UD and an increase of 23.93 (P.022) in UDI-6. Men reporting lower ppd before AUS placement were more likely to report higher public restroom urinal use (R = 0.366; P.043) and increased public restroom comfort level (R = 0.342; P.060) as compared with men with higher preoperative ppd usage.EPIC-UD and UDI-6 scores improved significantly and demonstrated high levels of correlation to self-reported ppd; however, both failed to show any correlation to patients' comfort level with public restrooms. The single predictor of patients' comfort was self-reported ppd with minimal activity.

approach to develop a guideline for the ED treatment modalities that had become available in the United States after publication of the 1996 Report. Guideline statements from the 1996 Report on previously available therapeutic modalities were either revised or brought forward unchanged depending on the existing evidence. All guideline statements were graded according to the degree of flexibility in clinical application: standard, recommendation, or option, with standard being the least flexible and option being the most flexible (Table 1). Grading is based on two characteristics: knowledge of the health outcomes of the alternative intervention and preference for the intervention. The Panel believed that the patient, with physician guidance, must make his own decision in selecting treatment. Outcome estimates derived from review and meta-analysis of evidence provide physicians and patients with scientifically based information to assist them in making appropriate treatment decisions. Thus, a second Panel objective was to determine whether or not there was sufficient evidence for outcomes (both benefits and risks) to be estimated.

Introduction The introduction of safe and effective therapies for sexual dysfunctions depend upon appropriate clinical protocol design, study procedures, data collection and analysis. Aim To provide recommendations/guidelines concerning state-of-the-art knowledge for standards for clinical trials in sexual dysfunction in men, particularly in the areas of erectile dysfunction and rapid ejaculation. Methods An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. Concerning the Standards for Clinical Trials in Male Sexual Dysfunction Committee, there were six experts from four countries. Main Outcome Measure Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate. Results Drug development requires a multiphased approach. Phase 1 studies investigate multiple-dose safety, tolerability and pharmacokinetic issues. Phase 2 programs explore dose ranging (lowest effective, maximally tolerated and toxic doses). Phase 3 trials provide the substantial evidence including drug–drug interaction data and studies in special populations. Clinical studies require validated outcome assessment instruments conducted in defined but representative patient populations. Daily diaries or per-event questionnaires are patient-reported outcomes that assist in retrospective questionnaire interpretation. A qualified biostatistician should calculate the sample power for the trial, type of statistical model and design employed, use of covariate or subgroup analyses, and calculation of effect sizes. Conclusions More research is needed in developing standards for use in the development of clinical trials and outcomes assessment researching either erectile dysfunction or rapid ejaculation.

The three major forms of male sexual dysfunction are ejaculatory dysfunction, erectile dysfunction (ED), and decreased libido (hypoactive sexual desire disorder). While survey findings vary considerably, most epidemiological studies suggest that premature ejaculation (PE) (also known as early ejaculation or rapid ejaculation) may be the most common male sexual disorder. Data from the National Health and Social Life Survey have revealed a prevalence of 21% in men ages 18 to 59 in the United States.1 Using various definitions, other studies report prevalences ranging from less than 5%2 to greater than 30%.3–5 A universally accepted definition of PE has yet to be established. Masters and Johnson proposed one of the earliest definitions that focused on the inability to delay ejaculation long enough for the woman to achieve orgasm fifty percent of the time, assuming that PE is the sole cause of the female anorgasmia.6 Kaplan first suggested that PE is primarily a problem of voluntary control over timing of ejaculation, a concept on which the current definition is based.7 The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (4th ed, text revision) (DSM-IV TR) (2000) defines PE with an added emphasis on the emotional and interpersonal impact of ejaculation that occurs earlier than the male desires.8 Premature ejaculation has been subclassified into two forms: a primary (lifelong) form that begins when a male first becomes sexually active and a secondary (acquired) form.9, 10 The present guidelines and recommendations are based on the following definition, which assumes the absence of partner sexual dysfunction: Premature ejaculation is ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners. The exact etiology of PE is unknown. Psychological/behavioristic and biogenic etiologies have been proposed. Consequently, the treatment of PE has encompassed psychological, behavioral, and pharmacologic interventions. Current treatments are largely based upon logical solutions (decreasing sensory input), behavior modification therapies, and observations of drug side effects (those with serotonin reuptake inhibiting activity). This guideline will address only pharmacologic therapies, as other therapies are not routinely prescribed by our target audience. To facilitate informed treatment decisions by physicians and their patients, recommendations on the use of medications currently available in the United States are provided. The majority of the recommendations contained herein are based on a consensus of expert opinion following review of the literature. In some cases, expert consensus is supplemented with a focused review of the limited data. This guideline does not preempt physician judgment in individual cases. Variations in patient subpopulations, physician experience, and available resources necessarily will influence choice of clinical strategy. Adherence to the recommendations presented in this document cannot assure a successful treatment outcome. For ease of review, the recommendations are bolded and followed by supporting text. The evidence supporting the recommendations is summarized in Appendices 1 to 3 (www.auanet.org).

OBJECTIVES To assess the efficacy and factors associated with successful treatment of sildenafil citrate for erectile dysfunction after radical prostatectomy (RP). METHODS Of the 470 patients who underwent RP at our institution between July 1998 and January 2000, 227 (48%) sought treatment for erectile dysfunction, and 174 (37%) were prescribed sildenafil citrate. The starting dose was 50 mg, which was increased to 100 mg if the patient did not have a positive response. Of the 174 patients, 104 (59.8%) had undergone a bilateral nerve-sparing (NS) procedure, 28 (16.1%) had undergone a unilateral NS procedure, and 42 (24.1%) had undergone a non-NS procedure. Erectile function was assessed by the abridged five-item version of the International Index of Erectile Function questionnaire, referred to as the Sexual Health Inventory for Men (SHIM), at baseline and 1 year after sildenafil use. The patients' charts were retrospectively reviewed to find factors associated with a successful outcome, which was defined as successful vaginal intercourse. Association with success was assessed by chi-square analysis and the Cochran Armitage test for trend. Bonferroni correction for multiple comparisons was used, with an overall significance level of 0.05 for each factor assessed. RESULTS The mean age was 60.1 +/- 6.25 years, and the mean interval from RP to drug use was 3 months. After treatment with sildenafil, 100 (57%) of 174 patients responded to the drug: 79 (76%) of 104 in the bilateral NS group, 15 (53.5%) of 28 in the unilateral NS group, and 6 (14.2%) of 42 in the non-NS group. SHIM analysis showed that the magnitude of the improvement was greater in the bilateral NS group (19.97 +/- 1.12) than in the unilateral NS (15.89 +/- 3.38) or non-NS (10.06 +/- 2.0) groups (P

priapism would eventually resolve on its own albeit with possible permanent damage to the penis. The literature reviewed for this guideline straddles both empirical and pathophysiology-based eras, and some of the reported positive responses to treatment may reflect the natural course of priapism rather than a true treatment success. In addition, the literature is bereft of followup data on patients with priapism. This document derives from a comprehensive review of the medical literature related to the management of priapism. As noted, deficiencies in this literature made it impossible to develop strict evidence-based guidelines. Most of the recommendations contained herein are based upon expert consensus following review of the literature. Where possible, expert consensus is supplemented with review of limited data. Because the literature review only considered reports of cases in which the duration of erections were longer than 4 hours, the recommendations made may not apply to erections of shorter duration. This guideline does not establish a fixed set of rules or define the legal standard of care for the treatment of priapism. Above all, it does not preempt physician judgment in individual cases. Variations in patient subpopulations, physician experience and available resources will necessarily influence choice of clinical strategy. Adherence to the recommendations presented in this document cannot assure a successful treatment outcome. The basis of each recommendation, consensus of the expert panel with or without data obtained by systematic review of evidence, is noted. A diagnostic and treatment algorithm is presented in the figure.

Urologists did not develop a significant interest in the treatment of erectile dysfunction until the introduction of the inflatable penile prosthesis in 1973. 27 For the next 10 years, the treatment of erectile dysfunction was fairly straightforward, that is, sex therapy for potentially reversible erectile dysfunction and penile prosthesis implantation for almost every other form. Currently, a variety of treatment options are available for erectile dysfunction, including systemic therapy, sex therapy, vacuum erection devices, intraurethral medication, penile injection therapy, penile revascularization, and penile prosthesis implantation. Topics discussed in this article include the role of penile prosthesis implantation in the treatment of erectile dysfunction, the selection of candidates for prosthesis implantation, the types of devices available and their indications, and the methods of implantation and the results.

Today most men with erectile dysfunction (ED) can be effectively treated with less invasive means than penile prosthesis implantation. Nevertheless, there remain men who do not respond to simple treatments such as systemic medication and who either do not respond to or reject intermediate treatment such as penile injection therapy. For these men, penile prosthesis implantation remains a reasonable option. This review discusses types of penile prostheses, how to choose among prosthesis types, key features of implant techniques, infection management, penile reconstruction related to prosthesis implantation, and patient and partner satisfaction.

To determine whether the response to sildenafil citrate (Viagra) in patients with erectile dysfunction after radical prostatectomy was influenced by the presence or absence of neurovascular bundles, the interval from surgery to the initiation of drug therapy, and the dose of the drug.Baseline and follow-up data from 91 patients presenting with erectile dysfunction after radical prostatectomy were obtained. The patients were stratified according to the type of nerve-sparing (NS) procedure: bilateral NS, unilateral NS, and non-NS. They were interviewed using the Cleveland Clinic Post Prostatectomy (CCPP) questionnaire and the International Index of Erectile Function (IIEF) questionnaire.The presence or absence of the neurovascular bundles influenced the ability to achieve vaginal intercourse. In the patients who had undergone bilateral NS, 71.7% (38 of 53) responded; in those with unilateral NS, 50% (6 of 12) responded; and in those with non-NS, 15.4% (4 of 26) responded. The IIEF questionnaire confirmed the quality of the positive responses, with significant improvements in response to question 3 (frequency of penetration), question 4 (frequency of maintenance of erection), and question 7 (satisfaction with intercourse). The magnitude of improvement in responses was higher in the bilateral NS group than in the unilateral NS and non-NS groups (P0.05). When the data of the 48 positive responders were analyzed, no difference in the response rate was found when the interval from surgery to drug therapy was stratified by the following three intervals: 0 to 6 months (44%), 6 to 12 months (55%), and greater than 12 months (53%). Of the positive responders, 14 (29.1%) required the 50-mg dose, and 34 (70.9%) required the 100-mg dose. The most common side effects were transient headaches (28.6%), flushing (21.9%), dizziness (8.8%), dyspepsia (6.5%), and nasal congestion (5.4%), with an increase in the incidence of headaches seen at the higher dose (P = 0.04).Successful treatment of erectile dysfunction with sildenafil citrate after radical prostatectomy depends on the presence of the neurovascular bundles. Our data suggest that the response to sildenafil is not related to the interval between the surgery and initiation of drug therapy but is related to the dose.

In 1994 we began performing the modified corporoplasty technique in patients undergoing surgery to correct penile curvature. The procedure consists of transverse closure of the longitudinal tunical incisions. This technique allows minimal mobilization of the neurovascular bundles or corpus spongiosum and potentially decreases the risk of injury to underlying erectile tissue. We report long-term results of and patient satisfaction with this procedure.From June 1994 to June 1997, 28 consecutive patients 16 to 65 years old (mean age 45) selected for corporoplasty underwent a total of 29 operative procedures for disabling penile curvature. The etiology of curvature was Peyronie's disease in 19 patients (68%) and congenital curvature in 9 (32%). Results were obtained by retrospective chart review and telephone interview. Long-term followup available for 19 patients ranged from 11 to 46 months (mean 24.1).Penile straightening was excellent in 25 patients (89%) and good with less than 20 degrees of residual curvature in 2 (7%). In 1 patient in whom the procedure failed excellent straightening was achieved after a repeat procedure. A total of 27 patients (96%) reported no change in erectile rigidity or maintenance postoperatively, while 1 described early detumescence. We contacted 19 patients at long-term followup, of whom 17 and 2 reported excellent and good penile straightening results, respectively. In 18 cases there was no change in erectile rigidity, while in 1 there was early detumescence. Some element of erectile shortening without functional problems was noticed by 11 patients, of whom 1 was bothered by shortening but achieves successful intercourse. Eight patients denied shortening. In regard to the overall result 9 patients were very satisfied, 6 satisfied, 2 neutral and 2 unsatisfied.In select patients modified corporoplasty as described is an effective and durable procedure with a high rate of patient satisfaction. Patients should be counseled preoperatively concerning postoperative erectile shortening.

Before the early 1970s the treatment of urinary incontinence owing to intrinsic sphincteric deficiency, particularly in men with this problem after prostatectomy, posed a nearly insurmountable challenge. Operations using the patient’s own tissues as well as bulbous urethral sling-type procedures with various types of prosthetic materials produced inconsistent and nondurable results [1–4]. The artificial urinary sphincter was introduced in 1973 [5]. In the first 10 yr after its introduction the basic device design changed four times. The fifth generation model, the AMS Sphincter 800 (American Medical Systems, Minnetonka, MN), was introduced in 1983 [6]. To decrease mechanical failure numerous changes have been made to the various components of this device; however, its basic design and mode of operation have remained unchanged for >20 yr. The AMS Sphincter 800 consists of three components: a urethral cuff, a scrotal pump-control assembly, and a single pressure-regulating balloon (PRB), which is usually implanted in the retropubic space. These three components are implanted individually and then connected by two tubing connectors. The control assembly, which is above the pump, has valves controlling the direction of flow, a delayed filled resistor, and a deactivation button. After the device is implanted, the pump is

Introduction Erosion of the reservoir into surrounding tissues is a rare complication after inflatable penile prosthesis (IPP) implantation. Aim To present a new case and a review of the literature including discussion of pathogenesis, risk factors, and management options. Methods We present the case of a 75-year-old male who underwent placement of an IPP for postoperative erectile dysfunction with a history of bladder cancer requiring radical cystoprostatectomy and Studer neobladder. Six years after IPP placement, he presented with recurrent febrile urinary tract infection that seemed to be precipitated by cycling of his penile prosthesis. Cystoscopy and cross-sectional computed tomography imaging demonstrated erosion of the inflatable penile prosthesis reservoir into the neobladder. Results Patient underwent open removal of the IPP reservoir and cystorrhaphy with a plan for future prefascial reimplantation of an IPP reservoir. Conclusions In patients with a history of abdomino-pelvic surgery or radiation therapy, the retroperitoneal space may be extremely fibrotic and the transversalis fascia may have thickened. Potential intraoperative complications as well as reservoir erosion may be avoided by using a two-piece device or ectopic reservoir placement. Management options for reservoir erosion include explantation of the entire device as well as reservoir removal with salvage of remaining components. Tran CN, Boncher N, Montague DK, and Angermeier KW. Erosion of inflatable penile prosthesis reservoir into neobladder. J Sex Med 2013;10:2343–2346.

Purpose: The American Urological Association convened the Clinical Guidelines Panel on Erectile Dysfunction to analyze the literature regarding available methods for treating organic erectile dysfunction and to make practice recommendations based on the treatment outcomes data.Materials and Methods: The panel searched the MEDLINE data base for all articles from 1979 through 1994 on treatment of organic erectile dysfunction and meta-analyzed outcomes data for oral drug therapy (yohimbine), vacuum constriction devices, vasoactive drug injection therapy, penile prosthesis implantation and venous and arterial surgery.Results: Estimated probabilities of desirable outcomes are relatively high for vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis therapy. However, patients must be aware of potential complications. The outcomes data for yohimbine clearly indicate a therapy with marginal efficacy. For venous and arterial surgery, based on reported outcomes, chances of suc...

Purpose: We determine the colony counts of organisms present on culture of clinically uninfected genitourinary prostheses at reoperation for reasons other than infection. These results served as control data for comparison with cultures from infected devices to determine the relative incidence of organisms involved.Materials and Methods: Cultures were prospectively obtained from 65 penile prostheses and 22 artificial urinary sphincters. Patients were followed for a minimum of 12 months after reoperation or until development of infection (mean 27 months) at which time cultures were again obtained.Results: Low colony counts of Staphylococcus epidermidis were isolated from 40 percent of uninfected penile prostheses and 36 percent of artificial urinary sphincters. Only 3 of these devices later became infected (9 percent) and in all cases a higher colony count of another organism was found at explantation.Conclusions: While Staph. epidermidis can cause prosthesis infection, low colony counts of the org...

Congenital penile curvature results from disproportionate development of the tunica albuginea of the corporal bodies and is not associated with urethral malformation. Patients usually present after reaching puberty as the curvature becomes more apparent with erections, and severe curvature can make intercourse difficult or impossible, at which point surgical repair is recommended. Excellent outcomes can be expected with surgical intervention. The three most commonly used repair techniques are the original Nesbit procedure, modified Nesbit procedure, and plication. Nesbit and modified Nesbit techniques require that an incision is made in the tunica albuginea while plication techniques utilize plicating sutures without an incision. While Nesbit and modified Nesbit techniques are more complex operations, these generally result in less recurrences and more satisfactory outcomes as opposed to the quicker and simpler plication technique.

Post-prostatectomy incontinence can be a significant complication of surgical treatment for prostate cancer, greatly affecting patient quality of life and social interaction. It is a complication, however, that can improve over time and has various treatment modalities available depending on its extent and bother to the patient. For the urologist, it is important to know exactly what options exist and their level of efficacy in order to appropriately council patients. The treatment options vary based on their levels of invasiveness, reported success, and potential complications. Some of the options are also better suited to specific degrees of incontinence. As a result, this enables the physician to set realistic expectations for their patients and offer the best care possible.

Surgical treatment for organic erectile dysfunction (ED) includes penile arterial revascularization, surgery for veno-occlusive dysfunction, and penile prosthesis implantation. In the 2005 American Urological Association Erectile Dysfunction Guidelines, surgery for veno-occlusive dysfunction was not recommended, and evidence to demonstrate efficacy for penile arterial revascularization was deemed to be lacking.