Faculty Bibliography

INTRODUCTION:Previous worked showed that the Andrianne Mini-Jupette (AMJ) procedure with inflatable penile prosthesis (IPP) significantly improves climacturia or stress urinary incontinence (SUI) that may accompany erectile dysfunction (ED) after radical prostatectomy. However, with the AMJ procedure, the graft is incorporated into the medial aspect of the corporotomy, thereby requiring a more complex closure. Moreover, in the original report, multiple graft materials were used. AIM:To describe our technique for "male urethral mini-sling" (MUMS) with a Virtue sling mesh, which is a modified approach to the AMJ, and to assess early postoperative outcomes. METHODS:A retrospective chart review was performed for men who underwent IPP and MUMS placement with a modified Virtue mesh by 2 high-volume prosthetic urologic surgeons using the same technique. After proximal urethral exposure, the MUMS is sutured to the latera corpora over the bulbar urethra, proximal to and separate from the planned corporotomy, with care taken to avoid excessive urethral tension. The IPP is then placed in standard fashion. Changes in patient-reported climacturia and pads per day for SUI were assessed before and after surgery. RESULTS:36 men underwent both IPP and MUMS placement between January 2016-October 2018. Mean patient age was 68 years. Etiology for ED and urinary symptoms was prostatectomy alone in 30 of 36 (83%) and prostatectomy plus radiation in 6 of 36 (17%). Preoperative urinary symptoms included climacturia in 30 of 36 (83%) and SUI in 27 of 36 (75%). Mean (SD) follow-up was 5.9 (3.7) months. Climacturia resolved in 28 of 30 (93%), and SUI improved in 23 of 27 (85%). The mean (SD) number of pads per day for those patients with SUI decreased significantly from 1.4 (1.1) before surgery to 0.4 (0.6) after surgery (P = .02). 1 patient required MUMS explantation for urethral erosion after prolonged postoperative catheterization. CLINICAL IMPLICATIONS:The MUMS with modified Virtue mesh at the time of IPP placement can be used to treat ED with climacturia or mild SUI after radical prostatectomy. STRENGTHS & LIMITATIONS:Strengths include the use of a consistent operative technique with a single graft material by 2 experienced prosthetic urologic surgeons. Limitations include the retrospective study design, use of subjective postoperative outcomes, lack of comparison group, and relatively moderate follow-up duration. CONCLUSIONS:Our early results suggest that the MUMS significantly improves bothersome climacturia and mild SUI in addition to treating ED, with little added morbidity. Although further study, including longer-term follow-up, is needed, this approach may be considered in the appropriately counseled patient. Valenzuela RJ, Ziegelmann MJ, Hillelsohn JH, et al. Preliminary Outcomes of the Male Urethral "Mini-Sling": A Modified Approach to the Andrianne Mini-Jupette Procedure With Penile Prosthesis Placement for Climacturia and Mild Stress Urinary Incontinence. J Sex Med 2019;16:1310-1317.

Peyronie's disease is a disorder of abnormal and dysregulated wound healing leading to scar formation in the tunica albuginea of the penis. Penile traction therapy has emerged as an attractive therapeutic option for men with Peyronie's disease in both the acute and chronic phases. Currently, clinical studies are limited by lack of randomization, small cohorts, and lack of patient compliance with therapy. Despite these shortcomings, studies have shown a potential benefit with minimal morbidity. Specifically, penile traction may help to preserve or increase penile length and reduce penile curvature when used as monotherapy or as adjuvant therapy for surgical and intralesional treatments. Further study is necessary to define patient characteristics that are predictive of improved outcomes, determine the duration of treatment needed for clinical effect, and improve patient compliance.

BACKGROUND:Silicone blocks and sleeves are simple devices used in cosmetic surgery. They are generally viewed as safe and effective; however, there is little information on their use in the penis. AIM:This study evaluates a large single-surgeon series using a novel silicone sleeve penile implant (Penuma) to cosmetically correct the flaccid penis. METHODS:526 patients underwent elective cosmetic penile surgery using a silicone sleeve penile implant between 2009 and 2014. Institutional Review Board approval was obtained for a retrospective analysis, and study consent was obtained from 400 patients. Penile circumference was measured before surgery, immediately after surgery, and 30-90 days after the implant surgery. Using the nonvalidated Augmentation Phalloplasty Patient Selection and Satisfaction Inventory (APPSSI), changes in self-confidence, self-esteem, and satisfaction scores were assayed 6-8 weeks postoperatively. Scores were again assayed 2-6 years postoperatively in 77% of patients. The questionnaires rated patient self-confidence, self-esteem, and satisfaction as very low, low, medium, high, or very high. MAIN OUTCOME MEASURE:Outcomes include changes in penile measurements; changes in APPSSI satisfaction, self-confidence, and self-esteem scores; and incidences of adverse events. RESULTS:In the 400 patients, the implantation of the Penuma silicone implant increased midshaft circumference from an average of 8.5 ± 1.2 cm to 13.4 ± 1.9 cm (56.7% increase; P < .001). A 2-category improvement in self-confidence and self-esteem was noted in 83% of patients 6-8 weeks postoperatively. On long-term follow-up (2-6 years; mean 4 years), 72% patients remained improved (2-category improvement in APPSSI scoring), and 81% of subjects reported "high" or "very high" levels of satisfaction. The most frequently reported postoperative complications were seroma (4.8%), scar formation (4.5%), and infection (3.3%). No patients reported any changes in sexual function, erections, or ejaculation. 3% experienced adverse events necessitating device removal. CLINICAL IMPLICATIONS:The Penuma silicone implant can help patients cosmetically correct the penis with increased flaccid penile girth and achieve enhanced self-confidence and self-esteem over the short- and long term. STRENGTHS AND LIMITATIONS:Strengths include the large number of subjects (400 men) and the long-term follow-up period (2-6 years). Limitations include the retrospective and single-surgeon (inventor) nature of the study; the presence of 126 non-consenting subjects, potentially impacting the complication rate; and the APPSSI's lack of validation. CONCLUSION:Retrospective analysis of 400 men electing to have penile cosmetic correction with the Penuma device demonstrates improvements in girth (56.7% increase) and high and sustained patient satisfaction, self-confidence, and self-esteem with minimal and manageable adverse events. Elist JJ, Valenzuela R, Hillelsohn J, et al. A Single-Surgeon, Retrospective, and Preliminary Evaluation of the Safety and Effectiveness of the Penuma Silicone Sleeve Implant for Elective Cosmetic Correction of the Flaccid Penis. J Sex Med 2018;15:1216-1223.

Children diagnosed with cancer continue to have improved survival due to advances in effective treatment options. Increased attention is therefore now focused on quality of life issues once they are cured. Fertility preservation is of paramount concern since gonadotoxic treatments, especially radiation and chemotherapy, often impair future fertility. The importance of family counseling and having an informed discussion about the potential for treatment to impair fertility and the options available for fertility preservation is crucial. However, fertility preservation in prepubertal boys is challenging, but not impossible. Experimental methods are being investigated including cryopreservation of immature testicular tissue, xenografting, and in vitro germ cell maturation. Despite the success and relative ease of sperm banking, barriers exist and affect the number of patients offered treatment. Education and awareness of the possibilities can overcome these barriers. In this way we will continue to preserve young patients' future fertility and quality of life.

Purpose: Prostate cancer screening is a controversial topic. We examined trends in Prostate Specific Antigen (PSA) testing in an underserved population before and after the United States Preventative Services Task Force (USPSTF) recommendation against screening. Methods: Data were collected on all PSA and cholesterol screening tests from 2008 to 2014. We examined the trend of these tests and prostate biopsies while comparing this data to lipid panel data to adjust for changes in patient population. Results: A decrease in PSA screening was observed from 2010 through 2014, with the greatest decline in 2012. The age group most affected was patients aged 55-69 years. The amount of prostate biopsies during this period decreased as well. Conclusions: Decreased rates of PSA screening were observed in our urban hospital population that preceded the publication of the USPSTF guidelines. The incidence of prostate biopsies decreased in this timeframe. It now remains to be demonstrated whether decreased PSA screening rates impact the diagnosis of and ultimately the survival from prostate cancer.

PURPOSE/OBJECTIVE:To determine if a pharmacological test could be developed to determine iris dilator dysfunction in patients taking tamsulosin. METHODS:Patients taking tamsulosin and controls were recruited from the Urology and Ophthalmology clinics at the Montefiore Medical Center. The patient's right eye (OD) was dilated with phenylephrine hydrochloride 2.5% and tropicamide 1%. The patient's left eye (OS) was dilated with tropicamide 1% alone. Forty minutes after dilation, pupillary diameter was measured in both eyes. RESULTS:Thirty-eight tamsulosin subjects and 43 controls met the inclusion criteria for the study. The tamsulosin-treated patients dilated less with phenylephrine than controls (0.61±0.4 vs. 1.10±0.45 mm, respectively P<0.001). Receiver operating characteristic curves comparing maximal pupillary dilation versus differential pupillary dilation in tamsulosin patients relative to controls shows a greater area under the curve for differential dilation (0.8 vs. 0.6, respectively). A correlation between smooth muscle dysfunction and length of time on tamsulosin was observed. Patients using tamsulosin for <1 month had an average OD-OS difference of 0.85±0.5 mm. Patients who were on tamsulosin for >1 month had an average OD-OS difference of 0.52±0.32 mm (P<0.01, Mann-Whitney). CONCLUSION/CONCLUSIONS:Patients treated with tamsulosin demonstrated a significantly decreased iris dilatory response to the selective adrenergic effects of phenylephrine compared to controls. Additionally, it appears that longer duration of exposure to tamsulosin increases the likelihood of dilator dysfunction.