Faculty Bibliography

BACKGROUND:In 1999, 1 year after the approval of the first oral phosphodiesterase type 5 (PDE5) inhibitor for the treatment of erectile dysfunction (ED), the first Princeton Consensus Conference was held to address the clinical management of men with ED who also had cardiovascular disease. These issues were readdressed in the second and third conferences. In the 13 years since the last Princeton Consensus Conference, the experience with PDE5 inhibitors is more robust, and recent new data have emerged regarding not only safety and drug-drug interactions, but also a potential cardioprotective effect of these drugs. AIM/OBJECTIVE:In March 2023, an interdisciplinary group of scientists and practitioners met for the fourth Princeton Consensus Guidelines at the Huntington Medical Research Institutes in Pasadena, California, to readdress the cardiovascular workup of men presenting with ED as well as the approach to treatment of ED in men with known cardiovascular disease. METHOD/METHODS:A series of lectures from experts in the field followed by Delphi-type discussions were developed to reach consensus. OUTCOMES/RESULTS:Consensus was reached regarding a number of issues related to erectile dysfunction and the interaction with cardiovascular health and phosphodiesterase-5 inhibitors. RESULTS:An algorithm based on recent recommendations of the American College of Cardiology and American Heart Association, including the use of computed tomography coronary artery calcium scoring, was integrated into the evaluation of men presenting with ED. Additionally, the issue of nitrate use was further considered in an algorithm regarding the treatment of ED patients with coronary artery disease. Other topics included the psychological effect of ED and the benefits of treating it; the mechanism of action of the PDE5 inhibitors; drug-drug interactions; optimizing use of a PDE5 inhibitors; rare adverse events; potential cardiovascular benefits observed in recent retrospective studies; adulteration of dietary supplements with PDE5 inhibitors; the pros and cons of over-the-counter PDE5 inhibitors; non-PDE5 inhibitor therapy for ED including restorative therapies such as stem cells, platelet-rich plasma, and shock therapy; other non-PDE5 inhibitor therapies, including injection therapy and penile prostheses; the issue of safety and effectiveness of PDE5 inhibitors in women; and recommendations for future studies in the field of sexual dysfunction and PDE5 inhibitor use were discussed. CLINICAL IMPLICATIONS/CONCLUSIONS:Algorithms and tables were developed to help guide the clinician in dealing with the interaction of ED and cardiovascular risk and disease. STRENGTHS AND LIMITATIONS/UNASSIGNED:Strengths include the expertise of the participants and consensus recommendations. Limitations included that participants were from the United States only for this particular meeting. CONCLUSION/CONCLUSIONS:The issue of the intersection between cardiovascular health and sexual health remains an important topic with new studies suggesting the cardiovascular safety of PDE5 inhibitors.

OBJECTIVE:To assess the difference in outcomes between single dilation (SingD) and sequential dilation (SeqD) in primary penile implantation, hypothesizing that patients who undergo SeqD had higher rates of noninfectious complications. METHODS:We performed a multicenter, retrospective study of men undergoing primary inflatable penile prosthesis placement. Intraoperative complications and postoperative noninfectious outcomes were assessed between the two groups. Multivariable analysis was performed to identify predictors of complications. RESULTS:A total of 3293 patients met inclusion criteria. After matching, there were 379 patients who underwent SingD and 379 patients who underwent SeqD. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length (20 cm with interquartile range [IQR] 18-21 cm vs 20 cm with IQR 18-20 cm respectively, P = .4). On multivariable analysis, SeqD (OR 5.23 with IQR 2.74-10, P < .001) and older age (OR 1.04 with IQR 1.01-1.06, P = .007) were predictive of postoperative noninfectious complications. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length. SeqD and older age were predictive of postoperative noninfectious complications. CONCLUSION/CONCLUSIONS:During inflatable penile prosthesis placement in the uncomplicated patient without fibrosis, SingD is a safe technique to utilize during implantation that will minimize postoperative adverse events, and promote device longevity without loss of cylinder length.

Peyronie's disease (PD) is a fibrotic disorder of the tunica albuginea that may result in penile deformity, pain, a palpable plaque, and erectile dysfunction. In order to understand the psycho-sexual impacts of PD on patients and their partners, we selected three online forums containing the largest number of threads on PD. Threads focusing on the psycho-sexual impacts posted from January 1, 2011 to January 1, 2021 were compiled, and thematic analysis was performed on Dedoose. There were 277 unique posters, including 225 patients and 52 partners. Eighty-four categories and five themes were developed including information and social support, physical symptoms, psycho-sexual symptoms, treatment and effect, and impacts on partners and relationship. Emotional distress including depressed mood (n = 75, 33.3%) and feelings of isolation (n = 41, 18.2%) was prevalent. Partners developed sexual dysfunction including sexual dissatisfaction (n = 11, 21.2%) and dyspareunia (n = 4, 7.7%). Relationships experienced disruption (n = 14, 5.1%) or termination (n = 10, 3.6%). Posters received psychological treatment including psychotherapy (n = 20, 8.9%) and antidepressants (n = 17, 7.6%). Of these, 12 reported improvement and 11 stated no improvement. On these forums, psychological burden affecting individuals with PD and their partners is reported. Few seek help from a psychologist or therapist, and psychological distress may persist even after successful PD treatment. Further research is needed to identify strategies for effective psychological management.

BACKGROUND:Corporal fibrosis is known to result from prolonged priapism; however, the impact of the timing of penile prosthesis placement after priapism on complication rates is poorly understood. AIM/OBJECTIVE:We sought to evaluate the impact of timing of inflatable penile prosthesis (IPP) placement on complications in men with a history of ischemic priapism. METHODS:We performed a multicenter, retrospective cohort study of patients with a history of priapism undergoing IPP placement by 10 experienced implantation surgeons. We defined early placement as ≤6 months from priapism to IPP. We identified a 1:1 propensity-matched group of men without a history of priapism and compared complication rates between men who had early placement, late placement, and no history of priapism. OUTCOMES/RESULTS:Our primary outcome was postoperative noninfectious complications, and secondary outcomes included intraoperative complications and postoperative infection. RESULTS:A total of 124 men were included in the study with a mean age of 50.3 ± 12.7 years. A total of 62 had a history of priapism and 62 were matched control subjects. The median duration of priapism was 37 (range, 3-168) hours and the median time from ischemic priapism to IPP placement was 15 months (range, 3 days to 23 years). Fifteen (24%) men underwent early (≤6 months) IPP placement at a median time of 2 months (range, 3 days to 6 months) following the ischemic priapism event. The remaining 47 (76%) underwent placement >6 months following priapism at a median time of 31.5 months (range, 7 months to 23 years). The complication rate in the delayed placement group was 40.5% compared with 0% in the early placement group and control group. Cylinder-related complications such as migration or leak accounted for 8 (57%) of 14 of the postoperative noninfectious complications. Full-sized cylinders were used in all patients who had a cylinder related complication. CLINICAL IMPLICATIONS/CONCLUSIONS:Priapism patients should be referred to prosthetic experts early to decrease complication rates in those needing an IPP. STRENGTHS AND LIMITATIONS/UNASSIGNED:This is a multicenter study from experienced prosthetic urologists but is limited by the retrospective nature and small number of patients in the early placement group. CONCLUSION/CONCLUSIONS:IPP complication rates are high in men with a history of ischemic priapism, especially when implantation is delayed beyond 6 months.

PURPOSE:Our aim was to determine if the AUA-recommended prophylaxis (vancomycin + gentamicin alone) for primary inflatable penile prosthesis surgery is associated with a higher infection risk than nonstandard regimens. MATERIALS AND METHODS:We performed a multicenter, retrospective study of patients undergoing primary inflatable penile prosthesis surgery. Patients were divided into those receiving vancomycin + gentamicin alone and those receiving any other regimen. A Cox proportional-hazards model was constructed adjusted for major predictors. A subgroup analysis to identify the appropriate dosage of gentamicin was also performed. RESULTS:= .1). CONCLUSIONS:Vancomycin + gentamicin alone for antibiotic prophylaxis for primary inflatable penile prosthesis surgery is associated with a higher infection risk than nonstandard antibiotic regimens while antifungal use is associated with lower infection risk. A critical review of the recommended antimicrobial prophylactic regimens is needed. Prospective research is needed to further elucidate best practices in inflatable penile prosthesis antimicrobial prophylaxis.

OBJECTIVE:To examine stakeholder perspectives regarding the lack of in-person externships and transition to a virtual urology residency interview format. The unprecedented disruption from the COVID-19 pandemic forced an abrupt pivot to a "virtual" Urology Match for the 2021 cycle. We aim for our study to inform ongoing deliberations on the future of the Urology Match. MATERIALS AND METHODS:Following Urology Match day in February 2021, two surveys were distributed by the Society of Academic Urologists to all applicants and program directors (PDs) who participated in the 2021 Urology Match. RESULTS:Overall, 192 of 481 applicants (40%) and 63 of 160 PDs (39%) responded. Most applicants (67%) were satisfied with their match outcomes, although unmatched applicants were significantly more likely to be unsatisfied than matched applicants (98% vs 9%, P <.0001). Most PDs were equally (79%) or more satisfied (13%) with their match outcomes compared with prior years. Nearly all applicants (93%) and PDs (94%) recommended retaining an in-person externship option. Most applicants (61%) and PDs (71%) felt their outcomes would not have changed with in-person interviews. Applicants and PDs were evenly split as to whether interviews should be conducted in-person or virtually in the future. CONCLUSION:The vast majority of applicants and PDs recommended retaining in-person externships for future match cycles despite high costs. In contrast, there was ambivalence amongst both groups of stakeholders regarding the format of interviews for future match cycles. We recommend virtual interviews moving forward to help alleviate the financial burden placed on applicants and increase equity.

PURPOSE:The prevalence of erectile dysfunction (ED) and the utilization of inflatable penile prosthesis (IPP) among prostate cancer patients are understudied. The aim of the study was to examine the relationships between ED, prostate cancer treatment type and IPP implantation in a national cohort. MATERIALS AND METHODS:We identified a retrospective cohort of Surveillance, Epidemiology, and End Results (SEER)-Medicare patients diagnosed with locoregional prostate cancer between 2006 and 2011 and treated with surgery or radiation. Chi-square tests were used to detect significant differences in ED rates as well as use of IPP among the subset with ED. Multivariable logistic regression was used to examine factors associated with the use of IPP. RESULTS:Among 31,233 patients in our cohort, 10,334 (33.1%) received prostatectomy and 20,899 (66.9%) received radiation. ED within 5 years was significantly more common in the prostatectomy group relative to those the radiation group (65.3% vs. 33.8%, p<0.001). In the subset of 13,812 patients with ED, the radiation group had greater median time to ED diagnosis compared to the prostatectomy group (346 vs. 133 days, p<0.001). IPP implantation was more frequent for prostatectomy patients than for radiation patients (3.6% vs. 1.4%, p<0.001). Cancer treatment type, race, and marital status were significantly associated with IPP utilization. CONCLUSIONS:ED is highly prevalent among prostate cancer patients, and IPP implantation is be underutilized. ED rates, time to ED diagnosis and utilization of IPP differed significantly by prostate cancer treatment type.