Low-intensity shockwave therapy improves baseline erectile function: a randomized sham-controlled crossover trial

Background

Low-intensity shockwave therapy for erectile dysfunction is emerging as a promising treatment option.

Aim

This randomized sham-controlled crossover trial assessed the efficacy of low-intensity shockwave therapy in the treatment of erectile dysfunction.

Methods

Thirty-three participants with organic erectile dysfunction were enrolled and randomized to shockwave therapy (n = 17) or sham (n = 16). The sham group was allowed to cross over to receive shockwave therapy after 1 month.

Outcomes

Primary outcomes were the changes in Sexual Health Inventory for Men (SHIM) score and Erection Hardness Score at 1 month following shockwave therapy vs sham, and secondary outcomes were erectile function measurements at 1, 3, and 6 months following shockwave therapy.

Results

At 1 month, mean SHIM scores were significantly increased in the shockwave therapy arm as compared with the sham arm (+3.0 vs -0.7, P = .024). Participants at 6 months posttreatment (n = 33) showed a mean increase of 5.5 points vs baseline (P < .001), with 20 (54.6%) having an increase ≥5. Of the 25 men with an initial Erection Hardness Score <3, 68% improved to a score ≥3 at 6 months. When compared with baseline, the entire cohort demonstrated significant increases in erectile function outcomes at 1, 3, and 6 months after treatment.

Clinical Implications

In this randomized sham-controlled crossover trial, we showed that 54.6% of participants with organic erectile dysfunction met the minimal clinically important difference in SHIM scores after treatment with low-intensity shockwave therapy.

Strengths and Limitations

Strengths of this study include a sham-controlled group that crossed over to treatment. Limitations include a modest sample size at a single institution.

Conclusions

Low-intensity shockwave therapy improves erectile function in men with erectile dysfunction as compared with sham treatment, which persists even 6 months after treatment.

Clinical Trial Registration

ClinicalTrials.gov NCT04434352.

The impact of cognitive impairment in urologic implants: a narrative review

Background and Objective

With the general population aging and thus more patients developing bothersome erectile dysfunction, stress urinary incontinence and overactive bladder, there will likely be a higher demand for three common interactive implants in urology, the penile prosthesis, artificial urinary sphincter (AUS) and sacral neuromodulation (SNM). Further, the prevalence of mild and major neurocognitive disorders (also known as mild cognitive impairment and dementia, respectively) is expected to increase. While the aforementioned urologic implants have excellent short and long term outcomes, there are also known device issues such as malfunction or misuse that may require surgical removal and/or revision. The objective of this narrative review is to describe the association of cognitive impairment and urologic implants.

Methods

We performed a search on PubMed between the years 1975-2023 for English language articles that reported on any type or severity of cognitive impairment and its association with penile prosthesis, AUS and/or SNM. While peer-reviewed published manuscripts were prioritized, abstracts that fit our search criteria were also included.

Key Content and Findings

Data assessing outcomes of patients with cognitive impairment who undergo placement of a urologic implant are limited. There is an association between AUS failure or misuse with cognitive impairment. SNM is efficacious in this population in the short term. In patients who develop dementia, an inflatable penile prosthesis can be deflated via in-office needle puncture and an AUS can be deactivated. The Memory Alteration Test, Quick Screen for Mild Cognitive Impairment and the Saint Louis University Mental Status Examination are relatively quick screening tests with good sensitivity and specificity for mild cognitive impairment.

Conclusions

While data on the association between urologic implants and cognitive impairment are sparse, there are tools that urologists can use to screen patients for cognitive impairment. With screening, urologists can provide appropriate preoperative counseling (including recommending against implantation) and can provide closer postoperative monitoring. Further study is required to assess which patients should be excluded from device implantation and how to properly assess for cognitive impairment in a manner that is both beneficial for the patient and convenient and efficient for a urologist.

Radial wave therapy does not improve early recovery of erectile function after nerve-sparing radical prostatectomy: a prospective trial

Background

Low intensity shockwave therapy is an emerging treatment option for men with vasculogenic erectile dysfunction. Radial wave therapy (rWT), which differs from focused shockwave (fSWT) as it produces lower pressure waves with lower peak energy, is used to treat soft tissue and skin conditions and has some data to support its use in vasculogenic erectile dysfunction. There is limited data for the use of rWT for the treatment of erectile dysfunction after nerve-sparing (NS) radical prostatectomy. We report the first trial of rWT for penile rehabilitation after NS radical prostatectomy.

Methods

We performed a prospective, non-randomized, open-label trial. Men with good pre-operative erectile function who underwent a NS radical prostatectomy at our institution from 2018-2020 were considered for inclusion. We compared post-operative erectile function outcomes between the rWT (6 weekly treatments initiated approximately 2 weeks post-operatively) plus standard of care (phosphodiesterase type 5 inhibitor) arm and the non-sham controlled standard of care arm. The primary end point for our study was the proportion of men who returned to "near normal" erectile function, defined as IIEF-5 score ≥17 and erectile hardness score (EHS) ≥3, by 3 months post-operatively between the intervention and control arm. We also compared mean IIEF-5 scores and median EHSs between the arms.

Results

One hundred and six patients were enrolled, of whom 73 patients had at least one reported survey response between 6 and 12 weeks post-operatively. Five (17%) and 11 (26%) patients recovered erectile function in the control and intervention arms, respectively, which was not a statistically significant difference (P=0.37). However, the intervention arm did have a significantly higher median EHS compared to the control arm (1 vs. 2, P=0.03). There were 4 adverse events related to pain during treatment and required only treatment intensity de-escalation.

Conclusions

rWT is safe but did not substantially improve the recovery of early erectile function after NS radical prostatectomy.

Using the UPOINT system to manage men with chronic pelvic pain syndrome

OBJECTIVE

: To outline our approach for the evaluation and management of patients with chronic prostatitis and chronic pelvic pain syndrome (CP/CPPS) based on our interpretation and application of currently available evidence.

METHODS

: CP/CPPS in men is a medical condition that plagues both the patient and the practitioner, as it is widely believed to be poorly understood and difficult to treat. While pelvic pain is typically the predominant symptom, many men may exhibit voiding symptoms, sexual dysfunction and psychiatric complaints. Still, most studies of CP/CPPS management have evaluated singular treatments, without focussing on individual patients' clinical phenotypes. This is a clinically practical mini-review based on the authors' interpretation and application of currently available evidence related to management of CP/CPPS.

RESULTS

: Patient evaluation should consist of history and physical examination (with focus on the genitourinary and digital rectal examination), laboratory tests (including urine analysis and urine culture with consideration of pre- and post-prostate massage urine cultures), post-void residual, and questionnaires including the National Institutes of Health Chronic Prostatitis Symptoms Index, which helps assess symptom severity and treatment response. Once CP/CPPS is diagnosed, the UPOINT phenotype system, which classifies patients into six domains: Urinary, Psychosocial, Organ Specific, Infectious, Neurological/systemic and Tenderness of skeletal muscles, is used to guide treatment. Each domain is characterised by specific complaints and thus is responsive to distinct treatments. As patients may be grouped into multiple domains, each patient's overall multimodal treatment can vary.

CONCLUSION

: Using the UPOINT phenotype system is a holistic approach that can yield significant benefits for patients with CP/CPPS.

Contemporary management of advanced prostate cancer: an evolving landscape

Recent population-based studies suggest that the incidence of advanced and metastatic prostate cancer may be increasing. Concurrently with this apparent stage migration toward advanced disease, several major developments have occurred in the treatment paradigm for men with advanced prostate cancer. These include the US Food and Drug Administration approval of 8 novel agents over the last decade. In addition to novel pharmaceuticals, rapidly evolving diagnostic tools have emerged. This review provides a primer for clinicians who treat men with advanced prostate cancer, including medical oncologists, radiation oncologists, and urologists.

MON-140 Prolactin to Testosterone Ratio Reduces Pituitary Magnetic Resonance Imaging Expenditures for Hypogonadal Men with Mild Hyperprolactinemia

Background: Hyperprolactinemia is a common laboratory finding in men with symptomatic hypogonadism. Persistent elevations in serum prolactin (PRL) are typically evaluated with pituitary magnetic resonance imaging (pitMRI) to assess for structural pathology. However, this practice pattern may result in overutilization of pitMRI and unnecessary healthcare expenditures.

Objective: We sought to examine the cost savings associated with utilizing combinations of serum PRL and the prolactin to testosterone ratio (PRL/T) to predict positive findings on pitMRI and obviate the need for unnecessary imaging studies.

Methods: A retrospective case-control study was performed. Men <75 presenting with symptomatic hypogonadism and mild hyperprolactinemia (15-55 ng/ml) who obtained pitMRI at a tertiary care center were included. Individuals previously evaluated for pituitary abnormality were excluded, as were those presenting with symptoms strongly concerning for a pituitary abnormality (e.g. visual change, headache). Laboratory studies were abstracted from the electronic medical record and pitMRI results were reviewed. A cost analysis was performed based on the institutional expense of pitMRI and laboratory evaluations. The cost of measuring PRL and T was calculated for all patients. The expense of pitMRI was calculated for those screening positive.

Results: 141 men were included in the study. Pituitary lesions were identified in 40/141 men (28%). The total cost of evaluation was calculated at $458,814.

Ordering pitMRI when PRL/T >0.10 is 80% sensitive (32/40 lesions captured) and 64% specific (65/101 with normal anatomy excluded). 68/141 are indicated for pitMRI, while 73 patients avoid imaging. Employing this threshold reduces expenses by 46% with cost savings calculated at $212,795. The cost of identifying each lesion was estimated at $7,688.

Ordering pitMRI when PRL/T >0.10 or when PRL >25 is 90% sensitive (36/40 lesions captured) and 48% specific (48/101 with normal anatomy excluded). 89/141 are indicated for pitMRI, while 52 patients avoid imaging. Employing this threshold reduces expenses by 33% with cost savings calculated at $151,580. The cost of identifying each lesion was estimated at $8,534.

Ordering pitMRI when PRL/T >0.08 or when PRL >25 is 98% sensitive (39/40 lesions captured) and 32% specific (32/101 with normal anatomy excluded). 108/141 are indicated for pitMRI, while 33 patients avoid imaging. Employing this threshold reduces expenses by 21% with cost savings calculated at $96,195. The cost of identifying each lesion was estimated at $9,011.

Conclusions: Serum PRL and PRL/T correctly predict the vast majority of pituitary lesions in patients with mild hyperprolactinemia, with screening costs increasing as more sensitive thresholds are employed. Future guidelines should establish a reasonable cutoff for pitMRI to minimize the expense of unnecessary imaging.

MON-275 Prolactin to Testosterone Ratio Predicts Pituitary Pathology in Hypogonadal Men with Mild Hyperprolactinemia

Background: Serum prolactin (PRL) and testosterone (T) levels are routinely evaluated in men presenting with clinical symptoms of hypogonadism. Persistent mild elevations in PRL are often benign, but may reflect structural pathology. Though pituitary magnetic resonance imaging (pitMRI) is often obtained to assess for anatomic lesions, it remains unclear how to optimize screening in hypogonadal men with mild hyperprolactinemia.

Objective: We sought to identify risk factors associated with detection of pituitary pathology among hypogonadal men with mild hyperprolactinemia and aimed to improve selection of those indicated for pitMRI.

Methods: A retrospective, case-control study was performed. Men under 75 presenting with clinical hypogonadism and mild hyperprolactinemia (15-50 ng/dL) who underwent pitMRI at a single tertiary care center were included. Individuals presenting with clinical symptoms strongly suggestive of a pituitary mass (e.g. visual change, headache, panhypopituitarism) were excluded, as were patients who had been previously evaluated for hyperprolactinemia. Age, body mass index (BMI), presenting symptoms, prescription history, and pitMRI findings were abstracted from the electronic medical record.

Results: 141 men met inclusion criteria. A minority exhibited pituitary pathology (n=40, 28%) with adenoma being the most common finding (n=35, 88%). Empty sella variants and non-neoplastic cysts comprised the remainder of pathologies (n=5, 12%). Mean PRL was higher in men with pituitary pathology than in controls (27.2 vs. 23.3 ng/mL; p=0.0106), while mean T levels were lower (190 vs 287 ng/dL; p=0.0001). Mean PRL/T ratio values were greater in cases (0.34 vs. 0.08; p<0.0001), as were median values (0.15 vs. 0.09). PRL/T outperformed PRL or T in predicting positive pitMRI findings (AUC: 0.75 vs. 0.64 vs. 0.71, respectively). A PRL/T ratio >0.08 was 90% sensitive, detecting 36/40 lesions, and 42% specific, excluding 42/101 patients with normal anatomy (p=0.0003). If applied to the study cohort, this cutoff would have reduced pitMRI burden by 30%. Ordering pitMRI when the PRL/T ratio >0.08 or when PRL >25 increases sensitivity (98%, 39/40 lesions detected) at the cost of decreased specificity (32%, 32/101 controls excluded). Presenting symptoms including fatigue, decreased libido, erectile dysfunction, and gynecomastia did not vary between cases and controls. Though patients with pituitary lesions were more likely to receive dopamine agonists than controls (40% vs. 23%; p=0.0392), they were not more likely to be prescribed testosterone, antipsychotics, or antidepressants.

Conclusions: The PRL/T ratio is superior to PRL or T alone in identifying pituitary pathology in hypogonadal men with mild hyperprolactinemia. Ordering pitMRI when the PRL/T >0.08 is sensitive for detecting pituitary lesions and may reduce pitMRI burden in this population by 30%.

Robotic radical cystectomy with intracorporeal urinary diversion: beyond the initial experience

Robotic assisted radical cystectomy (RARC) has gained popularity within minimally-invasive urologic surgery, and has been shown to be a safe procedure with similar oncologic outcomes when compared to the conventional open standard. While initial RARC feasibility and outcomes studies were performed with extracorporeal urinary diversion, intracorporeal urinary diversion (ICUD) is becoming increasingly utilized. Reported benefits of an intracorporeal approach include decreased blood loss and a lower incidence of ureteral strictures. While ICUD is technically challenging, many have overcome the learning curve associated with this procedure via a mentorship model and a dedicated operative team. Techniques vary between institutions, and ileal conduit, continent cutaneous and orthotopic continent (neobladder) diversions have all been performed. Herein, we describe the learning curve, technical points, and unique complications associated with ICUD.

Childless Men at the Time of Vasectomy are Unlikely to Seek Fertility Restoration

OBJECTIVE

To examine whether men who were childless at the time of vasectomy sought consultation for fertility restoration.

METHODS

Retrospective chart review was performed to determine if patients without children at the time of vasectomy sought consultation for fertility restoration (defined as vasectomy reversal or sperm retrieval). If the patient had not been seen in our healthcare system within the previous 12 months, he was contacted by phone to determine whether he had sought consultation for fertility restoration.

RESULTS

Of 1656 men, 68 men (4.1%) were childless at the time of vasectomy. Fifteen patients were excluded as they were not followed in our hospital system and were unreachable by phone. Zero patients sought consultation for fertility restoration.

CONCLUSION

Our single institution study demonstrated that no men who were childless at the time of vasectomy sought consultation for fertility restoration. Given that there are no other FDA approved methods for nonbarrier sterilization for males, men with no children at the time of vasectomy should receive the same AUA guideline-recommended counseling that men with children receive.

Bladder-sparing treatment of nonmetastatic muscle-invasive bladder cancer

Bladder-sparing therapies for the treatment of nonmetastatic muscle-invasive bladder cancers are included in both American and European guidelines. Numerous treatment approaches have been described, including partial cystectomy, radiation monotherapy, and radical transurethral resection. However, the most oncologically favorable and well-studied regimen employs a multimodal approach that consists of maximal transurethral resection of the bladder tumor followed by concurrent radiosensitizing chemotherapy and radiotherapy. This sequence, referred to as trimodal therapy (TMT), has been evaluated with robust retrospective comparative studies and prospective series, although a randomized trial comparing TMT with radical cystectomy has not been performed. Despite promising reports of 5-year overall survival rates of 50% to 70% in well-selected patients, relatively few patients qualify as ideal candidates for TMT. Specifically, contemporary series exclude patients who have clinical stage T3 disease, multifocal tumors, coexisting carcinoma in situ, or hydronephrosis. Herein, we review all forms of bladder-preserving therapies with an emphasis on TMT, highlighting the rationale of each component, survival outcomes, and future directions.

A Case of Metastatic Prostate Cancer to the Urethra That Resolved After Androgen Deprivation Therapy

An 83 year-old male with Gleason score 4+3 prostatic adenocarcinoma status post brachytherapy developed obstructive voiding symptoms 9 years after brachytherapy. Prostate-specific antigen was 0.67. Cystoscopy noted multiple papillary urethral tumors concerning for primary urethral carcinoma. Immunophenotype of biopsies supported diagnosis of Gleason score 4+4 prostatic adenocarcinoma. Androgen deprivation therapy was started. Cystoscopy performed 4 years later, for microhematuria workup, noted complete resolution of the urethral tumors. We present a patient with little serum Prostate-specific antigen change with urethral prostatic adenocarcinoma metastasis that resolved after androgen deprivation therapy.

Trifecta Outcomes in Multifocal Tumors: A Comparison Between Robotic and Open Partial Nephrectomy

OBJECTIVES

To report a comparative analysis of outcomes in patients who underwent multiple excisions for unilateral synchronous multifocal renal tumors using both open and robotic approaches.

METHODS

We retrospectively reviewed 110 patients who underwent robotic and open partial nephrectomy and had multiple tumor excisions in an ipsilateral kidney. "Trifecta" was defined as negative surgical margins, no urologic complications, and a glomerular filtration rate (GFR) preservation of ≥90% at last follow-up. Inverse probability of treatment weighting (IPTW) was applied to equilibrate treatment groups, minimize selection bias, and optimize inference on the basis of each patient's clinicodemographic characteristics.

RESULTS

Sixty-eight robotic and 42 open patient approaches had sufficient data for IPTW. After weighting, there were no statistical differences in baseline characteristics between the two groups. On adjusted analyses, robotic partial nephrectomy achieved equivalent rates of trifecta to open surgery (16.3% vs 16.5%, p = 0.99), which persisted on subgroup analyses of patients with two (20.1% vs 23.7%, p = 0.82) or more than two tumors (6.8% vs 7.4%, p = 0.95). There were no differences between robotic and open cohorts for negative margin rates, absence of complications, or GFR ≥90%. The robotic cohort had a shorter mean length of stay (3.4 vs 4.9 days, p < 0.001).

CONCLUSIONS

Surgical resection remains the mainstay for patients with unilateral, synchronous, and multifocal renal tumors. Our analysis found that both open and robotic approaches to partial nephrectomy are equally likely to achieve the "trifecta" outcome in an equilibrated high-risk group of patients. The robotic approach for these complex patients may be safe and feasible for a carefully selected group of patients.

The Role of Ipsilateral and Contralateral Transrectal Ultrasound-guided Systematic Prostate Biopsy in Men With Unilateral Magnetic Resonance Imaging Lesion Undergoing Magnetic Resonance Imaging-ultrasound Fusion-targeted Prostate Biopsy

OBJECTIVE

To determine how ipsilateral (ipsi) and contralateral (contra) systematic biopsies (SB) impact detection of clinically significant vs insignificant prostate cancer (PCa) in men with unilateral magnetic resonance imaging (MRI) lesion undergoing MRI-ultrasound fusion-targeted biopsy (MRF-TB).

MATERIALS AND METHODS

A total of 211 cases with 1 unilateral MRI lesion were subjected to SB and MRF-TB. Biopsy tissue cores from the MRF-TB, ipsi-SB, and contra-SB were analyzed separately.

RESULTS

A direct relationship was observed between MRI suspicion score and (1) detection of any cancer, (2) Gleason 6 PCa, and (3) Gleason >6 PCa. MRF-TB alone, MRF-TB + ipsi-SB, and MRF-TB + contra-SB detected 64.1%, 89.1%, and 76.1% of all PCa, respectively; 53.5%, 81.4%, and 69.8% of Gleason 6 PCa, respectively; and 73.5%, 96.0%, and 81.6% of Gleason >6 PCa, respectively. MRF-TB + ipsi-SB detected 96% of clinically significant PCa and avoided detection of 18.6% of clinically insignificant PCa. MRF-TB + contra-SB detected 81.6% of clinically significant PCa and avoided detection of 30.2% of clinically insignificant PCa.

CONCLUSION

Our study suggests that ipsi-SB should be added to MRF-TB, as detection of clinically significant PCa increases with only a modest increase in clinically insignificant PCa detection. Contra-SB in this setting may be deferred because it primarily detects clinically insignificant PCa.

Guideline of guidelines: a review of urological trauma guidelines

OBJECTIVE

To review the guidelines released in the last decade by several organisations for the optimal evaluation and management of genitourinary injuries (renal, ureteric, bladder, urethral and genital).

METHODS

This is a review of the genitourinary trauma guidelines from the European Association of Urology (EAU) and the American Urological Association (AUA), and renal trauma guidelines from the Société Internationale d'Urologie (SIU).

RESULTS

Most recommendations are guided by the American Association for the Surgery of Trauma (AAST) organ injury severity system. Grade A evidence is rare in genitourinary trauma, and most recommendations are based on Grade B or C evidence. The findings of the most recent urological trauma guidelines are summarised. All guidelines recommend conservative management for low-grade injuries. The major difference is for haemodynamically stable patients who have high-grade renal trauma; the SIU guidelines recommend exploratory laparotomy, the EAU guidelines recommend renal exploration only if the injury is vascular, and the AUA guidelines recommend initial conservative management.

CONCLUSION

There is generally consensus among the three guidelines. Recommendations are based on observational or retrospective studies, as well as clinical principles and expert opinions. Multi-institutional collaborative research can improve the quality of evidence and direct more effective evaluation and management of urological trauma.

Tissue transfer techniques in reconstructive urology

Tissue transfer techniques are an essential part of the reconstructive urologist's armamentarium. Flaps and graft techniques are widely used in genital and urethral reconstruction. A graft is tissue that is moved from a donor site to a recipient site without its native blood supply. The main types of grafts used in urology are full thickness grafts, split thickness skin grafts and buccal mucosa grafts. Flaps are transferred from the donor site to the recipient site on a pedicle containing its native blood supply. Flaps can be classified based on blood supply, elevation methods or the method of transfer. The most used flaps in urology include penile, preputial, and scrotal skin. We review the various techniques used in reconstructive urology and the outcomes of these techniques.

Natural History of Pathologically Benign Cancer Suspicious Regions on Multiparametric Magnetic Resonance Imaging Following Targeted Biopsy

PURPOSE

We determined the natural history of pathologically benign cancer suspicious regions on multiparametric magnetic resonance imaging following targeted biopsy.

MATERIALS AND METHODS

Between January 2012 and September 2014, 330 men underwent prostate multiparametric magnetic resonance imaging. A total of 533 cancer suspicious regions were identified and scored on a Likert scale of 1 to 5 based on suspicion for malignancy with 5 indicating the highest suspicion level. Following multiparametric magnetic resonance imaging all men underwent magnetic resonance imaging-ultrasound fusion targeted prostate biopsy using ProFuse software and the ei-Nav|Artemis system (innoMedicus, Cham, Switzerland), and a computer generated 12-core random biopsy. We analyzed a cohort of 34 men with a total of 51 cancer suspicious regions who had benign prostate biopsies and underwent repeat multiparametric magnetic resonance imaging and prostate specific antigen testing at 1 year. Changes in the greatest linear measurement, the suspicion score and serum prostate specific antigen were ascertained.

RESULTS

During 1 year the suspicion score distribution and the mean greatest linear measurement of the cancer suspicious regions decreased significantly (p <0.0001) while mean prostate specific antigen did not significantly change (p = 0.632). Two (3.9%), 15 (29.4%) and 34 cancer suspicious regions (66.7%) showed an increase, no change and decrease in suspicion score, respectively. No (0%), 21 (42.0%) and 29 cancer suspicious regions (58.0%) showed an increase of 20% or greater, no change and a decrease of 20% or greater in greatest linear measurement, respectively. Of the 2 cancer suspicious regions exhibiting an increased suspicion score neither showed a prostate specific antigen increase of 0.5 ng/ml or greater.

CONCLUSIONS

Our study provides compelling evidence that few benign cancer suspicious regions increase in suspicion score and/or the greatest linear measurement within 1 year independent of the baseline suspicion score. Therefore, routinely repeating multiparametric magnetic resonance imaging at 1 year in men with pathologically benign cancer suspicious regions should be discouraged since it is unlikely to influence management decisions.