Amichai Kilchevsky

Does Low Intensity Extracorporeal Shock Wave Therapy Have a Physiological Effect on Erectile Function? Short-Term Results of a Randomized, Double-Blind, Sham Controlled Study

PURPOSE We investigated the clinical and physiological effect of low intensity extracorporeal shock wave therapy on men with organic erectile dysfunction who are phosphodiesterase type 5 inhibitor responders. MATERIALS AND METHODS After a 1-month phosphodiesterase type 5 inhibitor washout period, 67 men were randomized in a 2:1 ratio to receive 12 sessions of low intensity extracorporeal shock wave therapy or sham therapy. Erectile function and penile hemodynamics were assessed before the first treatment (visit 1) and 1 month after the final treatment (followup 1) using validated sexual function questionnaires and venoocclusive strain gauge plethysmography. RESULTS Clinically we found a significantly greater increase in the International Index of Erectile Function-Erectile Function domain score from visit 1 to followup 1 in the treated group than in the sham treated group (mean ± SEM 6.7 ± 0.9 vs 3.0 ± 1.4, p = 0.0322). There were 19 men in the treated group who were initially unable to achieve erections hard enough for penetration (Erection Hardness Score 2 or less) who were able to achieve erections sufficiently firm for penetration (Erection Hardness Score 3 or greater) after low intensity extracorporeal shock wave therapy, compared to none in the sham group. Physiologically penile hemodynamics significantly improved in the treated group but not in the sham group (maximal post-ischemic penile blood flow 8.2 vs 0.1 ml per minute per dl, p <0.0001). None of the men experienced discomfort or reported any adverse effects from the treatment. CONCLUSIONS This is the first randomized, double-blind, sham controlled study to our knowledge that shows that low intensity extracorporeal shock wave therapy has a positive short-term clinical and physiological effect on the erectile function of men who respond to oral phosphodiesterase type 5 inhibitor therapy. The feasibility and tolerability of this treatment, coupled with its potential rehabilitative characteristics, make it an attractive new therapeutic option for men with erectile dysfunction.

Magnetic Resonance Imaging-Transrectal Ultrasound Guided Fusion Biopsy to Detect Progression in Patients with Existing Lesions on Active Surveillance for Low and Intermediate Risk Prostate Cancer

Purpose: Active surveillance is an established option for men with low risk prostate cancer. Multiparametric magnetic resonance imaging with magnetic resonance imaging‐transrectal ultrasound fusion guided biopsy may better identify patients for active surveillance compared to systematic 12‐core biopsy due to improved risk stratification. To our knowledge the performance of multiparametric magnetic resonance imaging in following men on active surveillance with visible lesions is unknown. We evaluated multiparametric magnetic resonance imaging and magnetic resonance imaging‐transrectal ultrasound fusion guided biopsy to monitor men on active surveillance. Materials and Methods: This retrospective review included men from 2007 to 2015 with prostate cancer on active surveillance in whom magnetic resonance imaging visible lesions were monitored by multiparametric magnetic resonance imaging and fusion guided biopsy. Progression was defined by ISUP (International Society of Urological Pathology) grade group 1 to 2 and ISUP grade group 2 to 3. Significance was considered at p ≤0.05. Results: A total of 166 patients on active surveillance with 2 or more fusion guided biopsies were included in analysis. Mean followup was 25.5 months. Of the patients 29.5% had pathological progression. Targeted biopsy alone identified 44.9% of patients who progressed compared to 30.6% identified by systematic 12‐core biopsy alone (p = 0.03). Fusion guided biopsy detected 26% more cases of pathological progression on surveillance biopsy compared to systematic 12‐core biopsy. Progression on multiparametric magnetic resonance imaging was the sole predictor of pathological progression at surveillance biopsy (p = 0.013). Multiparametric magnetic resonance imaging progression in the entire cohort had 81% negative predictive value, 35% positive predictive value, 77.6% sensitivity and 40.5% specificity in detecting pathological progression. Conclusions: Multiparametric magnetic resonance imaging progression predicts the risk of pathological progression. Patients with stable multiparametric magnetic resonance imaging findings have a low rate of progression. Incorporating fusion guided biopsy in active surveillance nearly doubled our detection of pathological progression compared to systematic 12‐core biopsy.

Male factor infertility in 2011: Semen quality, sperm selection and hematospermia

The past year has seen several new developments in the field of male reproductive health, including a major revision of how urologists should assess semen quality following the release of new WHO guidelines, novel approaches to sperm selection for intracytoplasmic sperm injection, and changes in how clinicians might evaluate and treat patients with hematospermia.

Clinical anatomy of the G-spot.

The existence of the G‐Spot has never been unequivocally confirmed. With increased public exposure and a trend towards sexual gratification, however, the impetus to elucidate this structure is greater than ever. This review will focus on research that has been conducted on the clinical anatomy of the G‐Spot. Ultimately this review will show that while the distal area of the anterior vaginal wall appears to be the most sensitive region of the vagina, the existence of an anatomical “G‐spot” remains to be demonstrated. Clin. Anat. 28:363–367, 2015.

MP05-19 PRIOR NEGATIVE FUSION-GUIDED PROSTATE BIOPSY: WHEN IS A REPEAT BIOPSY NECESSARY?

INTRODUCTION AND OBJECTIVES: The Prostate ImagingReporting and Data System (PIRADS) score was developed to evaluate the likelihood of malignancy for lesions seen in the peripheral zone and transition zone on multi-parametric Magnetic Resonance Imaging (MRI) of the prostate. We aim to determine if this same scoring system can be used to evaluate central zone lesions on MRI. METHODS: A retrospective review was performed of 73 patients who underwent MR/US fusion-guided biopsy of 139 suspicious lesions between February 2014 and October 2015. All patients underwent a 3 Tesla multi-parametric MRI. Indications for MRI include an abnormal digital rectal exam, PSA velocity >0.75ng/dl/year and patients on active surveillance. Our multi-parametric MRI sequence involved T2, diffusion weighted imaging and dynamic contrast enhancement. Using a 3-dimensional model software [InVivo (Phillips), Gainesville (USA)], at least 3 MR/US fusion-guided biopsies were performed on each prostate lesion seen on MRI regardless of PIRADS score under local anesthesia in the outpatient clinic. RESULTS: There were 80 peripheral zone lesions, 32 transitional zone lesions and 27 central zone lesions that were biopsied. Median PIRADS score for central zone lesions was 3 (range 1-5). Compared to the peripheral and transition zone, central zone lesions graded PIRADS 4 and 5 were more likely to be false positive, p1⁄40.012. Only two patients (7%) had clinically significant prostate cancer (Gleason >3+3) seen on central zone lesion. Both patients had lesions which were graded as PIRADS 3. Both lesions involved the transition zone as well and encompassed at least 50% of the entire central zone and transition zone. Both patients previously had transrectal ultrasound guided biopsy of the prostates which were negative for cancer. Both patients underwent a robotic assisted laparoscopic prostatectomy which yielded a Gleason score that were similar to MRI fusion biopsy. CONCLUSIONS: Lesions involving only the central zone seen on multi-parametric MRI are less concerning for malignancy and should not be given equal weightage as peripheral zone lesions. In our series, no lesions involving solely the central zone, regardless of PIRADS score was positive for malignancy on MR/US fusion-guided biopsy. A better PIRADS scoring system should be developed to help identify central zone lesions with malignant potential.

MP04-13 VALIDATION OF THE PROSTATE CANCER PREVENTION TRIAL RISK CALCULATOR 2.0 IN MULTIPARAMETRIC MRI ERA

INTRODUCTION AND OBJECTIVES: The Prostate Cancer Prevention Trial Risk Calculator 2.0 (PCPTRC2.0) represents a widely used tool developed to identify men for PSA testing or prostate biopsy. PCPTRC2.0 has been assessed in previous trials with traditional methodologies for identifying prostate cancer (PCa). The accuracy of the PCPTRC2.0 in correctly identifying patients at risk for PCa has been called into question, particularly in patients undergoing MRI/US fusion prostate biopsies. We aim to assess the accuracy of the PCPTRC2.0 estimation in identifying PCa in an MRI-US fusion biopsy cohort. METHODS: A review of men studied prospectively with MRI/ US fusion biopsy was conducted. Between August 2007 and February 2014, 595 MRI/US fusion prostate biopsies were selected. Patients0 complete data was used to calculate their PCPTRC2.0 scores using the PCPTRC2.0 R-code. Risk of positive biopsy and high-grade (Gleason 7) cancer on biopsy was calculated for each patient. Receiver operating characteristic (ROC) curves were analyzed and areas under the curve (AUC) were compared using DeLong0s test. RESULTS: Of 595 men included in the study, cancer was detected in 39% (232) by systematic biopsy compared to 48% (287) on MRI-targeted biopsy alone. Median age was 62.3 years with a mean PSA of 12.0. The AUCs for overall cancer detection rate (CDR) were similar at 0.69 and 0.70 for systematic and MRI-targeted biopsy, respectively (p1⁄40.69) [Figure 1a]. For high-grade disease according to the PCPTRC2.0 calculator, AUCs increased to 0.71 and 0.73 for systematic and MRI-targeted biopsy, but remained not statistically different (p1⁄40.54) [Figure 1b]. CONCLUSIONS: PCPTRC2.0 represents a valid prostate cancer prediction tool in men undergoing multiparametric MRI and fusion-guided prostate biopsy. Source of Funding: None.

Corrigendum to “A Case of In-Bore Transperineal MRI-Guided Prostate Biopsy of a Patient with Ileal Pouch-Anal Anastomosis”

[This corrects the article DOI: 10.1155/2015/676930.].