Christopher Yang

Testosterone Therapy after Radiation Therapy for Low, Intermediate and High Risk Prostate Cancer

PURPOSE Limited literature exists regarding the safety of testosterone therapy in men treated for prostate cancer. We present multi-institutional data on testosterone therapy in hypogonadal men with prostate cancer treated with radiation therapy. MATERIALS AND METHODS We retrospectively reviewed the records of hypogonadal men treated with testosterone therapy after radiation therapy for prostate cancer at 4 institutions. Serum testosterone, free testosterone, estradiol, sex hormone-binding globulin, prostate specific antigen, prostate specific antigen velocity and prostate biopsy findings were analyzed. RESULTS A total of 98 men were treated with radiation therapy. Median age was 70.0 years (range 63.0 to 74.3) at initiation of testosterone therapy. Median baseline testosterone was 209 ng/dl (range 152 to 263) and median baseline prostate specific antigen was 0.08 ng/ml (range 0.00 to 0.33). In the cohort the tumor Gleason score was 5 in 3 men (3.1%), 6 in 44 (44.9%), 7 in 28 (28.6%), 8 in 7 (7.1%) and 9 in 4 (4.1%). Median followup was 40.8 months (range 1.5 to 147). Serum testosterone increased to a median of 420 ng/dl (range 231 to 711) during followup (p <0.001). Overall a nonsignificant increase in mean prostate specific antigen was observed from 0.08 ng/ml at baseline to 0.09 ng/ml (p = 0.05). Among patients at high risk prostate specific antigen increased from 0.10 to 0.36 ng/ml (p = 0.018). Six men (6.1%) met criteria for biochemical recurrence. CONCLUSIONS Testosterone therapy in men following radiation therapy for prostate cancer was associated with a minor increase in serum prostate specific antigen and a low rate of biochemical recurrence.

Excision and Patch Grafting of a Lateral Peyronie's Plaque-Utilizing a Longitudinal "Window" Approach.

Introduction Peyronie’s disease (PD) is a debilitating disorder in which collagen deposition, fibrosis, and plaques in the tunica albuginea result in penile curvature, shortening, and pain. For severe curvatures requiring plaque incision or excision with grafting (PIEG), a subcoronal circumcising incision with penile degloving has historically been used. Aims The aim of this study was to report our unique approach to PIEG via a longitudinal “window” incision for the correction of PD, minimizing the surgical manipulation and dissection accompanying the traditional circumcising incisional approach that may lead to increased postoperative edema, pain, and prolonged healing time. Methods A patient presented with a stable, painless, 90-degree midshaft leftward curvature causing penetration difficulties and painful intercourse for his partner. His Sexual Health Inventory for Men (SHIM) score was 23. The patient opted for surgical correction with plaque excision and grafting via a 4-cm longitudinal incision overlying the point of maximal curvature along the left lateral penile shaft. This direct access to the left corpus cavernosum and plaque, along with dissecting skin, dartos, and Buck’s fascia, created a window with sufficient exposure for excision and patch grafting. Main Outcome Measures The main outcome measures were objective data and subjective data in men undergoing PIEG via lateral longitudinal “window” incision for PD repair. Results The plaque was excised and a porcine small intestinal submucosa graft was sewn in. Intraoperative artificial tumescence at the end of surgery revealed complete correction of the curvature. The patient experienced painless rigid erections by postoperative day three with minimal penile edema. By postoperative week four, he could successfully partake in coitus. His SHIM score remained unchanged. At maximum follow-up 6 months postoperatively, he still endorsed excellent cosmetic and functional outcomes with spontaneous unassisted erections and no recurrence of his curvature. Conclusion A lateral longitudinal incision for PIEG is a feasible technique and may reduce the postoperative morbidity and dissection required with traditional circumcising incision with penile degloving. Larger comparative studies are necessary for further evaluation.

Penile Artery Shunt Syndrome: A Novel Cause of Erectile Dysfunction after Penile Revascularization Surgery

INTRODUCTION Penile revascularization is a surgical treatment option for erectile dysfunction (ED) in healthy individuals due to a focal arterial occlusion in the absence of generalized vascular disease. Most described failures have been attributed to graft stenosis or disruption of the anastomosis. AIM We report a novel phenomenon called Penile Artery Shunt Syndrome that contributed to persistent ED in a patient after penile microvascular arterial bypass surgery. METHODS A 26-year-old man presented for evaluation of long-standing ED, which was attributed to trauma sustained 12 years earlier. He had difficulty obtaining and maintaining erections despite oral pharmacotherapy. Clinical data related to the case were studied, analyzed, and reviewed with urologic and radiologic specialists at multiple centers that collaborated in the care of this patient. MAIN OUTCOME MEASURES Penile duplex ultrasound peak systolic velocities and five-item International Index for Erectile Function questionnaire scores were the main outcome measures. RESULTS Initial diagnostic workup of the patient confirmed severe insufficiency of the left cavernosal artery, with no evidence of venous leak. The patient underwent penile microvascular arterial bypass surgery with anastomosis of the left inferior epigastric artery to the left dorsal penile artery. The patient had persistence of severe ED despite patent anastomosis by penile duplex ultrasound. Subsequent arteriography revealed an arterial shunt due to an aberrant obturator artery arising from the donor inferior epigastric artery. The patient underwent embolization of the aberrant obturator artery, with resolution of the shunt and marked improvement in erectile function. CONCLUSIONS The presence of an aberrant obturator artery arising from the inferior epigastric artery may predispose to persistent ED after revascularization due to the creation of a shunt phenomenon. Pelvic arteriography may be useful in identifying anomalous anatomic considerations prior to penile revascularization and to evaluate patients with persistent postoperative ED.

Partial Priapism Treated with Pentoxifylline.

ABSTRACT Main findings: A 26-year-old man suffering from partial priapism was successfully treated with a regimen including pentoxifylline, a nonspecific phosphodiesterase inhibitor that is often used to conservatively treat Peyronies disease. Case hypothesis: Partial priapism is an extremely rare urological condition that is characterized by thrombosis within the proximal segment of a single corpus cavernosum. There have only been 36 reported cases to date. Although several factors have been associated with this unusual disorder, such as trauma or bicycle riding, the etiology is still not completely understood. Treatment is usually conservative and consists of a non-steroidal anti-inflammatory and anti-thrombotic. Promising future implications: This case report supports the utilization of pentoxifylline in patients with partial priapism due to its anti-fibrogenic and anti-thrombotic properties.

Evaluation and Treatment of Orgasmic Dysfunction

Orgasm is the third phase of the sexual response cycle. Orgasm also describes the cerebral process of pleasure that is most often associated with ejaculation. Oxytocin and prolactin rise during ejaculation and orgasm, though the hormonal control of orgasm has not been completely elucidated. The most common cause of orgasmic dysfunction is iatrogenic, due to selective serotonin reuptake inhibitors, although anorgasmia associated with delayed ejaculation is also described. Treatment of orgasmic dysfunction is evolving, as there are no FDA-approved medications currently available. Further research is necessary in all aspects of the science of orgasm, especially the treatment of orgasmic dysfunction.

V8-08 REDUCTION SCROTOPLASTY WITH SIMULTANEOUS PLACEMENT OF INFLATABLE PENILE PROSTHESIS

INTRODUCTION AND OBJECTIVES: Placement of inflatable penile prosthesis is a common urologic surgery that dramatically aids patients with erectile dysfunction. There are a proportion of patients that have a severely redundant scrotum that can cause functional discomfort or pain due to the large size. We present a novel technique for reduction scrotoplasty with simultaneous placement of inflatable penile prosthesis. METHODS: A penoscrotal approach is taken for placement of the inflatable penile prosthesis. A ventral phalloplasty is performed using our previously described approach to excise the redundant skin at the penoscrotal web. We then follow our standard protocol for insertion of the penile prosthesis. The prosthesis pump is positioned in the most inferior portion of the scrotum. An inverted-Y reapproximation of the dartos layer is performed, and the overlying skin closed in the same fashion. This results in cephalad retraction of the scrotum, thus providing an overall reduction of scrotal sac dimensions. RESULTS: A total of seven patients have undergone reduction scrotoplasty with simultaneous placement of inflatable penile prosthesis at our institution. At last follow up, all patients have excellent cosmetic and functional outcomes. No known complications have occurred due to the reduction scrotoplasty. CONCLUSIONS: Inverted-Y reduction scrotoplasty is a feasible technique during placement of inflatable penile prosthesis. The added time during surgery is minimal, and functional outcomes are excellent. This simultaneous procedure can lead to improved quality of life for patients with concurrent erectile dysfunction and redundant scrotum.