Dimitri Papagiannopoulos

A Retrospective Comparative Study of Traction Therapy vs. No Traction Following Tunica Albuginea Plication or Partial Excision and Grafting for Peyronie's Disease: Measured Lengths and Patient Perceptions

INTRODUCTION Loss of penile length is a recognized and common consequence of Peyronies disease (PD). Traction therapy (TT+) has been reported to decrease post-op length loss as well as increase stretched penile length (SPL) prior to surgery. AIM The aim of this study was to study patient outcomes with penile length change and patient satisfaction after surgery following tunica albuginea plication (TAP) and partial plaque excision and grafting (PEG) with or without postoperative TT. METHODS Retrospective analysis was performed from our cohort of Peyronies reconstructive surgery between 2007 and 2010. SPL was measured dorsally from pubis to corona and recorded at the initial office visit and then compared to most recent postoperative visit. Patients were then stratified by procedure and whether TT was used (TT+ and TT-; TAP N = 52 [27 TT+ and 25 TT-] and PEG N = 59 [36 TT+ and 23 TT-). Traction therapy was initiated for >2 hours a day for 3 months typically starting 3-4 weeks postoperatively. A non-validated mailed questionnaire assessed patient perceptions. RESULTS Mean length change seen in TAP (TT+) was 0.85 cm (0.25-1.75) vs. -0.53 cm (-1.75 to 0.5) in TAP (TT-) (P < 0.001). The mean length change seen in PEG (TT+) was 1.48 cm (0-6) vs. PEG (TT-) 0.24 cm (-1 to 2.5 cm) (P < 0.001). Sixty-one percent of surveys were returned; 85% lost length prior to the initial office evaluation, with an average of -2.5 cm lost. Importantly, in those who used traction, there was no perceived length loss, 58% reported a mean erect length gain of 1.1 cm. However, only 54% of all patients were satisfied with their current erect length. CONCLUSIONS Loss of length in men with PD remains a serious concern. It appears that postoperative TT can result in length preservation, and in many, a measured and perceived length gain following correction of the curvature.

Evaluation of young men with organic erectile dysfunction

Erectile dysfunction (ED) in men under the age of 40 was once thought to be entirely psychogenic. Over the last few decades, advances in our understanding of erectile physiology and improvements in diagnostic testing have restructured our understanding of ED and its etiologies. Although psychogenic ED is more prevalent in the younger population, at least 15%-20% of these men have an organic etiology. Organic ED has been shown to be a predictor of increased future morbidity and mortality. As such, a thorough work-up should be employed for any man with complaints of sexual dysfunction. Oftentimes a treatment plan can be formulated after a focused history, physical exam and basic lab-work are conducted. However, in certain complex cases, more testing can be employed. The major organic etiologies can be subdivided into vascular, neurologic, and endocrine. Specific testing should be directed by clinical clues noted during the preliminary evaluation. These tests vary in degree of invasiveness, precision, and at times may not affect treatment. Results should be integrated into the overall clinical picture to assist in diagnosis and help guide therapy.

Examining Postoperative Outcomes after Employing a Surgical Algorithm for Management of Peyronie's Disease: A Single-Institution Retrospective Review

AIM Surgery remains the gold standard treatment for men with stable Peyronies disease (PD). In an attempt to guide operative selection, we report our series of penile-straightening procedures for PD, using a surgical algorithm that recommended tunica albuginea plication (TAP), partial plaque excision and grafting (PEG) or inflatable penile prosthesis (IPP) placement. With this study, we attempt to further refine surgical approach, define realistic surgical outcomes, and help establish reasonable postoperative expectations for treatment of PD. METHODS We retrospectively reviewed all patients who underwent surgery for PD at our institution between 2007 and 2013. Work-up involved a history, physical exam, and a duplex ultrasound. Several questionnaires were employed to assess bother and distress associated with PD. Objective outcomes and patient satisfaction were assessed postoperatively. Primary outcomes include postoperative patient satisfaction with rigidity, curvature, and ability to engage in intercourse. Secondary outcomes include comparing emotional, relationship, and psychological distress to severity of disease. RESULTS A total of 390 patients underwent penile-straightening procedures for correction of PD. Of these patients, 29%, (n = 114) underwent TAP, 41% (n = 159) PEG, and 30% (N = 114) IPP. Mean follow-up was 17 months. The three surgical modalities showed no significant difference in satisfaction with penile rigidity, presence of bothersome residual curve, or ability to engage in intercourse. Preoperatively, 80% of men reported a negative effect of PD on their emotional status. Postoperatively, 88.4% of men were able to engage in penetrative intercourse, while only 70% were satisfied with rigidity and 84.9% were satisfied with curvature correction. CONCLUSION Patient experience with postsurgical rigidity, ability to engage in intercourse, and residual bothersome curve was not statistically different across the three groups, supporting the use of this surgical algorithm. The majority of patients with PD experience some degree of emotional and psychological distress, which may compromise patient satisfaction.

Predictors of Infectious Complications after Targeted Prophylaxis for Prostate Needle Biopsy

Purpose The incidence of infectious complications after transrectal ultrasound guided prostate needle biopsy is rising. We sought to identify the incidence and predictors of infection in a large cohort of men undergoing biopsy who receive targeted prophylaxis. Materials and Methods We retrospectively reviewed the records of 5,214 consecutive patients who underwent transrectal ultrasound guided prostate needle biopsy from January 2013 to December 2014 at UroPartners, a large urology group comprising 28 clinics in metropolitan Chicago. At 1 microbiology laboratory all swabs were processed, the presence of fluoroquinolone resistant gram‐negative rods was identified and sensitivity tests were performed. Prophylaxis for biopsy was guided by rectal swab culture. Characteristics of patients with and without infectious complications were compared using the Kruskal‐Wallis and chi‐square tests. Multivariable logistic regression was done to determine predictors of infectious complications. Analyses were performed with R, version 2.14.2 (https://www.r‐project.org/). Results Of the 5,214 biopsies performed 56 infectious (1.1%) and 24 sepsis complications (0.46%) were found. On univariable analysis nonCaucasian race and fluoroquinolone resistant microbes were predictors of infection (p <0.05). On multivariable analysis fluoroquinolone resistant rectal vault flora (OR 9.98, 95% CI 3.79–26.3) and the number of biopsy cores taken (OR 1.28 per core, 95% CI 1.04–1.54) were independent predictors of infection. Conclusions Despite targeted prophylaxis patients with fluoroquinolone resistant rectal vault flora have higher odds of infectious complications following transrectal ultrasound guided prostate needle biopsy. In these patients one should consider using other biopsy approaches or techniques to minimize risk.

Surgical outcomes from limiting the use of nonabsorbable suture in tunica albuginea plication for Peyronie’s disease

Tunica albuginea plication (TAP) surgery for Peyronie’s disease (PD) is classically described using nonabsorbable suture. Many patients are aware of nodularity at the suture sites (50–88%), and some find them painful (10–33%). We explore whether limiting permanent sutures provides a durable correction of curve and report the incidence of bothersome nodules. Beginning in 2007, we modified our TAP procedure to limit the use of permanent sutures. We reviewed all patients who underwent TAP procedures from 2007 to 2014 at our institution. Patients were contacted to complete a previously published survey regarding postoperative satisfaction. In total, 142 PD patients underwent the TAP procedure and 81/142 (57%) completed the postoperative survey. Mean office follow-up and survey follow-up were 17.3 and 56.3 months, respectively. Of the surveyed patients, 6.2% complained of a bothersome residual curve, 19.8% experienced nodularity and 4.9% reported bothersome nodules. Men with dorsal curves experienced less painful nodularity than those with ventral (P=0.047) or lateral curves (P=0.017). In total, 4/142 (2.8%) of men underwent repeat intervention. At long-term follow-up, limiting permanent sutures during TAP procedures for PD is durable with respect to curvature correction and has encouragingly low levels of nodularity and bother at suture sites.

Robotic assisted laparoscopic radical cystectomy with stentless intracorporeal modified Ves.Pa neobladder: early experience

AbstractThis study aimed at demonstrating the feasibility of robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder with stentless ureteroileal anastomosis. Pure intracorporeal robotic assisted laparoscopic technique has been recently developed with a select number of high-volume centers utilizing various operative and neobladder techniques. We reviewed the patient characteristics, operative details and perioperative courses in the two patients who have undergone robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder and one who has undergone the Hautmann W neobladder. These results were compared to other contemporary robotic neobladder series. We demonstrate technical success with similar operative and perioperative results with the modified Ves.Pa neobladder. The robotic pure intracorporeal modified Ves.Pa neobladder is a technically feasible operation and may be easier to perform compared to other neobladders. Initial experience suggests operative time and perioperative outcomes are similar to other robotic techniques.

Procalcitonin is a strong predictor of urine culture results in patients with obstructing ureteral stones: A prospective, pilot study

Purpose: The appropriate management of infected obstructing ureteral calculi is prompt genitourinary decompression. Urine cultures are the gold standard for confirming infection but often take 24–48 h to result. Although white blood cell (WBC) count is an important diagnostic laboratory test, it is a nonspecific inflammatory marker. Similarly, urinalysis (UA) can be misleading in the setting of a contaminated sample, bladder colonization, or in cases of a completely obstructed the upper urinary tract. Procalcitonin (PCT) has shown promise in predicting the presence and degree of bacterial infections. In this proof-of-concept study, we explore whether PCT is effective at predicting concomitant infections in the setting of obstructing ureteral stones. Materials and Methods: This is a prospective, single-institution observational pilot study examining adult patients who presented to the emergency room with acute obstructing ureterolithiasis. In total, 22 patients were enrolled. At the time of presentation, data obtained were vital signs, WBC count, PCT, UA, urine, and blood cultures. Fisher-exact two-tailed t-tests and receiver operating characteristic statistics with area under the curve (AUC) calculations were used to determine the correlation between urine culture results and PCT, WBC count, nitrite-positive UA, heart rate, and fever. Results: In total, 5/22 patients had bacteria-positive urine cultures. PCT (P = 0.020) and nitrite-positive UA (0.024) were the only statistically significant predictors of urine culture results. In comparing the AUC, PCT (0.812) was strongly correlated with eventual urine culture results. Conclusions: This proof-of-concept pilot study gives encouraging results, in that PCT was a good predictor of positive cultures (P = 0.02, AUC 0.812). Given, the small sample size, one cannot directly compare PCT to other markers of infection. However, PCT shows promise in this arena and warrants future investigation.