Jason R. Kovac

Chronic scrotal pain and microsurgical spermatic cord denervation: tricks of the trade

Every practicing urologist encounters patients complaining of chronic scrotal content pain (CSCP). This condition can be equally frustrating for both patients and clinicians as there are no clear treatment guidelines, or pathways, for urologists to follow. As a result, most patients typically seek out multiple providers without improvements in their symptoms. Fortunately, microsurgical spermatic cord denervation (MSCD) is becoming an accepted, reliable and reproducible technique for definitively addressing CSCP in select patients. This manuscript reviews the background, effectiveness and current practice guidelines for scrotal pain in general, and MSCD in particular. Technical insights into how this technique can be performed both safely, and efficaciously, are provided. Finally, the manuscript presents a simple, yet detailed, easy to follow treatment algorithm to aid all urologists in the management of patients presenting with chronic pain.

Beyond testosterone cypionate: evidence behind the use of nandrolone in male health and wellness.

Characterized by low serum testosterone levels and diverse symptoms, male hypogonadism is a common condition. Current medical treatment focuses on testosterone supplementation using multiple modalities such as injections, gels and pellets. Interestingly, while testosterone is considered an anabolic androgenic steroid, it has not been saddled with the social stigma that other, similar medications have. The goal of this review is to highlight an anabolic steroid, 19-nortestosterone (i.e., nandrolone, deca-durabolin) and illustrate prospective therapeutic applications for male health. Containing a chemical structure similar to testosterone, nandrolone has a higher myotrophic: androgenic ratio resulting in improved effects on muscle mass. Animal models have suggested application in the improvement of joint healing following rotator cuff repair. Minimal literature exists regarding the use of nandrolone and, as such, further human studies are required.

Treatment of Peyronie’s disease via preoperative intralesional collagenase clostridium histolyticum followed by placement of an inflatable penile prosthesis: the new standard of care?

Penile prosthetic surgery via insertion of an inflatable penile prosthesis (IPP) is well established as the gold standard for patients with Peyronie’s disease and concurrent, severe erectile dysfunction (ED). For these patients, correction of curvature, erectile strength, and penile shortening have a significant impact on overall satisfaction and quality of life (1,2).

Amnion/chorion grafts and their applications in urology

The use of human amnion/chorion membranes in wound healing and skin grafting dates back to the early 1900s (1-4).

Centers of excellence for penile prosthetics are a novel concept that will likely prove difficult to implement

The surgical implantation of penile prosthetics has been evolving over many decades. The operation offers a durable treatment solution associated with a low complication rate and high patient satisfaction. The surgery itself is traditionally taught during urological residency; however, variable patient demographics and faculty expertise leads to differences amongst trainees nationwide. Only 15% of urology training programs have a dedicated prosthetic urologist. Indeed, overall perception of the penile prosthesis amongst general urologists is fraught with misinformation about high complication rates and poor outcomes (1). One strategy to overcome a lack of prosthetics exposure in residency is to have a traveling expert perform one or two operative training sessions (of 3–4 implants) per year (2). Other options include mini-fellowships and weekend courses. The prosthetics manufacturers traditionally sponsor these programs and studies on their effectiveness are limited. In 2015, the majority of penile prostheses (>75%) were placed by urologists who performed fewer than 5 implant surgeries per year (3). Thus, while penile prosthesis surgery is easily considered a low volume surgery for most; it is made exponentially more difficult by the lack of training received.

Challenges surrounding penile prostheses insertion following acute priapism

The role of immediate penile prosthesis placement in the management of patients suffering from acute priapism is controversial. Multiple temporal and intra-operative factors influence the decision of physicians to offer the option of early penile prosthesis placement. Although the duration of an ischemic priapism episode is the most predictive factor for determining long-term functional outcomes, treatments can range from conservative (observation) to aggressive (penile prosthesis insertion). In either situation, it is important to educate patients that many who present within 24 hours of priapism onset will still likely develop some form of lasting erectile dysfunction (ED) (1).

Informed consent for penile prosthesis surgery

The gold standard treatment for end-stage erectile dysfunction (ED) is the placement of a penile prosthesis. Informed consent is critical in helping to set expectations for this surgical procedure. All surgeons must help patients establish a solid understanding of the risks and benefits of the proposed treatment.

A novel proposal to address the future of penile prosthetics: are we currently focused in the wrong direction?

The future of penile prosthesis has been debated and postulated for decades. An excellent summary by Rodriguez et al. (1) in this issue of Translational Andrology and Urology describes nicely the history of the modern inflatable penile prosthesis while capturing possible future advances in rigidity, shape, composition and activation.

Basic concepts and recent advancements in penile prosthetic urology

Since the invention of the penile prosthesis, decades ago, many manuscripts and journals have been dedicated to the dissemination of research and new information about this sub-section of urology.

The value of medical pre-operative assessment for patients receiving penile prostheses

Penile prosthesis placement is both safe and efficacious for the treatment of medically refractory erectile dysfunction (ED). Nevertheless, as with all surgery, it carries with it the potential for complications. Consequently, both proper patient selection and risk management are essential for prosthetic surgeons. While very few patients are free of major comorbidities, others have multiple medical issues. Causes of ED include both systemic medical conditions such as diabetes, cardiac disease, hypertension and obesity as well as specific causes such as post surgical prostate, bladder and rectal cancer patients. As such, optimization prior to surgery could have multiple benefits to the prosthetic surgeon.