L. Boeri

Sexual functioning mirrors overall men's health status, even irrespective of cardiovascular risk factors

Erectile dysfunction has been described as a sentinel marker of co‐existing and undetected cardiovascular disease. Beside cardiovascular diseases, a correlation between erectile dysfunction and other major comorbidities has been also reported. The study was aimed to analyze the association between sexual functioning and overall mens health in sexually active, Caucasian‐European men with new‐onset sexual dysfunction. Data from the last 881 consecutive patients seeking first medical help for sexual dysfunction were cross‐sectionally analyzed. The International Classification of Diseases, 9th revision, Clinical Modification was used to classify health‐significant comorbidities, which were scored with the Charlson Comorbidity Index (CCI). A modified CCI score from which all potential cardiovascular risk factors (CCI‐CV) were subtracted was then calculated for every patient. Patients were requested to complete the International Index of Erectile Function (IIEF). The main outcome of the study was the association between the IIEF domain scores and CCI, which scored health‐significant comorbidities even irrespective of cardiovascular risk factors (CCI‐CV). The final sample included 757 patients (85.9%) (Median age: 48 years; IQ range: 37–59). Overall, erectile dysfunction was found in 540 (71.4%) patients. Of these, 164 (21.6%) had a CCI ≥ 1 and 138 (18.2%) had a CCI‐CV ≥ 1, respectively. At the analysis of variance, IIEF‐Erectile Function (EF) scores significantly decreased as a function of incremental CCI and CCI‐CV scores (all p < 0.01). At multivariable logistic regression analysis, both IIEF‐EF and IIEF‐total score achieved independent predictor status for either CCI ≥ 1 or CCI‐CV ≥ 1, after accounting for potential confounders (p < 0.01). We report novel findings of a significant association between erectile dysfunction severity and overall mens health, even irrespective of cardiovascular risk factors. Thereof, erectile dysfunction severity could serve as a proxy for general mens health, thus encouraging physicians to comprehensively assess patients complaining of sexual dysfunction in the real‐life everyday clinical practice.

Rectal Culture-Guided Targeted Antimicrobial Prophylaxis Reduces the Incidence of Post-Operative Infectious Complications in Men at High Risk for Infections Submitted to Transrectal Ultrasound Prostate Biopsy – Results of a Cross-Sectional Study

The role of rectal culture-guided antimicrobial prophylaxis (TAP) in reducing infectious complications (IC) after transrectal-ultrasound prostate biopsy (TRUSPBx) is conflicting. We assessed the prevalence of IC in a cohort of men at high risk for IC submitted to TRUSPBx and treated with either TAP or empirical prophylaxis (EAP). Data from 53 patients at high risk for IC undergoing TRUSPBx were collected. Patients who did not receive a rectal swab (RS) were treated with EAP with fluoroquinolones (FQs). Of those who received the RS, patients with FQ-susceptible organisms received ciprofloxacin while those with FQ-resistant organisms received TAP. Office visits were scheduled to investigate the rate of complication at day 7 and 30 after TRUSPBx. Comorbidities were scored with the Charlson Comorbidity Index (CCI). Descriptive statistics and logistic regression models detailed the association between clinical parameters and IC rate. Out of 53 men, 17 (32.1%) had RS while 36 (67.9%) did not. All RS cultures were positive for E. Coli and 4 (23.5%) reported FQ-resistant pathogens. Considering risk factors for IC, no difference was found in terms of CCI, rate of diabetes, UTIs or recent antibiotic utilization between groups. Overall, 12 (22.6%) men reported IC, with a greater proportion of them belonging to the group treated with EAP (30.6% vs 5.9%; p = 0.045). Of these, 9 (25.0%) patients, all treated with EAP, developed post biopsy UTIs. E. Coli sustained all UTIs and 7 (77.7%) were FQ resistant. At multivariable analysis, CCI≥1, a history of UTIs/prostatitis and recent antibiotic utilization (all p<0.04) were the most powerful predictors for ICs. In conclusion, we found that compared to EAP, TAP significantly reduces ICs, in men at high risk for post TRUSPBx IC. Patients at risk for IC, especially those with recent antibiotic utilization, CCI≥1 and a history of UTIs/prostatitis before biopsy, could benefit from TAP.

When to Perform Karyotype Analysis in Infertile Men? Validation of the European Association of Urology Guidelines with the Proposal of a New Predictive Model

Known genetic alterations play a major role in perturbing male reproductive health. We sought to retrospectively validate the European Association of Urology (EAU) guidelines for karyotype analysis (KA) in a homogenous cohort of 1168 White European men presenting for primary couples infertility (noninterracial infertile couples only) and to develop a novel nomogram capable of predicting karyotype alterations. Overall, 742 (63.5%) patients would have deserved KA according to the EAU guidelines. Of those, 48 (6.9% of the assessable patients according to EAU guidelines) displayed any kind of alteration at KA. Conversely, hypothetically relying on the EAU criteria, 12 (20%) out of 60 patients with karyotype abnormalities would not have been candidates for the same genetic assessment. Overall, 694 (62.6%) patients would have been candidates for genetic workup despite having a normal karyotype. As a whole, the EAU guideline sensitivity, specificity, and discrimination were 80%, 37%, and 59%, respectively. We developed a novel nomogram, with a 2% probability cut-off, which allows for a more careful detection of KA alterations. PATIENT SUMMARY The application of the European Association of Urology guidelines for karyotype analysis does not ensure an adequate diagnostic process. In this regard, we propose a novel diagnostic tool to improve detection of alterations at karyotype analysis.

Age at First Presentation for Erectile Dysfunction: Analysis of Changes over a 12-yr Period

BACKGROUND The awareness regarding erectile dysfunction (ED) may have increased over the past decade due to the widespread availability of phosphodiesterase type 5 inhibitors and the growing knowledge of a link between ED and mens overall health. OBJECTIVE We examined whether the increased awareness of ED has led to observable changes in patient characteristics among first-time assessments for ED. DESIGN, SETTING, AND PARTICIPANTS Data was collected from 1586 men seeking their first medical attention for ED at a single academic center during 2005-2017. INTERVENTION Patients completed the International Index of Erectile Function (IIEF) to assess ED. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Local polynomial regression models explored the relationship between patient characteristics and the year of first-time assessment. Linear and logistic regression models estimated the association between the time at first assessment and the investigated outcomes. Restricted cubic splines tested the nonlinearity for continuous variables. RESULTS AND LIMITATIONS We observed a nonlinear correlation between age and year of assessment (p=0.0003); the probability that a patient aged <40 yr presented for ED increased from 13.5% in 2006 to 21.7% in 2017 (p=0.002). Patients assessed over the last period were significantly healthier (Charlson Comorbidity Index≥1; odds ratio [OR]: 0.96; 95% confidence interval [CI]: 0.92-0.99, p=0.02). We observed an increase in the rate of smokers (OR: 1.19, 95% CI: 1.14-1.23, p<0.0001) and in regularly physically active men (OR: 1.05; 95% CI: 1.01-1.08, p=0.008) over the same period. No changes were observed in terms of baseline IIEF-Erectile function scores over time. The single center design is the main limitation of the study. CONCLUSIONS Age at first presentation for ED significantly decreased over the past decade. Physicians should carefully assess EF even at younger age groups, suggesting lifestyle modifications and relevant treatments for comorbid conditions as soon as possible. PATIENT SUMMARY Patients presenting for erectile dysfunction (ED) are younger than they were 10 yr ago. These findings may suggest an increase in ED awareness. Likewise, this age reduction could represent a worrisome increase in terms of ED incidence in young men.

Depressive Symptoms and Low Sexual Desire after Radical Prostatectomy: Early and Long-Term Outcomes in a Real-Life Setting

Purpose: We assessed the rate and predictors of depressive symptoms and impaired sexual desire in patients who underwent open or robot‐assisted radical prostatectomy. Materials and Methods: A total of 811 patients completed IIEF (International Index of Erectile Function) and BDI (Beck Depression Inventory) preoperatively, and 6, 12, 24 and 36 months postoperatively. Rates and predictors of depressive symptoms and impaired sexual desire were assessed with descriptive statistics and logistic regression models. Results: We analyzed data on 416 patients treated with robot‐assisted radical prostatectomy and 395 who underwent open radical prostatectomy. Overall the incidence of patients with postoperative BDI scores suggestive of depressive symptoms ranged between 26.3% at 6 months and 36.7% at 36 months. BDI scores were significantly higher in open than in robot‐assisted radical prostatectomy cases at every analyzed postoperative time point (all p <0.01). Patients treated with robot‐assisted radical prostatectomy showed higher IIEF‐EF (Erectile Function) domain scores and a greater proportion of them experienced erectile function recovery at each time point compared to those treated with open radical prostatectomy (all p <0.005). Postoperatively the rate of impaired sexual desire ranged between 40.9% at 6 months and 34.1% at 24 months. IIEF‐SD (Sexual Domain) scores were significantly lower in open radical prostatectomy cases at every followup (all p <0.02). Age, open radical prostatectomy and postoperative erectile dysfunction were independent predictors of BDI scores and impaired sexual desire. Conclusions: One of 3 men surgically treated for prostate cancer still report depressive symptoms months after surgery. Patients who undergo robot‐assisted radical prostatectomy reported lower depressive symptoms than those treated with open radical prostatectomy. Sexual desire was highly affected after radical prostatectomy with greater impairment reported by patients who underwent open radical prostatectomy.

Prevalence and predictors of being lost to follow-up after transurethral resection of the prostate

Patient follow-up after transurethral resection of the prostate (TURP) is crucial to evaluate treatment-related outcomes and potential adverse events. We sought to determine the rate of, and factors associated with, patient nonadherence to follow-up after TURP. Data from 180 patients who underwent TURP were analysed. Patient counselling and follow-up were standardized among the cohort. Patients were considered lost to follow-up (LTF) if they were at least 30 days from their first scheduled follow-up appointment. Descriptive statistics and logistic regression analyses were performed to determine the impact of predictors on the rate of compliance with prescribed follow-up. Of 180 patients, 55 (30.5%) were LTF. LTF patients were younger (p < 0.001), had lower educational status (p = 0.007) and were more frequently single (p = 0.03) than those who were not LTF. Importantly, patients who experienced a postoperative-related event (PRE) were more likely to follow-up (p = 0.04). Multivariable analysis revealed that younger age (p < 0.001) and low educational status (p < 0.001) were independent predictors of being LTF. One out of three men submitted to TURP is lost to follow-up in the real-life setting. Noncompliance to follow-up was more frequent among young, single patients with low educational status. On the contrary, patients who experienced a PRE were more likely to follow-up.

Incidence and predictors of readmission within 30 days of transurethral resection of the prostate: A single center European experience

Hospital readmission rates have been analyzed due to their contribution to increasing medical costs. Little is known about readmission rates after urological procedures. We aimed to assess the incidence and predictors of 30-day readmission after discharge in patients treated with transurethral resection of the prostate (TURP). Data from 160 consecutive patients who underwent TURP from January 2015 to December 2016 were analysed. Intra hospitalization characteristics included length of stay (LOS), catheterization time (CT) and complications. Comorbidities were scored with the Charlson Comorbidity Index (CCI). Mean (SD) age was 70.1 (8.1) yrs and mean prostate volume was 80 (20.1) ml. Mean LOS and CT were 4.9 (2.5) days and 3.3 (1.6) days, respectively. The overall 30-day readmission rate was 14.4%, but only 7 (4.4%) patients required hospitalization. The most frequent reasons for readmission were haematuria (6.8%), fever/urinary tract infections (4.3%) and acute urinary retention (3.1%). Multivariable logistic regression analysis revealed age, CCI and CT to be independent predictors of readmission. However, when analysed according to age at the time of surgery, a beneficial effect from longer CT was observed only for patients older than 75 years. These parameters should be taken in account at the time of discharge after TURP.

The role of neutrophil-to-lymphocyte ratio in men with erectile dysfunction-preliminary findings of a real-life cross-sectional study

The aim of this study was to investigate the role of systemic inflammation by means of the neutrophil‐to‐lymphocyte ratio (NLR) in men with erectile dysfunction (ED). Complete demographic, clinical, and laboratory data from 279 consecutive men with newly diagnosed ED were analyzed. Health‐significant comorbidities were scored with the Charlson Comorbidity Index (CCI). A complete blood count was requested for every man, and the NLR was calculated for every individual. Patients were invited to complete the IIEF questionnaire. Logistic regression models tested the odds (OR, 95% CI) of severe ED (defined as IIEF‐EF <11, according to Cappelleris criteria) after adjusting for age, BMI, comorbidities (CCI >0), metabolic syndrome, NLR, cigarette smoking, and color duplex Doppler ultrasound parameters. Likewise, LNR values were also dichotomized according to the most informative cutoff predicting severe ED using the minimum p value approach. Median [IQR] age of included men was 51 [40–64] years. Of all, 87 (31%) men had severe ED. Men with severe ED were older (median [IQR] age: 61 [47–67] vs. 49 [39–58] years) and had a higher rate of CCI>0 [46/87 (53%) vs. 44/192 (23%) patients]. Thereof, NLR was dichotomized according to the most informative cutoff (NLR>3); patients with severe ED more frequently had NLR>3 as compared to all other ED patients [namely, 18/87 (21%) vs. 13/192 (7%)]. At multivariable logistic regression analysis, NLR>3.0 emerged as an independent predictor (OR [CI] 2.43 [1.06; 5.63]) of severe ED, after accounting for other clinical variables. A NLR>3 increased the risk of having severe ED in our cohort, boosting the already existing evidence linking systemic inflammation to ED. Moreover, this easily obtainable index can be clinically useful in better risk‐stratifying patients with ED.

Long-term penile morphometric alterations in patients treated with robot-assisted versus open radical prostatectomy

Neglected side effects after radical prostatectomy have been previously reported. In this context, the prevalence of penile morphometric alterations has never been assessed in robot‐assisted radical prostatectomy series. We aimed to assess prevalence of and predictors of penile morphometric alterations (i.e. penile shortening or penile morphometric deformation) at long‐term follow‐up in patients submitted to either robot‐assisted (robot‐assisted radical prostatectomy) or open radical prostatectomy. Sexually active patients after either robot‐assisted radical prostatectomy or open radical prostatectomy prospectively completed a 28‐item questionnaire, with sensitive issues regarding sexual function, namely orgasmic functioning, climacturia and changes in morphometric characteristics of the penis. Only patients with a post‐operative follow‐up ≥ 24 months were included. Patients submitted to either adjuvant or salvage therapies or those who refused to comprehensively complete the questionnaire were excluded from the analyses. A propensity‐score matching analysis was implemented to control for baseline differences between groups. Logistic regression models tested potential predictors of penile morphometric alterations at long‐term post‐operative follow‐up. Overall, 67 (50%) and 67 (50%) patients were included after open radical prostatectomy or robot‐assisted radical prostatectomy, respectively. Self‐rated post‐operative penile shortening and penile morphometric deformation were reported by 75 (56%) and 29 (22.8%) patients, respectively. Rates of penile shortening and penile morphometric deformation were not different after open radical prostatectomy and robot‐assisted radical prostatectomy [all p > 0.5]. At univariable analysis, self‐reported penile morphometric alterations (either penile shortening or penile morphometric deformation) were significantly associated with baseline international index of erectile function–erectile function scores, body mass index, post‐operative erectile function recovery, year of surgery and type of surgery (all p < 0.05). At multivariable analysis, robot‐assisted radical prostatectomy was independently associated with a lower risk of post‐operative penile morphometric alterations (OR: 0.38; 95% CI: 0.16–0.93). Self‐perceived penile morphometric alterations were reported in one of two patients after radical prostatectomy at long‐term follow‐up, with open surgery associated with a potential higher risk of this self‐perception.

High Blood Pressure Is a Highly Prevalent but Unrecognised Condition in Primary Infertile Men: Results of a Cross-sectional Study

BACKGROUND Although most of the components related to metabolic syndrome were shown to have a detrimental effect on male fertility, the effects of high blood pressure (HBP) have been partially analysed. OBJECTIVE To investigate the prevalence and impact of hypertension on clinical and semen parameters in a cohort of white European men presenting for couples infertility at a single tertiary referral academic centre. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study was performed including analysis of data from 2185 primary infertile men. Comorbidities were scored with Charlson Comorbidity Index (CCI; categorised 0 vs ≥1). HBP was defined as blood pressure ≥140/90mmHg. Semen analyses followed the 2010 World Health Organization reference criteria. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Descriptive statistics and logistic regression analyses tested the association among semen parameters, clinical characteristics, and HBP. RESULTS AND LIMITATIONS Overall, HBP was found in 6.8% of infertile patients and in 3.6% of age-comparable men without known fertility problems. Of 148 patients, 85 (58%) were either unaware of their HBP or not adequately medically-controlled. +HBP men were older (median age [interquartile range], 37 [33-40] vs 39 [36-44] yr; p<0.001), had higher CCI scores (X2=25.6; p<0.001), higher BMI (25.1 [23.3-27.3] vs 26.8 [24.9-29.4]; p<0.001), and a waist circumference >102cm in a greater proportion of individuals (41% vs 23%; X2=4.68 p<0.05) than -HBP men. Hypertensive and normotensive men did not differ in terms of hormonal milieu and semen parameters. Patients did not differ in terms of HPB rates according to oligozoospermia, asthenozoospermia, and teratozoospermia status. The lack of a real control group represents the main limitation of the study. CONCLUSIONS Hypertension and unrecognised or not adequately controlled HBP are highly prevalent among white European primary infertile men. Hypertension per se did not have an impact on hormonal and semen parameters. PATIENT SUMMARY Because of its effects in terms of overall prospective mens health, high blood pressure must be comprehensively considered over the basic work-up of every infertile man in the outpatient clinic setting.