Laith Alzweri

Grower or shower ? Predictors of change in penile length from the flaccid to erect state

In colloquial English, a “grower” is a man whose phallus expandsxa0significantly in length from the flaccidxa0 to the erect state; a “shower” is a man whose phallus does not demonstrate such expansion. We sought to investigate various factors that might predict a man being either a grower or a shower. A retrospective review of 274 patients who underwent penile duplex Doppler ultrasound (PDDU) for erectile dysfunction between 2011 and 2013 was performed. Penile length was measured, both in the flaccid state prior to intracavernosal injection (ICI) of a vasodilating agent (prostaglandin E1), and at peak erection during PDDU. The collected data included patient demographics, vascular, and anatomic parameters. The median change in penile length from flaccid to erect state was 4.0u2009u2009cm (1.0–7.0), and was used as a cut-off value defining a grower (≥4.0u2009cm) or a shower (4.0u2009cm). A total of 73 men (26%) fit the definition of a grower (mean change in length of 5.3u2009cm [SD 0.5]) and 205 (74%) were showers (mean change in length of 3.1u2009cm [SD 0.9]). There were no differences between the groups with regards to race, smoking history, co-morbidities, erectile function, flaccid penile length, degree of penile rigidity after ICI, or PDDU findings. Growers were significantly younger (mean age 47.5 vs. 55.9 years, pu2009u2009<u20090.001), single (37% vs. 23%, pu2009u2009=u2009u20090.031), received less vasodilator dose (10.3u2009u2009mcg vs. 11.0u2009u2009mcg, pu2009u2009=u2009u20090.038) and had a larger erect phallus (15.5u2009cm vs. 13.1u2009cm, pu2009<u2009u2009u20090.001). On multivariate analysis, only younger age was significantly predictive of being a grower (pu2009<u20090.001). These results suggest that younger age and single status could be predictors of a man being a grower, rather than a shower. Larger, multicultural and multinational studies are needed to confirm these results.

Collagenase Clostridium Histolyticum in the Treatment of Peyronie's Disease: Review of a Minimally Invasive Treatment Option

Peyronies disease (PD) is an inflammatory disorder characterized by an abnormal collagen deposition in the tunica albuginea of the penis, leading to fibrous and non-compliant plaques that can impede normal erection. Although pharmacological treatments are available, only intralesional injection therapy and surgical reconstruction have demonstrated tangible clinical efficacy in the management of this condition. Intralesional injection of collagenase clostridium histolyticum (CCH) has come to the forefront of minimally invasive treatment of PD. In this review, the authors provide an update on the safety, efficacy, and indications for CCH. The efficacy of CCH will be assessed on the basis of improvement in the severity of penile fibrosis, curvature, and pain. Numerous well-designed clinical trials and post-approval studies involving more than 1,500 patients have consistently demonstrated the efficacy and tolerability of CCH in the treatment of PD. CCH significantly decreases penile curvature and plaque consistency, as well as improves quality of life. Post-approval studies continue to demonstrate the efficacy of CCH despite broader inclusion criteria for treatment, such as the case with acute phase disease and atypical plaque deformities (i.e., ventral plaques, hourglass narrowing). CCH continues to be the gold standard for non-surgical management of stable phase PD, in the absence of strong evidence supporting oral therapy agents and ongoing evaluation of extracorporeal shockwave therapy. However, recent studies are beginning to provide precedent for the use of CCH in the management of acute phase and atypical PD.

Role of Penile Prosthesis in Priapism: A Review

Ischemic priapism is a urological emergency that has been associated with long-standing and irreversible adverse effects on erectile function. Studies have demonstrated a linear relationship between the duration of critically ischemic episodes and the subsequent development of corporal fibrosis and irreversible erectile function loss. Placement of a penile prosthesis is a well-established therapeutic option for the management of erectile dysfunction secondary to ischemic priapism, and will be the focus of this review. Review of the current literature demonstrates a growing utilization of penile prostheses in the treatment of erectile dysfunction secondary to ischemic priapism. Unfortunately, there is a paucity of randomized-controlled trials describing the use of prosthesis in ischemic priapism. As a result, there is a lack of consensus regarding the type of prosthesis (malleable vs. inflatable), timing of surgery (acute vs. delayed), and anticipated complications for each approach. Both types of prostheses yielded comparable complication rates, but the inflatable penile prosthesis have higher satisfaction rates. Acute treatment of priapism was associated with increased risk of prosthetic infection, and could potentially cause psychological trauma, whereas delayed implantation was associated with greater corporal fibrosis, loss of penile length, and increased technical difficulty of implantation. The paucity of high-level evidence fuels the ongoing discussion of optimal use and timing of penile prosthesis implantation. Current guidance is based on consensus expert opinion derived from small, retrospective studies. Until more robust data is available, a patient-centered approach and joint decision-making between the patient and his urologist is recommended.

Andrianne Mini-Jupette Graft at the Time of Inflatable Penile Prosthesis Placement for the Management of Post-Prostatectomy Climacturia and Minimal Urinary Incontinence

BACKGROUNDnAfter radical prostatectomy (RP), erectile dysfunction, often necessitating the need for inflatable penile prosthesis (IPP) insertion, and urinary incontinence and climacturia can ensue.nnnAIMnTo assess the efficacy and safety of the mini-jupette, a mesh used to approximate the medial aspects of the 2 corporotomies at the time of IPP insertion, for the management of climacturia and urine leakage in patients with minimal incontinence.nnnMETHODSnWe conducted a pilot multicenter study of patients with post-RP erectile dysfunction and climacturia and/or mild urinary incontinence (≤2 pads/day [ppd]) undergoing IPP insertion with concomitant placement of a mini-jupette graft.nnnOUTCOMESnPre- and postoperative erectile function, continence and climacturia, and overall surgical outcomes were assessed.nnnRESULTSn38 patients underwent the mini-jupette procedure. The mean age of the population was 65.3 years (SDxa0= 7.7). 30 had post-RP climacturia and 32 patients had post-RP incontinence (meanxa0= 1.3 ppd, SDxa0= 0.8). 31 patients received Coloplast Titan, 4 received AMS 700 LGX, and 3 received AMS 700 CX IPPs. Mean corporotomy size was 2.9 cm (SDxa0= 1.0). Mean graft measurements were 3.2 cm (SDxa0= 0.9) for width, 3.3 cm (SDxa0= 1.3) for length, and 11.0 cm2 (SDxa0= 5.1) for surface area. At a mean follow-up of 5.1 months (SDxa0=xa06.9), there were 5 postoperative complications (13.2%) of which 4 required explantation. Climacturia and incontinence were subjectively improved in 92.8% and 85.7%, respectively. Mean ppd decreased by 1.3xa0postoperatively.nnnCLINICAL IMPLICATIONSnThe Andrianne mini-jupette is a feasible adjunct to IPP placement that can be used for subsets of patients with post-RP climacturia and/or minimal incontinence.nnnSTRENGTHS AND LIMITATIONSnStrengths of this study include the novel nature of this intervention, the multi-institutional nature of the study, and the promising results demonstrated. Limitations include the retrospective nature of the study and the heterogeneity of the techniques and grafts used by different surgeons involved.nnnCONCLUSIONnLonger follow-up and larger patient cohorts are needed to confirm the long-term safety and benefits of this intervention. Yafi FA, Andrianne R, Alzweri L, etxa0al. Andrianne Mini-Jupette Graft at the Time of Inflatable Penile Prosthesis Placement for the Management of Post-Prostatectomy Climacturia and Minimal Urinary Incontinence. J Sex Med 2018;15:789-796.

Penile Prosthesis Complications: Planning, Prevention, and Decision Making

INTRODUCTIONnInflatable penile prosthesis (IPP) is an established treatment option for men with erectile dysfunction (ED) refractory to medical therapy. Standardization of surgical technique and improvements in device construction have reduced all-cause complication rates to less than 5% in recent reports. Nonetheless, complications do exist, and can strongly impact morbidity and the quality of life of patients. Prosthetic urologists must be aware of the constellation of complications that can arise during or after IPP placement.nnnAIMnTo provide a comprehensive review of penile prosthesis complications and discuss preventative strategies, as well as proper preoperative, intraoperative, and postoperative decision making.nnnMETHODSnA review of the available literature from 1973 to 2018 was performed using PubMed with regard to IPP complications.nnnMAIN OUTCOME MEASURESnWe reviewed publications that outlined preoperative planning strategies and the following IPP complications: hematoma, floppy glans, corporal fibrosis, corporal perforation and crossover, urethral injury, infection, impending erosion, and glandular ischemia.nnnRESULTSnCareful patient and device selection, setting realistic expectations of postsurgical outcomes, and adherence to a perioperative checklist is essential in the preoperative period. Intraoperatively, anticipate corporal fibrosis situations and always dilate laterally during corporal passage to reduce the risk of crossover and urethral injury. Limit perioperative antiplatelet therapy, apply compressive dressing, use a closed suction drain if indicated, and leave the device partially inflated postoperatively to reduce risk of hematoma. After surgery, monitor patients for potential complications that may warrant device explantation or salvage: IPP infection, glans ischemia, and impending erosion.nnnCONCLUSIONSnBy using evidence and expert opinion-based decision-making strategies in the preoperative, intraoperative, and postoperative period of IPP placement, surgeons can reduce the risk of complications and dissatisfaction, even in ED patients with multiple comorbid conditions. Scherzer ND, Dick B, Gabrielson AT, etxa0al. Penile Prosthesis Complications: Planning, Prevention, and Decision Making. Sex Med Rev 2019;7:349-359.

Male Orgasmic Dysfunction Post-Radical Pelvic Surgery

BACKGROUNDnPelvic surgeries are recognized to cause dysfunction of the male sexual response, which consists of erection, emission, expulsion, and orgasm. However, the least attention has been paid to male orgasmic dysfunction after invasive pelvic surgery.nnnAIMnTo describe the available literature on post-pelvic surgery orgasmic dysfunction disorders.nnnMETHODSnA literature search was performed on PubMed using the search strings related to dysfunction of the male sexual cycle and orgasm after pelvic surgery.nnnOUTCOMESnOrgasmic dysfunction after pelvic procedures in urologic, colorectal, and vascular surgeries was assessed.nnnRESULTSnRadical prostatectomy was the most common procedure where orgasmic dysfunction was quantified. Anorgasmia post-operatively occurred in patients in a range of 5-70%. Dysorgasmia occurred less frequently from 7-14%. The prevalence of climacturia was highly variable occurring in 20-93% of patients. Radical cystectomy resulted in anorgasmia 33-62% of the time and climacturia ranged from 6-45%. Studies involving colorectal surgeries were less likely to assess for dysorgasmia and climacturia, but anorgasmia rates ranged from 0-52%. Most current studies do not differentiate between ejaculatory and orgasmic dysfunction. However, more recent studies have started to distinguish between the 2 disorders and publish more specific data on what components of the male sexual response has been affected by the specific surgery.nnnCONCLUSIONSnThe male sexual response, specifically the male orgasm, is difficult to quantify in a non-obtrusive setting and can exhibit variability between patients and between sexual encounters in the same patient. Data involving the outcome of male orgasmic dysfunction after pelvic surgery are sparse, limiting health professionals ability to appropriately counsel patients. Future work needs to standardize outcome assessment for orgasmic disorders, which, in turn, can be used across all surgical specialties. Haney NM, Alzweri LM, Hellstrom WJG. Male Orgasmic Dysfunction Post-Radical Pelvic Surgery. Sex Med Rev 2018;6:429-437.