Manaf Alom

The Temporal Association of Robotic Surgical Diffusion with Overtreatment of the Small Renal Mass

Purpose We evaluated contemporary practice patterns in the management of small renal masses. Materials and Methods We identified 52,804 patients in the NCDB (National Cancer Database) who were diagnosed with a small renal mass (4 cm or less) between 2010 and 2014. Utilization trends of active surveillance, ablation and robotic, laparoscopic and open surgical techniques were compared among all comers, elderly patients 75 years old or older and individuals with competing health risks, defined as a Charlson index of 2 or greater. Multivariable logistic regression models were used to assess factors associated with robotic renal surgery and active surveillance. Results Surgery remained the primary treatment modality across all years studied, performed in 75.0% and 74.2% of cases in 2010 and 2014, respectively. Although increases in active surveillance from 4.8% in 2010 to 6.0% in 2014 (p <0.001) and robotic renal surgery (22.1% in 2010 to 39.7% in 2014, p <0.001) were observed, the increase in the proportion of small renal masses treated with robotic partial and radical nephrectomy was greater than that of active surveillance (82.0% and 63.0%, respectively, vs 25.0%). Subgroup analyses in individuals 75 years old or older, or with a Charlson index of 2 or greater likewise revealed preferential increases in robotic surgery vs active surveillance. On multivariable analysis later year of diagnosis was associated with increased performance of robotic renal surgery compared to active surveillance (2014 vs 2010 OR 1.44, 95% CI 1.20–1.72, p <0.001) and nonrobotic procedural interventions (2014 vs 2010 OR 2.59, 95% CI 2.30–2.93, p <0.001). Conclusions Robotic surgical extirpation has outpaced the adoption of active surveillance of small renal masses. This raises concern that the diffusion of robotic technology propagates overtreatment, particularly among elderly and comorbid individuals.

Emerging complications following alternative reservoir placement during inflatable penile prosthesis placement: a 5-year multi-institutional experience.

Purpose: Alternative or ectopic reservoir placement has recently gained popularity among prosthetic surgeons to avoid injury to pelvic structures during inflatable penile prosthesis implantation. However, the true incidence of complications associated with these new techniques remains under studied. We performed a 5-year multicenter, retrospective study with the aim of evaluating complications related to alternative reservoir placement. Materials and Methods: We retrospectively reviewed the database of inflatable penile prosthesis surgery at 3 institutions from February 2011 to December 2016. The mechanism of failure and complications related to reservoir placement were analyzed. Results: A total of 974 inflatable penile prostheses were placed in the 5-year period by 3 surgeons, including 612 surgeries with alternative reservoir placement. Mean followup to the emergence of reservoir related complications was 20.4 months. There was no significant difference in complication rates between primary and revision cases (p = 0.72). A total of 12 cases (2.0%) required revision for reservoir related complications in the alternative reservoir placement group vs 1.3% in the space of Retzius group (p = 0.44). The most common complication in the alternative reservoir placement group was reservoir leakage, which developed in 5 patients. Three cases required revision due to abdominal muscular pain. Torsion in the tubing of 3 Conceal™ reservoirs was found which caused blockage of fluid transportation. One reservoir was incidentally found to be intraperitoneal on unrelated imaging. Conclusions: Alternative reservoir placement is a safe and mechanically reliable approach, including in men with prior pelvic surgery. However, there are associated risks, including reservoir leakage, tubing torsion, muscle discomfort and unintended reservoir malposition which may require surgical revision.

Modified Glanulopexy Technique for Supersonic Transporter Deformity and Glanular Hypermobility in Men With Penile Prostheses

BACKGROUNDnGlanular hypermobility (GH) or supersonic transporter (SST) deformity are occasionally encountered during penile prosthesis (PP) implantation, yet management strategies are underreported with minimal data available on surgical outcomes.nnnAIMnTo describe a modified technique for glanulopexy to correct GH/SST in men undergoing PP placement and assess outcomes associated with this technique.nnnMETHODSnGlanulopexy was performed in men with GH/SST identified at the time of or following PP placement. A modification to previously described techniques was performed, whereby a suture is passed into the glans and secured to the tissue overlying the corpora through small incisions on the lateral aspects of the distal penile shaft.nnnOUTCOMESnCorrection of the anatomic deformity (GH/SST), device infection, and changes in penile sensation were evaluated during post-operative follow-up.nnnRESULTSnFrom 2014-2017, a total of 12 patients underwent modified glanulopexy for GH/SST. Nine (75%) were performed at the time of PP, while the remaining 3 were performed in a delayed fashion. At a median follow-up of 12 months (range 1-33 months), all patients with the device in situ demonstrated appropriate glanular positioning, and no patients reported changes in penile sensation. A single patient required device removal secondary to infection.nnnCLINICAL TRANSLATIONnGlanulopexy with permanent suture successfully corrects severe GH or SST in men with inflatable PP without reduced penile sensation.nnnCONCLUSIONSnStrengths of the current study include the description of a simple, safe, and reproducible technique for GH/SST that adds minimal operative time and can be performed under local anesthesia when necessary. To our knowledge, this represents one of the largest reported series of glanulopexy outcomes reported in the literature. Limitations include that this is a single-surgeon series, there is limited follow-up, and lack of a comparison group. Further study with external validation is warranted to establish the optimal role for the procedure. Ziegelmann MJ, Alom M, Bole R, etxa0al. Modified Glanulopexy Technique for Supersonic Transporter Deformity and Glanular Hypermobility in Men With Penile Prostheses. J Sex Med 2018;15:914-919.

Penile Traction Therapy and Vacuum Erection Devices in Peyronie's Disease

INTRODUCTIONnPeyronies disease (PD) has historically been managed by at least 1 treatment, including oral supplements or medications, intralesional injections, or surgery. Adjunctive mechanical therapies also have been described, including penile traction therapy (PTT) and vacuum erection devices (VEDs), although relatively limited data are available on their use with PD.nnnAIMnTo review and summarize the published literature on the role and efficacy of PTT and VED in men with PD.nnnMETHODSnA PubMed search was performed of all publications on PTT and VED in men with PD from inception through Septemberxa02017.nnnMAIN OUTCOME MEASURESnChanges in penile curvature, length, girth, erectile function, and adverse events with PTT or VED.nnnRESULTSnPTT and VED exhibit mechanisms to improve aspects of PD, although clinical outcomes data are limited. Based on current data, PTT likely has a potential role as a primary lengthening therapy (modest improvements), in curvature correction (acute phase; unclear role in chronic phase), before penile prosthesis insertion, and after surgical correction of PD. The role of PTT as a combination therapy during collagenase Clostridium histolyticum injections is unclear. Fewer and lower level-of-evidence studies are available on VEDs and suggest potential roles in curvature correction, before penile prosthesis placement, or after PD surgery. Guideline statements from the American Urological Association and International Consultation on Sexual Medicine also support the potential role of PTT and VED in managing PD.nnnCONCLUSIONSnPTT and VED represent viable therapeutic options for managing PD, with more data currently available on PTT. Because all PTT studies used a similar style of traction device, it is unclear whether results reflect outcomes of these particular devices or traction more broadly. Further studies are required to better delineate the benefits of PTT and VED, particularly in relation to other established treatments. Avant RA, Ziegelman M, Nehra A, etxa0al. Penile Traction Therapy and Vacuum Erection Devices in Peyronies Disease. Sex Med Rev 2019;7:338-348.

The Impact of Lifestyle Factors on Male Reproduction: Body Composition, Diet, Exercise, and Recreational Drug Use

Abstract The prevalence of male infertility, particularly in the context of decreasing semen quality and sperm concentration, is being reported throughout many countries and has emerged as a matter of increasing concern. In some cases causation can be easily established; however, in the majority of cases, the etiology remains unknown. More recently there has been an escalation of interest in societal changes, particularly those relating to chronic rather than acute exposure to chemicals through both direct and indirect methods, and how they may be impacting male fertility either in isolation or cumulatively. Although some of these changes are of a permanent nature, many are modifiable and concern themselves with exposure primarily through diet and recreational drug use. Additionally, there are existing lifestyle correlations between male subfertility and infertility and a corresponding rise in obesity, which often coexist with a sedentary lifestyle or general lack of exercise. In this chapter, we explore how lifestyle factors, including chronic exposures to select agents, directly impact male infertility. Where available, the impact of lifestyle modification on improving male sub/infertility is also reviewed, with emphasis on higher levels of evidence when available.

Implementation of multiparametric magnetic resonance imaging technology for evaluation of patients with suspicion for prostate cancer in the clinical practice setting

To investigate the impact of implementing magnetic resonance imaging (MRI) and ultrasonography fusion technology on biopsy and prostate cancer (PCa) detection rates in men presenting with clinical suspicion for PCa in the clinical practice setting.