Mary K. Powers

Outcomes of Intralesional Interferon-α2B for the Treatment of Peyronie Disease

PURPOSE We evaluated the efficacy of intralesional interferon-α2b for Peyronie disease, reviewed the impact of the timing of therapy from disease onset and identified variables predictive of a response. MATERIALS AND METHODS We retrospectively reviewed the charts of patients treated with intralesional interferon-α2b from 2001 to 2012. Demographic information, disease characteristics, pretreatment and posttreatment penile duplex ultrasound findings, and objective measures were analyzed. Response was defined as a 20% or greater improvement in curvature. Statistical analysis was done to identify significant changes in variables and identify predictive factors. RESULTS A total of 127 patients with a mean age of 55 years (range 25 to 76) and a mean±SD pretreatment curvature of 42.4±18.6 degrees underwent a median of 12 biweekly interferon-α2b injections (range 6 to 24). The median history of Peyronie disease was 2.0 years (range 0.5 to 23). Of the patients 54% responded to therapy with an overall mean improvement of 9.0 degrees (p<0.001). Patients with less than 30-degree curvature were most likely to experience a 20% or greater improvement with interferon-α2b (86% response, p<0.001). However, similar overall improvement in pretreatment curvature was noted in all cases. No statistically significant improvement was observed in penile vascular status or ultrasound parameters. The duration of Peyronie disease did not impact the change in curvature. Age, pretreatment curvature, vascular status, penile ultrasound findings, curvature site and International Index of Erectile Function (IIEF) score did not predict the response to therapy. CONCLUSIONS Intralesional therapy with interferon-α2b resulted in significantly improved curvature without impacting penile vascular parameters. The absolute improvement in curvature was independent of pretreatment curvature or Peyronie disease duration.

Three-dimensional printing of surgical anatomy.

Purpose of review Over the past decade, three-dimensional printing for the medical field has been expanding rapidly throughout all of medicine. This manuscript reviews the current and potential applications for three-dimensional printing, including education, presurgical planning, surgical simulation, bioprinting, and printed surgical equipment. Recent findings Three-dimensional printing has proved most relevant in the fields of craniofacial, plastic, orthopedics, and especially, urologic surgery. This review focuses on several examples of how three-dimensional printing can be utilized, with emphasis on renal models for renal cell carcinoma, ureteral stents, and staghorn calculus. From an education standpoint, both patients and residents can benefit from the use of three-dimensional printed models, and even skilled surgeons report better understanding of complex procedures by using printed models. Summary Three-dimensional printing in the field of medicine is growing quickly, and will soon be incorporated into the way residents are taught and patients are educated. For surgical simulation in a variety of disease processes, this will be particularly useful for urologic surgery.

Trends in Toilet Training and Voiding Habits among Children with Down Syndrome.

PURPOSE Children with Down syndrome are at risk for lower urinary tract dysfunction and delayed toilet training. Comparative studies regarding voiding function in the Down syndrome population are lacking. We assessed urinary continence and voiding function in patients with Down syndrome and a control group. MATERIALS AND METHODS A questionnaire designed to assess toilet training, continence status, symptoms of lower urinary tract dysfunction and prior evaluation of urological complaints was sent to parents of 326 children with Down syndrome who had been seen at our institution previously. The same survey was administered to parents of patients without Down syndrome. Data were compiled, and descriptive and comparative statistical analyses were performed. RESULTS A total of 77 patients comprised the Down syndrome group and 78 patients without Down syndrome comprised the control group. Average age of reported toilet training completion was 5.5 years in children with Down syndrome and 2.2 years in controls. Of children 5 years or older 79% with Down syndrome were toilet trained, compared to 100% of those without Down syndrome. Incontinence was reported in 46% of previously toilet trained children with Down syndrome and 24.5% of controls. These findings were statistically significant. No significant difference was observed in the rate of urinary tract infection, symptoms of lower urinary tract dysfunction or evaluation for urological complaints. CONCLUSIONS Children with Down syndrome can experience marked delay in toilet training and are more likely to suffer incontinence afterward. This study was ineffective in determining whether symptoms of lower urinary tract dysfunction could be related to decreased continence rates.

Contemporary Review of Artificial Urinary Sphincters for Male Stress Urinary Incontinence

INTRODUCTION The most common cause of urinary incontinence in men after radical prostatectomy is intrinsic sphincter deficiency, which can affect long-term quality of life. The prevalence of stress urinary incontinence (SUI) after radical prostatectomy has been reported to be 2.5% to 90%. For patients with moderate to severe male SUI, the artificial urinary sphincter (AUS) is considered the gold standard in surgical treatment. AIM To review the available literature on the development, patient selection, surgical technique, complications, and management of AUS for male SUI. METHODS A literature review was performed through PubMed from 1947 to 2015 regarding AUS for male SUI. MAIN OUTCOME MEASURES To assess various surgical techniques related to AUS insertion, outcomes, and complications and to offer recommendations regarding management of complications. RESULTS The AUS can be placed through a perineal or trans-scrotal incision, particularly in the setting of dual insertion of an AUS and an inflatable penile prosthesis. The most commonly used cuff is 4.0 cm. The efficacy of InhibiZone is debatable. Pressure-regulating balloons can be filled with saline or contrast material and can be placed in an orthotopic or an ectopic location. In a systematic review of the literature, dry or improved continence rates are achieved in 79% of patients, with 90% reporting satisfaction and improved quality-of-life index scores after surgery. The most common AUS complications include a nonfunctioning device, sub-cuff atrophy, erosion, and infection. These complications are managed by strategies such as cuff downsizing, tandem cuff placement, and explantation. Dual AUS and inflatable penile prosthesis insertion is feasible for patients with SUI and erectile dysfunction. CONCLUSION The AUS is a durable and effective device for the management of SUI. Surgeons should be versed in the different device components, their potential complications, and their management.

Current and emerging treatment options for Peyronie's disease

Peyronie’s disease (PD) is a condition of the penis, characterized by the presence of localized fibrotic plaque in the tunica albuginea. PD is not an uncommon disorder, with recent epidemiologic studies documenting a prevalence of 3–9% of adult men affected. The actual prevalence of PD may be even higher. It is often associated with penile pain, anatomical deformities in the erect penis, and difficulty with intromission. As the definitive pathophysiology of PD has not been completely elucidated, further basic research is required to make progress in the understanding of this enigmatic condition. Similarly, research on effective therapies is limited. Currently, nonsurgical treatments are used for those men who are in the acute stage of PD, whereas surgical options are reserved for men with established PD who cannot successfully penetrate. Intralesional treatments are growing in clinical popularity as a minimally invasive approach in the initial treatment of PD. A surgical approach should be considered when men with PD do not respond to conservative, medical, or minimally invasive therapies for approximately 1 year and cannot have satisfactory sexual intercourse. As scientific breakthroughs in the understanding of the mechanisms of this disease process evolve, novel treatments for the many men suffering with PD are anticipated.

Collagenase Clostridium histolyticum for the pharmacological management of Peyronie's disease.

Peyronies disease (PD) is defined as the abnormal accumulation of connective tissue in the tunica albuginea of the penis, and is an ongoing physical and psychological challenge for thousands of Americans. In vitro studies in the 1950s uncovered the potential of collagenase Clostridium histolyticum (CCH) to disrupt the collagen-containing plaques in PD, and opened the door to more in-depth clinical trials. Results indicated that with multiple dosage cycles followed by plaque modeling, penile curvature can be corrected, on average, in up to 35% of cases, with the majority of patients achieving ≥ 25% improvement in penile curvature. Most studies also indicated an improvement in patient-reported symptoms from the Peyronies Disease Questionnaire. Adverse events from treatment with CCH included penile bruising, pain and edema, but most were mild to moderate in severity and usually resolved without intervention, suggesting that CCH is an effective and safe treatment for PD.

Penile Priapism, Clitoral Priapism, and Persistent Genital Arousal Disorder: A Contemporary Review

INTRODUCTION Priapism is a persistent erection that arises from a dysfunction of the normal regulatory mechanisms of penile tumescence, rigidity, and flaccidity. It is defined as an erection lasting longer than 6 hours that is not related to sexual stimulation. There are three types of priapism: ischemic, non-ischemic, and stuttering. Similarly, clitoral priapism may occur in females manifested by symptoms such as engorgement with pain and swelling of the clitoris and surrounding tissue. Persistent genital arousal disorder (PGAD) is uncontrollable genital arousal in females, with or without orgasms, that occurs spontaneously and without any sexual feelings. AIM The aim of this article is to review the available literature on priapism, clitoral priapism, and PGAD. METHODS A literature review was performed through PubMed regarding priapism, clitoral priapism, and PGAD. MAIN OUTCOME MEASURES The main outcome is an assessment of the potential etiologies, pathophysiology, diagnostic tools, and management options (medical and surgical) for these conditions. RESULTS Initial workup of priapism should include a thorough history, physical examination, and cavernous arterial blood gas measurement. Findings should guide further management depending on the etiology of priapism (ischemic vs. non-ischemic). For ischemic priapism, a widely used therapeutic algorithm has been described. For patients with stuttering priapism, multiple oral therapies are currently available. Most reported cases of clitoral priapism appear to be drug-induced, and the primary treatment is stopping the offending agent. Medications like phenylpropanolamine and phenylephrine can also be utilized. PGAD may be associated with anatomical abnormalities, such as Tarlov cysts for which an epidural anesthesia block may be considered. CONCLUSIONS Early recognition and diagnosis of priapism is paramount to preserving erectile function. Current treatment regimens for ischemic priapism have room for innovation in both pharmacological and surgical therapies. Further investigation into the etiologies and treatment options for clitoral priapism and PGAD are required. Yafi FA, April D, Powers MK, Sangkum P, and Hellstrom WJG. Penile priapism, clitoral priapism, and persistent genital arousal disorder: A contemporary review. Sex Med Rev 2015;3:145-159.

Neoadjuvant Tyrosine Kinase Downstaging of T2 Renal Cell Carcinoma in Solitary Kidney Before Robotic Partial Nephrectomy

Abstract We highlight the use of a tyrosine kinase inhibitor, pazopanib, for neoadjuvant downstaging a 7.4 cm right biopsy-proven clear cell renal-cell carcinoma in a solitary kidney before surgical intervention of robotic partial nephrectomy with retrograde cooling to induce cold ischemia in a 79-year-old male.