Matthew J. Pagano

Variation in Penile Hemodynamics by Anatomic Location of Cavernosal Artery Imaging in Penile Duplex Doppler Ultrasound

INTRODUCTION Standard operating procedures (SOP) for penile duplex Doppler ultrasound (PDDU) were published in 2013 to promote uniform vascular assessment for erectile dysfunction (ED). However, SOPs do not specify a standard anatomic location for cavernosal artery (CA) imaging. AIM The aim of this study was to determine the effects of CA imaging location on measured penile hemodynamics assessed by PDDU. METHODS PDDU was performed in men with ED and/or Peyronies disease. CA peak systolic velocity (PSV) and end diastolic velocity (EDV) were measured at three points: the origin of the CA within the penile crus, the proximal CA, and mid-CA. Differences in PSV and EDV were assessed by Friedman test and categorical vascular outcomes by Fishers exact test. Data were analyzed for the main cohort, the subgroup with maximal smooth muscle relaxation (SMR) as defined by negative EDV, and the subgroup with valid-for-intromission erections. MAIN OUTCOME MEASURES Mean PSV and EDV at three specified CA locations and the vascular diagnoses resulting from these measurements. RESULTS One hundred four CAs were imaged in 52 men. Mean PSVs at the crus, proximal, and mid-CA were 52.9 ± 20.2, 29.5 ± 15.1, and 21.6 ± 10.6 cm/s, respectively (P < 0.0001); mean EDVs were 2.1 ± 8.9, 3.2 ± 5.4, and 3.3 ± 3.5 cm/s, respectively (P = 0.1225). The distribution of arteriogenic (P < 0.0001) and venogenic (P < 0.0001) diagnoses both differed significantly by location. Significant differences in vasculogenic diagnoses were also observed in the subgroup of CAs with definite maximal SMR (n = 38, arteriogenic P < 0.0001, venogenic P = 0.007) and in those with valid-for-intromission erections (n = 68, arteriogenic P < 0.0001, venogenic P = 0.0002). CONCLUSION There is large variability in measured PSV and EDV on PDDU depending on the site of Doppler imaging, which can often sway clinical diagnosis. Future guidelines should attempt to incorporate standard locations of CA imaging, and new normative values may be necessary for each location.

Lengthening strategies for Peyronie’s disease

Loss of penile length is a common complaint of men with Peyronie’s disease (PD), both before and after corrective intervention, which has a significant negative effect on patient quality of life. We sought to identify and describe the methods by which penile length can be preserved or increased. We conducted an extensive, systematic literature review, based on a search of the PUBMED database for articles published between 1990 and 2015. Articles with the key words “Peyronie’s disease”, “penile length” and/or “penile lengthening” were reviewed if they contained subjective or objective penile length outcomes. Only English-language articles that were related to PD and penile size were included. We found no evidence in the literature that medical therapy alone increases penile length. Classic inflatable penile prosthesis (IPP) placement, plication procedures, and the Nesbit procedure appear likely to maintain or decrease penile length. Plaque incision (PI) and grafting appears likely to maintain or increase penile length, but is complicated by risk of post-operative erectile dysfunction (ED). There are several surgical procedures performed concomitantly with IPP placement that may be suitable treatment options for men with comorbid ED, and consistently increase penile length with otherwise good outcomes concerning sexual function. These include the subcoronal penile prosthesis (scIPP), Egydio circumferential technique, the sliding technique, the modified sliding technique (MoST), and the multiple slice technique (MuST). In addition, adjuvant therapies such as penile traction therapy (PTT), post-operative inflation protocols, suspensory ligament relaxation, lipectomy, and adjuvant medical therapy for glans engorgement appear to increase subjective and/or objective penile length for men at high risk of decreased penile length after PD surgery. Considering the psychological burden of length loss in men with PD, providers with adequate volume and expertise should attempt, if possible, to maintain or increase penile length for men undergoing surgical intervention. There are several evidence-based, safe, and effective ways to increase penile length for these men and multiple emerging adjuvant therapies that may help ensure adequate length.

Predictors of biochemical recurrence in pT3b prostate cancer after radical prostatectomy without adjuvant radiotherapy

Men with pathologic evidence of seminal vesicle invasion (SVI) at radical prostatectomy (RP) have higher rates of biochemical recurrence (BCR) and mortality. Adjuvant radiotherapy (XRT) has been shown to increase freedom from BCR, but its impact on overall survival is controversial and it may represent overtreatment for some. The present study, therefore, sought to identify men with SVI at higher risk for BCR after RP in the absence of adjuvant XRT.

Osteoporosis and Low Bone Mineral Density in Men with Testosterone Deficiency Syndrome

INTRODUCTION Testosterone deficiency syndrome (TDS) is a risk factor for low bone mineral density (BMD) and osteoporosis. Knowledge of the relationship between TDS and bone health, as well as the practical aspects of how to diagnose and treat low BMD, is therefore of practical importance to sexual medicine practitioners. AIM The aim of this study was to review the physiologic basis and clinical evidence of the relationship between TDS and bone health; and to provide a practical, evidence-based algorithm for the diagnosis and management of low BMD in men with TDS. METHODS Method used was a review of relevant publications in PubMed. MAIN OUTCOME MEASURES Pathophysiology of low BMD in TDS, morbidity, and mortality of osteoporosis in men, association between TDS and osteoporosis, indications for dual X-ray absorptiometry (DXA) scanning in TDS, evidence for testosterone replacement therapy (TRT) in men with osteoporosis, treatment for osteoporosis in the setting of TDS. RESULTS Sex hormones play a pleomorphic role in maintenance of BMD. TDS is associated with increased risk of osteoporosis and osteopenia, both of which contribute to morbidity and mortality in men. DXA scanning is indicated in men older than 50 years with TDS, and in younger men with longstanding TDS. Men with TDS and osteoporosis should be treated with anti-osteoporotic agents and TRT should be highly considered. Men with osteopenia should be stratified by fracture risk. Those at high risk should be treated with anti-osteoporotic agents with strong consideration of TRT; while those at low risk should be strongly considered for TRT, which has a beneficial effect on BMD. CONCLUSION Low BMD is a prevalent and treatable cause of morbidity and mortality in men with TDS. Utilization of a practical, evidence-based approach to diagnosis and treatment of low BMD in men with TDS enables sexual medicine practitioners to make a meaningful impact on patient quality of life and longevity. Gaffney CD, Pagano MJ, Kuker AP, Stember DS, and Stahl PJ. Osteoporosis and low bone mineral density in men with testosterone deficiency syndrome.

Gender Differences in the Urology Residency Match—Does It Make a Difference?

OBJECTIVE To assess the differences between the male and female urology resident applicant pool. Urology is a competitive field with a selective match process. Women have historically been a minority in medicine. Although this has equalized, women continue to be underrepresented in urology. MATERIALS AND METHODS All application submitted through the Electronic Residency Application Service to the Columbia University Department of Urology for the 2015 and 2016 match were reviewed. The differences between the cohorts of matched female and male urology applicants were assessed. RESULTS Two hundred fifty-six students in 2015 and 259 students in 2016 submitted applications to Columbia and completed rank lists (60% of the national cohort in 2015 and 62% in 2016). We did find that the overall male applicant pool had a slightly lower number of honors (3 vs 2, P = .02) and higher United States Medical Licensing Examination (USMLE) step 1 score (238 vs 234, P <.001). The only other statistically significant difference between the matched male and female cohorts was the average number of urology subinternships (1.4 [0.9] for men vs 1.18 [0.8] for women, P = .04). CONCLUSION Overall matched male and female applicants appeared to have very similar qualifications. Men had a higher USMLE step 1 score and women had a higher average number of honors. These data support the finding that contemporary male and female residency candidates who matched in urology had comparable achievements, and the criteria for residency selection in both cohorts are similar.

MP56-15 BEYOND CURVATURE: PREVALENCE AND CHARACTERISTICS OF PENILE VOLUME LOSS DEFORMITIES IN MEN WITH PEYRONIE'S DISEASE

any significant difference in negative relationship effects based on penile curvature, calcification, hourglass deformity, or stretched penile length. CONCLUSIONS: Several patient-reported variables including penile shortening and partner pain with intercourse are associated with a higher-reported rate of negative impact on sexual relationships in patients with PD, while longer relationship durations may be protective.

Diagnostic yield of cystoscopy in the evaluation of recurrent urinary tract infection in women.

Due to a paucity of evidence‐based guidelines, anecdotal practice patterns often dictate clinical management of recurrent urinary tract infection (UTI) in women. Our aim was to identify pathologic findings of the urinary tract through cystoscopy and imaging in women with recurrent UTI, and to determine if specific risk factors are associated with a higher rate of abnormal findings.