Nikhil Gupta

Penile Doppler Ultrasound Predicting Cardiovascular Disease in Men with Erectile Dysfunction

Cardiovascular disease is a major cause of morbidity and mortality in the USA. Traditional risk factors such as obesity, physical inactivity, and diet are used to screen for cardiovascular disease. However, these risk factors miss a significant population who are at risk for future cardiac events. Erectile dysfunction (ED) has many associated conditions in common with cardiovascular disease and has been shown to be an independent risk factor for cardiovascular. Measurements made on penile Doppler ultrasound (PDU), such as cavernosal artery peak systolic velocity (PSV), cavernosal artery intima-medial thickness, and the finding of cavernosal artery calcification, are indicators of generalized vascular disease. Thus, elements of PDU can identify men at higher risk for cardiovascular disease. This review outlines the proper technique for PDU and the literature supporting the use of PDU to predict cardiovascular disease in men with erectile dysfunction.

The penoscrotal surgical approach for inflatable penile prosthesis placement

Optimizing outcomes with placement of inflatable penile prostheses (IPPs) can be challenging, especially in inexperienced hands. In this article, we outline Dr. Köhler’s penoscrotal penile prosthesis surgical approach. We also highlight patient selection, post-operative care and complications.

Contemporary management of ureteral strictures

Ureteral stricture disease is a luminal narrowing of the ureter leading to functional obstruction of the kidney. Treatment of strictures is mandatory to preserve and protect renal function. In recent times, the surgical management of ureteral strictures has evolved from open repair to include laparoscopic, robotic and interventional techniques. Prompt diagnosis and early first line intervention to limit obstructive complications remains the cornerstone of successful treatment. In this article, we discuss minimally invasive, endo-urological and open approaches to the repair of ureteral strictures. Open surgical repair and endoscopic techniques have traditionally been employed with varying degrees of success. The advent of laparoscopic and robotic approaches has reduced morbidity, improved cosmesis and shortened recovery time, with results that are beginning to mirror and in some cases surpass more traditional approaches. Level of evidence: Not applicable for this multicentre audit.

MP35-03 SEX HORMONE BINDING GLOBULIN INDEPENDENTLY PREDICTS OLIGOSPERMIA IN MALE FERTILITY PATIENTS

INTRODUCTION AND OBJECTIVES: We previously reported that due to the inherent variability of SHBG, clinical hypogonadism is over/under-diagnosed in 20% of patients. We further analyzed the data between classically hypogonadal men (G1 total testosterone (TT) < 300) and those men who were “missed” but were hypogonadal using calculated bioavailable testosterone (cBT < 210) with the use of SHBG (G2). We analyzed the role of SHBG in the routine testing of male factor infertility by analyzing the relationship of TT and BT to common infertility parameters. METHODS: Retrospective review of 168 males seen in a fertility clinic from 2012-2014, to investigate the accuracy of TT in the biochemical diagnosis of hypogonadism using cBT as the reference value. The relationship between TT and other infertility parameters were calculated using nonparametric Spearman correlations. We compared semen parameters between G1 and G2 in men with and without azoospermia. We utilized a multivariable sub-analysis with linear regression with backward elimination of non-significant variables. The possible predictors in the model included age, TT, varicocele, FSH, and SHBG. RESULTS: Using Spearman correlations, SHBG independently predicted lower semen parameters by a similar magnitude as FSH for sperm concentration (r1⁄4 -0.24, p 1⁄4 0.0027) and motility (r1⁄4 -.16, p1⁄4.0447). Semen parameters were available for 76 men who met criteria for G1 and 46 for G2. Only SHBG levels differed significantly upon initial group comparision (p1⁄4.0001). After excluding men with azoospermia, G1 had 62 and G2 had 45 men respectively. SHBG remained significant (P1⁄4.0001) and sperm motility (p 1⁄4 .057) and sperm concentration (p1⁄4.09) approached significance. Using a more stringent cutoff for G2 (T<156) sperm motility was significantly different in G1 and G2 (p1⁄4.014). Linear regression to predict sperm motility and concentration eliminated age, TT, and varicocele from the model e leaving just FSH and SHBG. When predicting sperm motility, SHBG was no longer statistically significant (p1⁄4.0973) when FSH (p1⁄40.0231) was in the model. For sperm concentration, SHBG was significant (p1⁄40.0186) when FSH (p1⁄40.0079) was in the model. CONCLUSIONS: Our data demonstrates the utility of SHBG in the initial hormonal evaluation of males seen in a fertility clinic. The addition of SHBG to TT serum testing facilitates more accurate diagnosis with FT and cBT, as SHBG was the only significant parameter able to distinguish between true hypogonadal and eugonadal patients. In addition, elevated SHBG levels independently predicted decreased sperm motility and sperm concentration.

PNFBA-01 CONVECTIVE RADIOFREQUENCY WATER VAPOR ENERGY ABLATION (REZUM®) EFFECTIVELY TREATS LOWER URINARY TRACT SYMPTOMS DUE TO BENIGN PROSTATIC ENLARGEMENT REGARDLESS OF OBESITY WHILE PRESERVING ERECTILE AND EJACULATORY FUNCTION

INTRODUCTION AND OBJECTIVES: To assess the impact of convective RF water vapor thermal therapy (WaVE) to treat LUTS due to BPE (LUTS/BPE) on subjective and objective voiding and sexual function parameters and to compare results between obese (BMI > 30) and non-obese subjects. METHODS: Men 50 years old with IPSS 13, peak flow rate (Qmax) between 5 and 15 mL/s, and prostate size 30 to 80cc were randomized 2:1 between WaVE and sham procedure with cystoscopy and simulated treatment sounds. Blinded comparison was done at 3 months and the treatment arm was followed for 12 months for IPSS, Qmax, and sexual function via IIEF-15 and Male Sexual Health Questionnaire for Ejaculatory Function (MSHQ-EjF). Percentage of subjects who achieved minimal clinically important difference in erectile function perceived by subjects as beneficial (MCID) was determined. Treatment outcomes for obese and non-obese subjects were compared. RESULTS: 197 men were randomized, 136 in WaVE group, 61 in sham group. WaVE group and control group IPSS reduced by 11.2 and 4.3 at 3 months (p<0.0001). WaVE group IPSS decreased by 50% or greater at 3, 6, and 12 months (p<0.0001). Peak flow rate in WaVE group increased by 6.2 mL/s at 3 months and sustained through 12 months (p<0.0001). 42 treatment subjects had a median lobe, 30 had the median lobe treated with similar outcomes to treated subjects without median lobes. Obese subjects had similar improvement in IPSS as compared to non-obese subjects, including both storage and voiding domains. IIEF-15 and MSHQ-EjF scores were not different between WaVE or control groups at 3 months and were not different in WaVE group from baseline at 12 months. Ejaculatory bother improved 31% in WaVE group over baseline (p1⁄40.0011). 32% of subjects in WaVE group achieved MCID at 3 months and 27% at 1 year, in all ED categories. Obese subjects were more likely to have severe ED but experienced similar rate of MCID and improvement in ejaculatory bother as nonobese subjects. Adverse effects included hematuria, irritative voiding symptoms, hematospermia, and UTI and all resolved within 3 weeks. There were no serious adverse effects. Decreased ejaculatory volume occurred in 6 men and anejaculation was reported by 4 men. CONCLUSIONS: Convective RF water vapor thermal therapy provides a rapid and sustainable improvement in LUTS/BPE through 1 year, can be applied to all zones including the median lobe, and preserves erectile and ejaculatory function. Results are similar for both obese and non-obese subjects.

MP27-20 CONVECTIVE RADIOFREQUENCY WATER VAPOR ENERGY PROSTATE ABLATION (REZUM®) EFFECTIVELY TREATS URINARY RETENTION

INTRODUCTION AND OBJECTIVES: New minimally invasive surgical therapies (MIST) for lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) such as prostatic urethral lift and convective radiofrequency water vapor energy prostate ablation (WaVE) have shown promising intermediate-term results in improving voiding symptoms. However, the initial trials excluded men in urinary retention; thus the ability of these new technologies to achieve catheter independence has not been evaluated. This study investigated outcomes of patients with urinary retention at baseline treated with WaVE. METHODS: Patients in urinary retention who underwent WaVE were retrospectively identified. Urinary retention was defined as dependence on an indwelling catheter or performance of clean intermittent catheterization (CIC) for bladder emptying. Age, duration of catheter dependence, prostate size, baseline IPSS and PVR, and number of treatments per procedure were recorded. For subjects with successful trials without catheter (TWOC), time to catheter independence and post-procedure PVR and IPSS were recorded. Baseline characteristics between subjects with successful TWOC and unsuccessful TWOC were compared using Mann Whitney U test and T-test for continuous variables and Chi-square test and Fisher0s exact test for non-continuous variables. RESULTS: 30 patients were identified with urinary retention who underwent WaVE. 22 subjects had an indwelling catheter, 8 subjects performed clean intermittent catheterization (CIC). Mean age was 76 years. Relevant baseline measures included (mean): duration of catheter dependence (6.9mo), prostate size (64.3 ml), PVR (538 mL), and number of treatments per procedure (6.4). 28/30 subjects had middle lobe treatment (1 treatment per procedure). 23 of 30 subjects (77%) achieved successful TWOC post-procedure. Mean time to catheter independence was 29 days post-procedure with mean post-procedure PVR 84 mL and post-procedure IPSS 9. There were no differences between subjects with or without successful TWOC in age, duration of catheter dependence, prostate size, baseline PVR, baseline IPSS, number of treatments per procedure, or treatment of median lobe. CONCLUSIONS: WaVE can effectively treat patients with urinary retention and successfully render patients catheter independent, including patients with a median lobe. Longer-term follow up is necessary to evaluate the durability of this technology.

MP56-09 INTERMEDIATE OUTCOMES OF CONCURRENT TACHOSIL GRAFTING WITH INFLATABLE PENILE PROSTHESIS PLACEMENT

INTRODUCTION AND OBJECTIVES: Intralesional (IL) injection of CCH is the first FDA approved pharmacotherapy for the treatment of men with PD. This analysis was conducted to define the outcome of IL CCH in our program. METHODS: Study population included men with PD, had stable disease for >3 months, met the other label criteria and underwent IL CCH. Men received up to 8 injections of CCH divided into 4 treatment cycles. Curvature assessments were done at baseline, between cycles 2 and 3 and after cycle 4. Traction therapy was used as our modeling technique to standardize the mechanical therapy. Patient demographics, PD factors and IL CCH complications were recorded. Multivariable analysis (MVA) was used to explore predictors of improvement. Two definitions were used: >10 and >25% improvement. RESULTS: To date, 69 subjects have completed baseline and the mid-treatment assessments (mean age1⁄455 10 years). 25 of these subjects also completed the end of treatment assessment. As baseline, the mean duration of PD was 20.5 20 months. 62% had dorsal curvature, 18% had an hourglass deformity, and 6% had tapering. Mean curvature was 44 20 , and decreased at mid-treatment to 40 20 (p1⁄40.01). For the 25 men who completed the end of treatment assessment, their baseline curvature was 49 23 , and decreased at end of treatment to 44 23 (p1⁄40.12). Three categories of curvature change were created: 00improvement00 (>10 ); 00no change00 ( 10 change), and 00worsened00 (>10 ). After 4 IL CCH injections: 33% improved, 54% had no change, and 13% worsened. After 8 IL CCH injections: 36% improved, 48% no change, and 15% worsened. On univariable analysis, only degree of baseline curvature (r1⁄40.4, p1⁄40.01) was positively correlated to improvement. On multivariable analysis, predicting improvement, baseline curvature remained the only significant predictor of improvement (OR1⁄41.04; 95% CI 1.01-1.07, p1⁄40.04). For improvement defined as >25%, after 4 IL CCH injections, 32% improved and after 8 48% improved. While clinically significant, this difference (between 4 and 8 injections) did not reach statistical significance (p1⁄40.21). There were no significant predictors of improvement of >25% at mid-treatment assessment in either univariable or multivariable analyses. CONCLUSIONS: These data reflect our clinical experience, which is quite different to those presented in the IMPRESS trials. Approximately one third of men significantly improve their penile curvature and it appears that maximum response occurs after 4 injections of CCH.