Search

Introduction: Bilateral testicular tumors are very rare, accounting for 1%–5% of all testicular germ-cell tumors (TGCTs). The vast majority of primary bilateral TGCTs are metachronous, with synchronous tumors comprising approximately 0.5%–1% of all cases. Those occurring synchronously share mostly the same histological pattern, predominantly seminoma, with synchronous bilateral TGCTs (SBTGCTs) with discordant subtypes being extremely rare.Case presentation: We present the case of a 20-year-old male complaining of a palpable painless right testicular mass incidentally noticed during sexual intercourse. Ultrasonography (US) and magnetic resonance imaging (MRI) of the scrotum demonstrated bilateral testicular lesions, while staging with contrast-enhanced computed tomography (CT) exhibited normal findings. Right radical orchiectomy and left testis-sparing surgery (TSS) with concomitant onco-testicular sperm extraction (onco-TESE) were initially performed. Histology of the right testis revealed a mixed germ-cell tumor, consisting of seminoma and embryonal carcinoma, while that from the left testis disclosed embryonal carcinoma and intratubular germ-cell neoplasia unclassified (IGCNU) infiltrating the surgical margins. Hence, left orchiectomy was subsequently scheduled with histology unveiling IGCNU in the greatest part of the remaining testicular parenchyma. Following adjuvant chemotherapy, with bleomycin, etoposide, and cisplatin (BEP), the patient received testosterone replacement therapy and remained free of recurrence at an 18-month follow-up.Conclusion: This case highlights both the rarity of a bilateral testicular tumor’s synchronous appearance and its extremely infrequent discordant histopathology. A comprehensive review of the major series of SBTGCTs with discordant histology cited in the literature is additionally presented.

Background: Currently, there is no efficacious treatment method for chronic prostatitis type IIIb/chronic pelvic pain syndrome (CP/CPPS). Aim of the study was to investigate and compare the efficacy and safety of low-intensity shockwave therapy (LiST) vs. sham treatment in CP/CPPS patients. Methods: Patients with CP/CPPS diagnosis were randomized in this prospective, sham-controlled, double-blind study either to the active groups (Group B, C) who received 5000 shockwaves per session with energy flux density 0.1 mJ/mm2or to the sham group (Group A) who received 5000 shockwaves from a visually identical sham probe. All groups underwent six sessions (once/week). LiST effects on pain, micturition, quality of life (QoL), and erectile function were evaluated at 4, 12, and 24 weeks after treatment. The parameters were investigated using validated questionnaires. Uroflowmetry and post void residual calculation were performed at baseline and at 4- and 12-week FU visit. Prostate mpMRI and PSA measurement were performed at baseline and 12-week FU visit. Results: Overall, 45 men were randomized to the active (n= 30) and sham groups (n= 15). Regarding impact of LiST in National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) total, pain, and QoL subdomains scores a clear and persistent in all FU timepoints improvement was found compared to sham treatment. NIH-CPSI urinary subdomain, International Prostate Symptom Score [IPSS], PSA, and mpMRI-PIRADS scores did not differ between the two groups. The mean difference between the LiST and sham group in the change of the NIH-CPSI pain-domain score (Q1–4) from baseline to 12 weeks after final treatment which was 3.3 (95% CI, 1.8, 4.7). Perineal LiST was easy and safe to perform without anesthesia or any side-effects. Conclusions: LiST seems to be a safe and effective treatment option for CP/CPPS, considerably improving pain and quality of life. Lack of any side-effects, and the potential for repetition make LiST a promising treatment choice for CP/CPPS patients.

The impact of energy flux density (EFD) used on low-intensity shockwave therapy (LiST) for erectile dysfunction (ED) has not been explored. Our aim was to compare EFD 0.05 versus 0.10 mJ/mm2regarding efficacy and safety of 12-treatment sessions when applied two or three times per week. Ninety-seven patients with vasculogenic ED, PDE5 inhibitors users were randomized into four groups, to receive 12 LiST sessions. Group A (n= 24) : two sessions per week, EFD 0.05 mJ/mm2; Group B (n= 24): three sessions per week, EFD 0.05 mJ/mm2; Group C (n= 24): two sessions per week, EFD 0.10 mJ/mm2; Group D (n= 25): three sessions per week, EFD 0.10 mJ/mm2. International Index for Erectile Function—Erectile Function domain (IIEF-EF), Minimally clinical important differences (MCID), sexual encounter profile, and triplex ultrasonography parameters were used to asses erectile function. Eighty-nine patients completed the 6-month follow-up (FU). All four groups improved in mean IIEF-EF score, average SEP3 “Yes” response rates at 6-month FU visit compared with baseline (p< 0.001). MCID at 6-month FU visit was achieved in 82.6%, 77.3%, 87%, and 81% in Groups A, B, C, and D, respectively. Mean PSV (cm/s) at baseline versus 3-month FU visit were 30.32 versus 34.67 for Group A, 30.02 versus 35.02 for Group B, 30.2 versus 36.02, for Group C, 29.43 versus 34.3 for Group D (p< 0.01). There were no statistical significant differences in the change of all outcome measures assessing erectile function between different sessions frequency. A tendency for better efficacy using EFD 0.10 mJ/mm2was noticed, although it did not reach statistical significance. No treatment-related side‐effects were reported. This study lacks a sham-controlled arm. However, all patients were randomized to the four groups, and baseline characteristics were similar between the groups. Moreover, arterial insufficiency was confirmed among all patients by penile triplex ultrasonography. Conclusively, patients may benefit equally when sessions are applied either two or three per week. An EFD of 0.10 mJ/mm2could result in better outcomes, but further studies are needed to validate this observation.

To investigate possible effects of sildenafil on the cardiopulmonary responses during sexual intercourse we evaluated cardiopulmonary responses during exercise in a group of impotent patients.

A Nesbit or plication procedure for correcting penile deformities is associated with penile shortening, especially in patients with excessive curvature and/or rotation. On the other hand, grafting procedures are associated with poor postoperative results due to graft shrinkage and veno-occlusive dysfunction. To minimize penile shortening and preserve potency we describe a new surgical technique combining the Nesbit procedure with tunica albuginea free grafting. Long-term functional results and patient satisfaction are reported.

We present 7 cases of arterial high flow priapism and propose management algorithms for the condition.

The necessity for a thorough diagnostic evaluation for erectile dysfunction has been questioned after the availability of effective oral therapies. We determined the impact of the different diagnostic steps on the management strategy for erectile dysfunction.

Objectives:To characterize hemodynamically a functional/rigid erection and study the hypothesis that a positive intracavernosal injection test indicates normal arterial and corporeal veno-occlusive function. Methods:33 patients (mean age 39.5 ± 9 years), who developed rigid erection during pharmacocavernosometry, included in the present study. The presence of axial rigidity was determined at steady state equilibrium intracavernosal pressure, by absence of buckling to axial force of 1 kg, applied to the erect penis and sustained for ≥15 min. Arterial and veno-occlusive hemodynamic parameters were analyzed. Results:Flow-to-maintain at intracavernosal pressure 150 mm Hg and mean pressure decay values ranged between 0.5–13 ml/min and 5–85 mm Hg, respectively. Flow-to-maintain values >5 ml/min were noticed in 8 patients (24.24%), while pressure decay values >45 mm Hg in 13 patients (39.39%). Pharmacocavernosography revealed moderate opacification of venous structures in 7 cases (21.21%). Abnormal systemic-cavernosal systolic arterial pressure gradients in both cavernosal arteries were noticed in 9 patients (27.27%). All patients with flow-to-maintain values >5 ml/min had normal arterial function. Conclusions:A functional/rigid erectile response may coexist with arterial insufficiency or corporeal veno-occlusive dysfunction. Presence of normal or borderline arterial inflow may compensate minimal or moderate veno-occlusive dysfunction, resulting in a functional – but not normal – erection. Such information is critical when the intracavernosal injection test is used for diagnostic purposes.

Abstract: The subjective definition of impotence, the multifactorial origin of the disease and the lack of standarization of the diagnostic procedures has led to lack of universally accepted diagnostic algorithm for the evaluation of erectile dysfunction. The “Patient Profile-Oriented Algorithm”, a realistic approach for the diagnostic evaluation of the impotent male, which reflects the philosophy that “different impotent patients have different needs” is proposed in this paper. The algorithm is based on three major determinants: age, health status and patient special concerns. Patient profile 1, which accounts for the vast majority of impotent men, consists of: a) patients with documented neurogenic impotence, b) impotent patients with vascular risk factor exposure, c) older patients. The evaluation of such patients includes medical and sexual history, physical examination, laboratory testing and psychologic consultation and treatment options, intracavernosal injection of vasoactive agents, vacuum constrictor devices and penile prosthesis implantation. Patient profile 2 consists of: a) young impotent patients without vascular risk factors or other health status concerns, b) patients with special concerns who desire to know the etiology of their erectile dysfunction and c) physicians with special concerns who deem it necessary to know the etiology of their patients erectile dysfunction. For these patients, however, precise information of their erectile mechanism is needed to obtain a more accurate diagnosis of the etiology of their erectile insufficiency. Sophisticate neurologic and hemodynamic tests may therefore be included in their evaluation. The application of the patient profile-oriented algorithm for the diagnosis and treatment of impotence may result in the ability to individualize patient concerns and needs, to gain needed information and when needed, to perform testing that is comparable and reproducible.

During impotence evaluations a positive intracavernous injection test has been presumed to signify normal erectile hemodynamics. This premise was tested by obtaining hemodynamic data in 80 patients 17 to 65 years old with positive injection tests: patients achieved maximal circumference responses and equilibrium intracavernous pressures of 80mm. Hg or more (range 80 to 136) sustained for 30 minutes or longer. Corporeal veno-occlusive testing revealed that flow-to-maintain (0.5 to 3ml. per minute) and pressure decay (0 to 47mm. Hg) values as well as pharmaco-cavernosography findings (absent or minimal contrast medium in venous structures m 92% of the cases) were all consistent with low outflow erection states. Arterial testing revealed right and/or left cavernous systolic arterial blood pressures always at 80mm. Hg or more, consistent with a prerequisite cavernous artery pressure value for a positive injection test. Systemic-cavernous systolic arterial blood pressure gradients were 0 to 24mm. Hg, 25 to 34mm. Hg and 35mm. Hg or more in 47 (59%), 18 (22%) and 15 (19%) patients, respectively. Large systemic-cavernous pressure gradients suggested the presence of arterial occlusive disease. In 8 patients with positive injection tests and gradients of 35mm. Hg or more pharmaco-arteriography revealed hemodynamically significant arterial occlusions. In conclusion, hemodynamic data in selected patients with positive injection tests revealed low outflow erection states, threshold cavernous artery pressures and disparities in systemic-cavernous systolic pressure gradients that suggested arterial disease in 19% of the cases. The erectile response in a positive test is equal to or greater than a threshold response, not always the maximum response as determined by the systemic blood pressure. A positive intracavernous injection test did not necessarily signify normal erectile hemodynamics.

The quality of the anastomosed vessels berore vascular grafting has been shown to influence long-term patency rates in arterial reconstructive procedures. A study was designed to assess vascular graft quality during microvascular artery bypass procedures for impotence, correlate identified vasculopathy with the clinical history and gain insight into vascular pathophysiological mechanisms. A total of 194 donor or recipient vessel segments was biopsied m 111 patients with impotence who underwent microvascular artery bypass surgery during a 10-year period. A prospective histological grading system was used m a blinded randomized fashion. A preexisting vascular pathological condition was identified m 48% of the patients. Proliferative lesions above the internal elastic lamina with luminal stenosis were identified in 38 of 69 dorsal penile artery segments (55%) and 8 of 69 inferior epigastric artery segments (12%). Venous hypertrophy or sclerosis was observed in 13 of 56 deep dorsal vein segments (23%). Systemic atherosclerosis was likely the underlying pathophysiology of vascular disease in the inferior epigastric artery. Vasculopathy in the deep dorsal vein and the dorsal penile artery segments was probably related to the consequences of blunt trauma to the pelvis, perineum or penis, which was considered to occur following direct vessel wall injury with immediate or delayed vascular disease or indirect vessel wall injury secondary to proximal arterial occlusion and delayed distal vascular disease. Future studies are needed to investigate the relationship between preexisting graft vasculopathy in microvascular artery bypass surgery for impotence and long-term clinical success rates.

A retrospective multi-institutional study was performed to document and characterize the arterial vascular disease in the hypogastric-cavernous arterial bed and/or veno-occlusive dysfunction of the corpora cavernosa in patients with end stage renal disease. We evaluated 20 impotent patients (mean age 40 ± 9 years) with chronic renal failure using pharmaco-cavernosometry and pharmacocavernosography (4 also underwent pharmaco-arteriography). Patients were divided into groups based on the treatment (14 with renal transplantation and 6 with hemodialysis or peritoneal dialysis), as well as by history of vascular risk factors (16 with and 4 without risk factors). Of the patients 19 revealed abnormal intracavernous pressure responses to repeated intracavernous injections of vasoactive agents implying vascular disease of the penis. Cavernous artery occlusive disease was found in 78% of the patients. All patients who underwent arteriography had diffuse atherosclerotic disease of the distal penile arteries. Corporeal veno-occlusive dysfunction was found in 90% of the patients, of whom 60% had diffuse pan-cavernous leakage involving the dorsal, cavernous and crural veins, glans penis and corpus spongiosum. This renal failure-associated vascular disease of the penis was found to occur independently of the presence of known systemic atherosclerotic vascular risk factors. Patients who underwent early treatment of the uremia by renal transplantation had vasculogenic impotence only in the case of rejection of the renal transplant, suggesting that early renal transplantation may delay or prevent the development of the penile vasculopathy. The most likely pathophysiology of the vascular impairment includes renal failure-associated atherosclerosis, and renal failure-associated hypoxia changes of the contractile (smooth muscle) and structural (collagen/elastin) components of the erectile tissue. Strategies for future research and clinical therapies are suggested.

We provide current, normative data on the prevalence of impotence, and its physiological and psychosocial correlates in a general population using results from the Massachusetts Male Aging Study. The Massachusetts Male Aging Study was a community based, random sample observational survey of noninstitutionalized men 40 to 70 years old conducted from 1987 to 1989 in cities and towns near Boston, Massachusetts. Blood samples, physiological measures, socio-demographic variables, psychological indexes, and information on health status, medications, smoking and lifestyle were collected by trained interviewers in the subject’s home. A self-administered sexual activity questionnaire was used to characterize erectile potency.

Endothelial injury in a deep dorsal vein graft may result from thermal, ischemic or mechanical trauma during surgical preparation or following exposure to systemic blood pressures and flow. We removed a functioning in situ deep dorsal vein graft section 10 months after microvascular arterial bypass surgery due to glans hyperemia. This section was compared and contrasted histomorphologically with a preoperative deep dorsal vein section that was procured for routine histological examination before the arteriovenous anastomosis. Detailed examination of the vein graft tissues by light microscopy, computer morphometrics and immunological staining demonstrated no evidence of vascular pathology. In the normal, healthy deep dorsal vein graft exposure to systemic arterial blood pressures and flow for 10 months did not result in myointimal proliferative lesions. Such histological changes seem more likely to be attributable to endothelial injury following iatrogenic surgical trauma. In situ vein grafts offer the opportunity to use “no-touch” endothelium preserving vascular techniques. Use of these grafts may improve long-term clinical results in penile microvascular arterial bypass surgery for impotence as it has in other vascular beds.

Without Abstract:

We studied the reproducibility of nocturnal penile tumescence, rigidity evaluation criteria and the possible effects of sexual intercourse in young, healthy, potent male volunteers.

Abstract: Surgical treatment options for Peyronie’s disease include tunica shortening (Nesbit and plication) and grafting procedures. Tunica shortening procedures are associated with penile shortening. However, the amount of penile shortening is rarely significant for the patient. Although grafting procedures aim to prevent penile shortening, this may still be an issue due to the pathologic extent of Peyronie’s disease. Long-term postoperative erectile dysfunction is the major drawback. Many types of grafting material have been used, but only saphenous vein has gained certain acceptance. Grafting procedures must be restricted to patients with normal preoperative erectile status and excessive curvature. Nesbit or plication procedures may be associated with significant penile shortening. Grafting procedures are also indicated in cases of hourglass deformities, because they cannot be corrected by the Nesbit procedure. Nesbit wedge resection is still the gold standard for treating Peyronie’s disease.

IMPORTANCE: Combining 2 first-line treatments for erectile dysfunction (ED) or initiating other modalities in addition to a first-line therapy may produce beneficial outcomes. OBJECTIVE: To assess whether different ED combination therapies were associated with improved outcomes compared with first-line ED monotherapy in various subgroups of patients with ED. DATA SOURCES: Studies were identified through a systematic search in MEDLINE, Cochrane Library, and Scopus from inception of these databases to October 10, 2020. STUDY SELECTION: Randomized clinical trials or prospective interventional studies of the outcomes of combination therapy vs recommended monotherapy in men with ED were identified. Only comparative human studies, which evaluated the change from baseline of self-reported erectile function using validated questionnaires, that were published in any language were included. DATA EXTRACTION AND SYNTHESIS: Data extraction and synthesis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. MAIN OUTCOMES AND MEASURES: A meta-analysis was conducted that included randomized clinical trials that compared outcomes of combination therapy with phosphodiesterase type 5 (PDE5) inhibitors plus another agent vs PDE5 inhibitor monotherapy. Separate analyses were performed for the mean International Index of Erectile Function (IIEF) score change from baseline and the number of adverse events (AEs) by different treatment modalities and subgroups of patients. RESULTS: A total of 44 studies included 3853 men with a mean (SD) age of 55.8 (11.9) years. Combination therapy compared with monotherapy was associated with a mean IIEF score improvement of 1.76 points (95% CI, 1.27-2.24; I2?=?77%; 95% PI, -0.56 to 4.08). Adding daily tadalafil, low-intensity shockwave therapy, vacuum erectile device, folic acid, metformin hydrochloride, or angiotensin-converting enzyme inhibitors was associated with a significant IIEF score improvement, but each measure was based on only 1 study. Specifically, the weighted mean difference (WMD) in IIEF score was 1.70 (95% CI, 0.79-2.61) for the addition of daily tadalafil, 3.50 (95% CI, 0.22-6.78) for the addition of low-intensity shockwave therapy, 8.40 (95% CI, 4.90-11.90) for the addition of a vacuum erectile device, 3.46 (95% CI, 2.16-4.76) for the addition of folic acid, 4.90 (95% CI, 2.82-6.98) for the addition of metformin hydrochloride and 2.07 (95% CI, 1.37-2.77) for the addition of angiotensin-converting enzyme inhibitors. The addition of a-blockers to PDE5 inhibitors was not associated with improvement in IIEF score (WMD, 0.80; 95% CI, -0.06 to 1.65; I2?=?72%). Compared with monotherapy, combination therapy was associated with improved IIEF score in patients with hypogonadism (WMD, 1.61; 95% CI, 0.99-2.23; I2?=?0%), monotherapy-resistant ED (WMD, 4.38; 95% CI, 2.37-6.40; I2?=?52%), or prostatectomy-induced ED (WMD, 5.47; 95% CI, 3.11-7.83; I2?=?53%). The treatment-related AEs did not differ between combination therapy and monotherapy (odds ratio, 1.10; 95% CI, 0.66-1.85; I2?=?78%). Despite multiple subgroup and sensitivity analyses, the levels of heterogeneity remained high. CONCLUSIONS AND RELEVANCE: This study found that combination therapy of PDE5 inhibitors and antioxidants was associated with improved ED without increasing the AEs. Treatment with PDE5 inhibitors and daily tadalafil, shockwaves, or a vacuum device was associated with additional improvement, but this result was based on limited data. These findings suggest that combination therapy is safe, associated with improved outcomes, and should be considered as a first-line therapy for refractory, complex, or difficult-to-treat cases of ED.

Without Abstract: