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Introduction: Radiofrequency (RF)-based treatment has been introduced as an esthetic alternative treatment for various medical indications without the scientific backup of a satisfactory body of evidence. Furthermore, the United States Food and Drug Administration issued a warning regarding the safety of energy-based technologies for indications such as vaginal "rejuvenation," cosmetic vaginal treatment, vaginal conditions related to menopause, and symptoms of urinary incontinence and sexual function on July 30, 2018., Aim: To perform a thorough review of the existing literature regarding RF-based vaginal devices for the treatment of female genitourinary indications and summarize the evidence available in a few short statements., Methods: A thorough review of the literature regarding RF treatments for gynecological indications was performed based on several databases. Studies that included at least 15 patients were eligible for analysis., Main Outcome Measure: Efficacy of RF devices for different genitourinary indications., Results: Although a high level of heterogeneity of studies poses a serious challenge, the committee reached a decision on several statements related to the use of RF-based devices for genitourinary indications., Clinical Implications: RF-based vaginal treatments have not been studied thoroughly enough in order to establish decisive recommendations regarding their safety and efficacy., Strength & Limitations: These position statements have been established by a group of experts. The lack of strong evidence makes it difficult to give decisive recommendations., Conclusions: Further randomized controlled trials with proper methodology and design are required to establish both benefits and possible harm these treatments may have in both short and long term for all the different indications studied. Otero JR, Lauterbach R, Aversa A, et al. Radiofrequency-Based Devices for Female Genito-Urinary Indications: Position Statements From the European Society of Sexual Medicine. J Sex Med 2020;17:393-399., (Copyright © 2019. Published by Elsevier Inc.)

To date, surgical correction remains the gold standard for patients with stable Peyronie's disease (PD) due to its high efficacy and low morbidity. Among the surgical procedures, penile plication (PP) can be offered to men who have adequate erectile function and penile length (>13 cm), with a curvature <60° and a predicted shortening of maximum 20% of the penis. The aim of this paper is to review the new developments that have emerged in the last years about the use of PP in patients with PD. A nonsystematic review of the literature was carried out searching in the PubMed and EMBASE databases from January 01, 2009 to April 01, 2019 including the words 'Peyronie', 'penile curvature', 'penile induration', 'plication', and 'plicature'. New developments in PP in the last 10 years include avoiding degloving by using a penoscrotal incision, a new mathematical model to predict loss of length after PP, a wider range of indications including patients with severe (≥60°) or complex curvatures, burying knots to avoid later discomfort, and thinning or incising the plaque to prevent excessive shortening. PP is a well-founded procedure with great results in appropriately selected patients. Given the lack of any prospective randomized trial, no clear recommendation can be made of one technique over another.

Objectives: To assess the impact of transrectal versus transperineal prostate biopsy on erectile function., Methods: This was a single-center, observational, prospective study of consecutive patients who underwent a prostate biopsy (transrectal or transperineal/fusion biopsy). Study participants completed the International Index of Erectile Function-5 questionnaire before the procedure, and 3 and 6 months after. Prostatic biopsies were carried out following the standard procedure for both techniques., Results: The study included 135 male patients with a mean age of 63.5 years. At baseline, 28 patients (21%) presented normal erectile function, whereas 107 patients (82%) presented erectile dysfunction, which was severe in four (3%), moderate in 49 (36%) and mild in 54 (40%), with an overall mean International Index of Erectile Function-5 score of 17.70. After 3 months, the rates were 29%, 3%, 27% and 38%, respectively (mean International Index of Erectile Function-5 score 17.95). At 6 months, the rates were 30%, 6%, 28% and 34%, respectively (mean International Index of Erectile Function-5 score of 17.77). No significant differences between pre- and post-biopsy International Index of Erectile Function-5 scores at 3 and 6 months were observed, even when analyzing transrectal and transperineal separately. The number of biopsy cores and number of previous biopsies did not influence the International Index of Erectile Function-5 scores., Conclusions: Our findings suggest that prostate biopsy technique, number of biopsy cores and history of previous biopsy do not significantly impact erectile function in the medium term up to 6 months., (© 2019 The Japanese Urological Association.)

Objective: To assess blood loss during holmium laser enucleation of the prostate (HoLEP) and investigate the factors influencing it., Patients and Methods: Analysis of patients with benign prostatic hyperplasia (BPH) treated with HoLEP at 3 centers. Hemoglobin and hematocrit were measured before surgery and hospital discharge. All blood transfusions performed during and after HoLEP were recorded. Blood loss outcomes were analyzed regarding antithrombotic (antiplatelet/anticoagulant) therapies and drug treatments for BPH and other conditions., Results: The analysis included 963 patients with a mean age of 72 years. Mean (range) prostate size was 102 (40-316) g; 28% of patients were receiving antiplatelets and 11% anticoagulants. Mean (range) prostate-specific antigen was 6.0 (0.3-43.5) ng/dL. Mean (range) operation time was 77 (28-178) minutes. Bladder calculi were found in 54 (5.6%) patients; all of them were successfully treated with cystolitholapaxy. Forty-eight (5%) patients required blood transfusion during or immediately after the HoLEP procedure. Overall, mean (SD) hemoglobin decreased from 14.6 (1.5) g/dL to 12.3 (2.1) g/dL (P <.001), and mean (SD) hematocrit decreased from 44.3% (4.7) to 37.7% (6.5) (P <.001). Neither hemoglobin nor hematocrit decreases were significantly different between patients receiving and not receiving antithrombotic therapy or BPH therapy., Conclusion: HoLEP is safe and has no remarkable impact on blood loss. Patients at high risk, such as those receiving antithrombotic therapy, had the same outcome than the rest regarding blood loss, although showed a higher transfusion rate. Operating time may influence hemoglobin decrease; therefore, it should be considered in patients with higher risk of bleeding., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Oxidative stress contributes to endothelial dysfunction, a key step in cardiovascular disease development. Ageing-related vascular dysfunction involves defective antioxidant response. Nuclear factor erythroid 2-like-2 (Nrf2), orchestrates cellular response to oxidative stress. We evaluated the impact of Nrf2-activation on endothelium-dependent and H 2 O 2 -mediated vasodilations in: aorta (RA), mesenteric artery (RMA), coronary artery (RCA) and corpus cavernosum (RCC) from ageing rats and in human penile arteries (HPRA) and corpus cavernosum (HCC) from erectile dysfunction (ED) patients. Relaxant responses were evaluated in organ chambers and wire myographs. Nrf2 content and heme oxygenase-1 (HO-1) were determined by ELISA. Superoxide and Nrf2 were detected by immunofluorescence. Pharmacological activation of Nrf2 with sulforaphane (SFN) improved NO- and endothelium-derived hyperpolarizing factor-mediated endothelium-dependent vasodilation and H 2 O 2 -induced relaxation in vascular beds from aging rats. SFN-induced effects were associated with increased Nrf2 (RMA, RCA) and reduced superoxide detection in RCA. Improvement of vascular function was confirmed in HPRA and HCC from ED patients and mimicked by another Nrf2 activator, oltipraz. Nrf2 increase and superoxide reduction together with HO-1 increase by Nrf2 activation was evidenced in HCC from ED patients. PDE5 inhibitor-induced relaxations of HPRA and HCC from ED patients were enhanced by SFN. Nrf2 short-term pharmacological activation attenuates age-related impairment of endothelium-dependent and reactive oxygen species (ROS)-induced vasodilation in different rat and human vascular territories by upregulation of Nrf2-related signaling and decreased oxidative stress. In ED patients target tissues, Nrf2 potentiates the functional effect of ED conventional pharmacological therapy suggesting potential therapeutic implication., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Purpose: To assess the influence of holmium laser cystolitholapaxy (HLC) concomitantly with holmium laser prostate enucleation (HoLEP) on patients with benign prostatic hyperplasia (BPH) presenting bladder calculi. Materials and Methods: We present a retrospective analysis of patients with BPH (with or without concomitant HLC) at three Spanish centers. Intraoperative variables (e.g., time and resected tissue), changes in functional parameters of the prostate, and frequency of complications (intraoperative, early postoperative, and at 12 months) in patients with and without HLC were compared. Results: The analysis included 963 patients aged 48 to 91 years, of which 54 (5.6%) underwent HLC to treat vesical lithiasis. Mean (range) prostate size (measured by transrectal ultrasound) was 79 (43-173) g and 91 (35-247) g for patients with and without concomitant HLC, respectively ( p  = 0.080). All bladder calculi were effectively removed. No significant differences were found regarding enucleation and morcellation times, but total operation time was significantly higher in patients with HLC: mean (standard deviation [SD]) of 78 (27) minutes vs 95 (41) minutes ( p  < 0.001). Three patients underwent conversion to open surgery because of bladder perforation, all of them from the group without HLC. Rates of intraoperative, early, and 12-month complications were similar in both groups. No significant differences in International Prostate Symptom Scale, maximum flow rate (Qmax), and mean flow were observed between groups 12 months after surgery. Conclusions: Simultaneous HoLEP and HLC increases the total operation time, but does not influence the risk of clinically relevant perioperative and postoperative complications.

Objectives: To comprehensively evaluate the efficacy and safety of the hexanic extract of Serenoa repens (HESr, Permixon ® ; Pierre Fabre Médicament, Castres, France), at a dose of 320 mg daily, as monotherapy for the treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH)., Materials and Methods: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) and prospective observational studies in patients with LUTS/BPH identified through searches in Medline, Web of Knowledge (Institute for Scientific Information), Scopus, the Cochrane Library, and bibliographic references up to March 2017. Articles studying S. repens extracts other than Permixon were excluded. Data were collected on International Prostate Symptom Score (IPSS), maximum urinary flow rate (Q max ), nocturia, quality of life, prostate volume, sexual function, and adverse drug reactions (ADRs). Data obtained from RCTs and observational studies were analysed jointly and separately using a random effects model. A sub-group analysis was performed of studies that included patients on longer-term treatment (≥1 year)., Results: Data from 27 studies (15 RCTs and 12 observational studies) were included for meta-analysis (total N = 5 800). Compared with placebo, the HESr was associated with 0.64 (95% confidence interval [CI] -0.98 to -0.31) fewer voids/night (P < 0.001) and an additional mean increase in Q max of 2.75 mL/s (95% CI 0.57 to 4.93; P = 0.01). When compared with α-blockers, the HESr showed similar improvements on IPSS (weighted mean difference [WMD] 0.57, 95% CI -0.27 to 1.42; P = 0.18) and a comparable increase in Q max to tamsulosin (WMD -0.02, 95% CI -0.71 to 0.66; P = 0.95). Efficacy assessed using the IPSS was similar after 6 months of treatment between the HESr and 5α-reductase inhibitors (5ARIs). Analysis of all available published data for the HESr showed a mean improvement in IPSS from baseline of -5.73 points (95% CI -6.91 to -4.54; P < 0.001). HESr did not negatively affect sexual function and no clinically relevant effect was observed on prostate-specific antigen. Prostate volume decreased slightly. Similar efficacy results were seen in patients treated for ≥1 year (n = 447). The HESr had a favourable safety profile, with gastrointestinal disorders being the most frequent ADR (mean incidence of 3.8%)., Conclusion: The present meta-analysis, which includes all available RCTs and observational studies, shows that the HESr (Permixon) reduced nocturia and improved Q max compared with placebo and had a similar efficacy to tamsulosin and short-term 5-ARI in relieving LUTS. HESr (Permixon) appears to be an efficacious and well-tolerated therapeutic option for the long-term medical treatment of LUTS/BPH., (© 2018 The Authors BJU International Published by John Wiley & Sons Ltd on behalf of BJU International.)

Context: The revolution of digital technologies constitutes a new setting for the patient-physician relationship and provides patients with a scenario of privacy and universal access to a vast amount of information. However, there is little information on how digital resources are used and what their advantages and disadvantages are., Objectives: To explore the scope of the scientific research on the use of digital technology related to men's sexual disorders and to analyze the primary sources of digital information related to this field., Acquisition of Evidence: Systematic searches of the scientific literature, websites (10 first results in each google search) and mobile applications (apps). The searches combined the keywords "web" and "app" with "erectile dysfunction", "premature ejaculation", "Peyronie", "male hypogonadism", and "infertility". Websites and apps were assessed for quality according to predefined indicators., Synthesis of Evidence: The qualitative analysis of the scientific literature included 116 manuscripts; 47% were clinical studies based on online survey, 9% dealt with digital treatments, 11% with quality/safety of digital healthcare environment, 3% with digital activity, 21% with patient empowerment, and 9% with online drug selling. Of 50 websites assessed for quality, 29 (58%) scored 4 or 5 on a 5-point Likert scale. The app search yielded 40 apps; only 3 of them (8%) reported the identity of a health center or healthcare professional involved., Conclusions: Patients and healthcare professionals may benefit from digital resources related to men's sexual disorders; however, a strong commitment by the scientific and healthcare community is essential to increase the quality of these resources., (Copyright © 2017 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: Urinary incontinence (UI) is a significant complication after radical prostatectomy (RP). Although sphincter incompetence is considered the main cause; bladder dysfunction can contribute substantially. Our objective was to evaluate the results of the urodynamic study (UDS) in men with UI after radical prostatectomy and analyze the correlation between symptoms and urodynamic parameters., Methods: We carried out a retrospective study reviewing the symptoms and urodynamics in patients with urinary incontinence after RP. We describe the symptoms, urodynamic findings and we analyze the correlation between both., Results: Our study included 74 patients. The median number of pads used per day was 3. 61% reported urgency, 63% stress urinary incontinence, 11% urgency urinary incontinence and 26% mixed urinary incontinence. The UDS showed stress urinary incontinence in 53% of patients, detrusor overactivity in 53% and, reduced bladder compliance in 43%. Urgency urinary incontinence was reported in 56% of patients with reduced bladder compliance. Urodynamics showed no incontinence in 16% of patients, of whom 80% showed urgency urinary incontinence. Urodynamics data showing obstruction of the urinary tract was reported in 17% and detrusor hypo or acontractility in 36%. Among patients with obstruction, 46% showed incontinence due to detrusor overactivity. The correlation of symptoms and urodynamics showed that only 31% of patients with stress urinary incontinence had incontinence due to detrusor overactivity in urodynamics. Among those with mixed urinary incontinence, urodynamic stress urinary incontinence only was found in 42% and 33% incontinence due to detrusor overactivity only. Finally, among those with symptoms of urgency urinary incontinence, the urodynamics showed detrusor overactivity in 27%., Conclusions: In patients with urinary incontinence after radical prostatectomy, there is a high percentage of patients with urinary tract obstruction, detrusor overactivity and decreased compliance. Moreover, the correlation between symptoms and urodynamics is low.

Objectives: The treatment of metastatic prostate cancer has remained unchanged for more than 70 years, based on androgen deprivation therapy (ADT). In 2015, following the CHAARTED and STAMPEDE trials, it was established that the addition of 6 cycles of docetaxel to ADT was associated with significantly increased survival. In June 2017, the LATITUDE trial and the G arm of the STAMPEDE trial showed that the addition of Abiraterone with Prednisone (5 mg/day) to ADT was also associated with a significant increase in survival in metastatic patients. The present study analyzes these two trials., Results: LATITUDE demonstrated a 38% reduction in the risk of death (HR=0.62, 95% CI, 0.61-0.76) in almost all sub-groups. Risk reduction for radiological progression was 53% (HR=0.47, 95% CI 0.39-0.55). Secondary objectives such as prostate specific antigen progression, time to chemotherapy or a new skeletal event are also significantly delayed. STAMPEDE also showed that the combination of Abiraterone and Prednisone is associated with a 37% increase in survival (HR=0.63, 95% CI, 0.52- 0.76, p<0.001) in metastatic patients, but not in nonmetastatic patients. Progression-free survival was greatly improved in this arm (HR=0.29, 95% CI 0.25-0.34, p<0.001). The side effects reported show the known pattern of mineral corticosteroid excess with increased blood pressure, hypokalemia, and of liver enzymes elevation., Conclusions: The indirect comparison of docetaxel and abiraterone studies confirms that both populations and results are comparable. Two comparative indirect metanalysis (>6000 patients) gave marginal superiority to abiraterone. In favor of abiraterone we have that it is an oral, comfortable medication with a good tolerance profile and side effects that are easy to manage, useful in patients who are old and fragile, in whom chemotherapy may not be indicated; the downsides are prolonged exposure to the drug and its current price. Future trials, currently in progress, will determine the ideal patient profile, or a potential association of both therapies.

Objective: To explore the potential relationship between erectile dysfunction (ED), low testosterone levels, and the Charlson Comorbidity Index (CCI)., Material and Methods: Cross-sectional study on patients referred to the andrology unit in 7 Spanish centers. The ED was diagnosed and graded using the International Index of Erectile Function (IIEF-5) score. Total testosterone, the prevalence of each comorbidity, and the CCI were compared between patients with different grades of ED. Besides, the correlation between total testosterone and the CCI score, the influence of each comorbidity, and the ED severity on the CCI was assessed in a multiple linear regression., Results: The study included 430 men with a mean age of 61 years. The mean CCI was 3.5, and mean total testosterone 15.2 nmol/L; 389 (91%) subjects had some grade of ED: 97 (23%) mild, 149 (35%) mild-to-moderate, 86 (20%) moderate, and 57 (13%) severe. The increase in ED severity was significantly associated with a decrease in total testosterone (P=.002), and an increase in the CCI score (P<.001). Testosterone levels were significantly lower in patients with obesity, diabetes, hypercholesterolemia, and hypertriglyceridemia (P<.05). However, only the prevalence of diabetes and hypertension was significantly associated with the severity of ED. The multivariate analysis including variables related to all assessed comorbidities, total testosterone levels, and the DE severity significantly predicted the CCI score (P<.001, R 2 =.426). The severity of ED significantly contributed to this model (P=.011), but total testosterone did not (P=.204)., Conclusions: The CCI is significantly associated with the ED severity, but it shows a weak correlation with the testosterone levels., (Copyright © 2017 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.)

Purpose: To assess the performance of the Brief Sexual Symptom Checklist for men (BSSC-M) questionnaire in General Practitioner's (GP) consults in Spain., Methods: Multicenter, cross-sectional study conducted in Spain among men ≥50 years, visiting a GP for any reason, and being able to answer self-administered questionnaires. Patients receiving medicines for erectile dysfunction (ED) and those with poor functional status were excluded. Sexual satisfaction was assessed by the BSSC-M, ED by the Sexual Health Inventory for Men (SHIM), and quality of life (QoL) using a 5-point Likert scale., Results: In all, 770 men met all the selection criteria and 556 patients (72.2%) reported sexually related problems, ED being the most frequent (n = 427; 55.5%). The SHIM score decreased progressively with the number of causes of sexual dissatisfaction. Prevalence of ED (SHIM ≤21) was greater in patients who referred problems with erection in the BSSC-M questionnaire (76 vs. 14%; p < 0.001). Multivariate analysis for ED prediction revealed that sexual dissatisfaction, QoL (average or low/very low), and the presence of 3 or more comorbidities significantly influenced the chances of having ED., Conclusions: Our results encourage the use of the BSSC-M for identifying suspicion of ED and other sexual problems in patients > 50 who visit their GP for a routine follow-up., (© 2018 S. Karger AG, Basel.)

Peyronie's disease (PD) is an acquired connective tissue disorder of the tunica albuginea with fibrosis and inflammation that lead to palpable plaques formation, penile curvature, and pain during erection. Patients report negative effects on main domains such as physical appearance and self-image, sexual function, and performance. The aim of this study was to evaluate plication of the albuginea outcomes after a long-term follow-up period. Between 1998 and 2006, a total of 204 patients with PD underwent surgical correction with albuginea plication technique. We obtained complete long-term follow-up data in 187 cases. The follow-up data included evaluation of curvature correction, penile shortening, sexual function, complications, and patient satisfaction. After a mean follow-up of 141 months, the most common postoperative complications were: loss of length (150 patients had a minimal penile shortening ≤1.5 cm, 37 patient between 1.5, and 3 cm, none >3 cm), recurrent or residual penile curvature (15 patients, without impairing sexual intercourse), erectile dysfunction (15 patients had IIEF-5 < 10 at 5 years of follow-up vs. 28 patients at 10 years), change in penile sensation (37 patients experienced paresthesia of the glans 1 year after surgery, 28 at 5 years, and 15 at 10 years); painful or palpable suture knots (in 20 cases) spontaneously healed in 3 months. Overall, 77% of the patients and partners were completely satisfied, 14% partially satisfied, and 9% unsatisfied. Plication procedure is safe and simple to be performed compared with the classical Nesbit's procedure. It has a shorter surgical time, lower costs, and could be successfully performed by less experienced surgeons too. It has a minimal risk of de novo erectile dysfunction, injury to the dorsal neurovascular bundle. Results are good in terms of patient satisfaction according to anatomical outcome and functional correction., (© 2017 American Society of Andrology and European Academy of Andrology.)

The difficulty implicit in combining all the characteristics that an ideal patch to treat Peyronie's disease with a lengthening procedure should have, together with the challenges of comparing results from different series, means that the ideal patch has yet to be determined. Our objective with this review was to determine whether any given patch type is preferable to the others based on the evaluation of the results of published studies. A systematic search of the literature was conducted from PubMed until December 2016. Articles reporting basic research, animal research, reviews or meta-analyses and studies in children were eliminated. Series with patients undergoing some kind of other surgical intervention were only included if results were reported separately. Case reports and series of five patients were excluded. Five variables were selected to evaluate the results: number of patients, follow-up period, straightening rate, shortening rate and post-operative ED rate. For this purpose, 69 papers were included for review, and the outcomes of the use of autologous dermis, tunica vaginalis, dura mater, fascia, saphenous vein, tunica albuginea, buccal mucosa, porcine intestinal submucosa, pericardium, TachoSil ® and synthetic materials were presented and analysed separately. The different series published are extremely variable and heterogeneous in terms of the number of patients included, patient selection, follow-up periods, and in the measurement and interpretation of the outcomes analysed. Given these facts, it is not possible to draw any definitive conclusion, homogeneous, prospective studies using validated tools are required to determine which the ideal graft is., (© 2017 American Society of Andrology and European Academy of Andrology.)

Urology is defined as the medical-surgical specialty that includes the study, diagnosis and treatment of medical conditions of the urinary system. It is well specified by the National Commission of Specialties that we must know the medical pathology that concerns us. However, on occasions, resident training focuses on the surgical field and oncological pathology, which, although one of the main pillars of the specialty, is usually to the detriment of training in medical and functional pathology. We conducted a survey of residents in the fourth year of Urology in Spain, where we asked about the quality of training in Andrology and Functional Urology. The average rotation time is 3.5 months in each unit. Only 20% consider that their training is satisfactory and sufficient in Andrology. Seventy-five percent of residents surveyed believe that their training in Functional Urology is acceptable or sufficient, both medical and surgical. There are numerous fields of action to improve the training of residents and young urologists in this country in the management of urological medical pathology. The future is open, and it is in our hand to set up a training for urology residents within excellence and to be recognized both nationally and internationally as one of the great pillars of Spanish Urology. In this chapter we will analyze the current situation in the training of Spanish Urology Residents in urological medical pathology, and we will focus on training in functional urology and andrology.

Background: The benefits and risks of long-term testosterone administration have been a topic of much scientific and regulatory interest in recent years., Aim: To assess long-term quality of life (QOL) and sexual function benefits of testosterone replacement therapy (TRT) prospectively in a diverse, multinational cohort of men with hypogonadism., Methods: A multinational patient registry was used to assess long-term changes associated with TRT in middle-age and older men with hypogonadism. Comprehensive evaluations were conducted at 6, 12, 24, and 36 months after enrollment into the registry., Outcomes: QOL and sexual function were evaluated by validated measures, including the Aging Males' Symptom (AMS) Scale and the International Index of Erectile Function (IIEF)., Results: A total of 999 previously untreated men with hypogonadism were enrolled at 25 European centers, 750 of whom received TRT at at least one visit during the period of observation. Patients on TRT reported rapid and sustained improvements in QOL, with fewer sexual, psychological, and somatic symptoms. Modest improvements in QOL and sexual function, including erectile function, also were noted in RHYME patients not on TRT, although treated patients showed consistently greater benefit over time in all symptom domains compared with untreated patients. AMS total scores for patients on TRT were 32.8 (95% confidence interval = 31.3-34.4) compared with 36.6 (95% confidence interval = 34.8-38.5) for untreated patients (P < .001). Small but significant improvements in IIEF scores over time also were noted with TRT. Approximately 25% of treated and untreated men also used phosphodiesterase type 5 inhibitors, with notable differences in the frequency of phosphodiesterase type 5 inhibitor prescription use according to physician specialty and geographic site location., Clinical Implications: TRT-related benefits in QOL and sexual function are well maintained for up to 36 months after initiation of treatment., Strengths and Limitations: The major strengths are the large, diverse patient population being treated in multidisciplinary clinical settings. The major limitation is the frequency of switching from one formulation to another., Conclusion: Overall, we confirmed the broad and sustained benefits of TRT across major QOL dimensions, including sexual, somatic, and psychological health, which were sustained over 36 months in our treatment cohort. Rosen RC, Wu F, Behre H, et al. Quality of Life and Sexual Function Benefits Effects of Long-Term Testosterone Treatment: Longitudinal Results From the Registry of Hypogonadism in Men (RHYME). J Sex Med 2017;14:1104-1115., (Copyright © 2017 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the use of sexual dissatisfaction as a marker of poor overall health. Secondary objectives were to assess the effect of age on this measure and the utility of the Brief Sexual Symptom Checklist (BSSC) for general practitioners (GPs) and patients., Methods: This is a multicenter, cross-sectional study conducted in Spain among men aged ≥50 years presenting with mood disorders or cardiovascular comorbidities (hypertension, dyslipidemia, or diabetes) visiting a GP for any reason. A group of men without these comorbidities were also analyzed. The main outcome measures were prevalence of sexual dissatisfaction, based on the comorbidities analyzed (type, number, or their absence) and problems with sexual function in dissatisfied men (overall and in men aged < 60 or ≥60 years)., Results: Seven hundred eighteen men aged 61.7 ± 7.1 years who presented the analyzed comorbidities participated, 69.8% of whom were sexually dissatisfied. Men without comorbidities (n = 144) were younger and had lower prevalence of sexual dissatisfaction (54.2%; P = .001). Sexual dissatisfaction increased with age. Having these comorbidities (especially mood disorders) significantly increased the likelihood of sexual dissatisfaction after adjusting for age. Erection problems and lack of interest in sex were the most reported problems, independent of the presence of comorbidities. Differences in the prevalence of these problems were found in men with and without comorbidities after splitting the population into 2 age groups. GPs and dissatisfied patients found the BSSC useful and easy to use., Conclusion: Assessment of sexual satisfaction and related sexual problems using the BSSC could help in approaching men's overall health. Further research is needed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To determine the role of penile Doppler ultrasound (PDU) compared with magnetic resonance imaging (MRI) in preoperative diagnostic evaluation of patients with penile squamous cell carcinoma., Materials and Methods: A prospective analysis on patients presenting with clinical diagnosis of penile squamous cell carcinoma from 6 different European hospitals between 2012 and 2014 was carried out. Each patient who had planned an organ sparing approach underwent an MRI and PDU both with an artificial erection with prostaglandin E 1. Age, evidence of MRI or PDU corpora cavernosa infiltration, frozen section examination report, definitive pathological report, and surgical approach used per patient were recorded. Accuracy, precision, negative predictive value, sensitivity, and specificity were calculated. Outcomes were statistically evaluated., Results: Two hundred patients were enrolled in the study. The mean age of the patients was 67.35 ± 15.45 (range 51-82). All of the patients were treated surgically. Of the 200 patients, 135 (67.5%) underwent a corpora sparing approach, whereas 65 had a partial penectomy because of the frozen section outcome. About corpora cavernosa infiltration, the definitive outcome confirmed the frozen section examination. PDU vs MRI accuracy was 96.5% vs 90.5%; precision was 92.6% vs 96%; sensitivity was 96.9% vs 73.8%, specificity was 96.2% vs 98.5%. Despite sensitivity (P <.05) no statistical evidence was found between ultrasound and MRI., Conclusion: PDU has a statistical similar outcome on detecting infiltration of corpora cavernosa and could be used as a less expensive tool to drive surgical strategy in patient with a diagnosis of penile squamous cell carcinoma., (Copyright © 2016 Elsevier Inc. All rights reserved.)

It is worth distinguishing between the two strategies of expectant management for prostate cancer. Watchful waiting entails administering non-curative androgen deprivation therapy to patients on development of symptomatic progression, whereas active surveillance entails delivering curative treatment on signs of disease progression. The objectives of the two management strategies and the patients enrolled in either are different: (i) to review the role of active surveillance as a management strategy for patients with low-risk prostate cancer; and (ii) review the benefits and pitfalls of active surveillance. We carried out a systematic review of active surveillance for prostate cancer in the literature using the National Center for Biotechnology Information's electronic database, PubMed. We carried out a search in English using the terms: active surveillance, prostate cancer, watchful waiting and conservative management. Selected studies were required to have a comprehensive description of the demographic and disease characteristics of the patients at the time of diagnosis, inclusion criteria for surveillance, and a protocol for the patients' follow up. Review articles were included, but not multiple papers from the same datasets. Active surveillance appears to reduce overtreatment in patients with low-risk prostate cancer without compromising cancer-specific survival at 10 years. Therefore, active surveillance is an option for select patients who want to avoid the side-effects inherent to the different types of immediate treatment. However, inclusion criteria for active surveillance and the most appropriate method of monitoring patients on active surveillance have not yet been standardized., (© 2015 The Japanese Urological Association.)

Objectives: To assess the feasibility and the safety of conservative surgery to treat spermatic cord leiomyosarcoma., Methods: Patients undergoing inguinoscrotal exploration in 10 different Urological Centers with diagnosis of leiomyosarcoma were enrolled. Preoperative evaluation included physical examination, Scrotal US, Abdominal CT and Scrotal MRI in selected cases. Patients underwent organ sparing surgery or orchiectomy in case of intraoperative FSE was positive for a local infiltration. Data collected were: age, presence of infiltration, length of the lesion, number of lesions, definitive histological outcome, pre and postoperative testosterone level. Follow up was performed with abdomen CT scan and scrotal US., Results: From January 2007 to December 2013, 23 patients (mean age: 64.7 yrs) were diagnosed with spermatic cord leiomyosarcoma. Each patients underwent scrotal US. 10 patients underwent radical orchiectomy and 13 patients underwent conservative surgery. Mean follow up was 36.5 months. 5 patients (21.7%) developed a recurrent disease, 18 patients (78.3%) had a negative follow up (mean time: 40.8 months). Statistical analysis reveals that there is a significant correlation between number of lesions, length of the lesions and recurrent disease., Conclusions: Spermatic cord leiomyosarcoma is a rare disease. Conservative surgical treatment of spermatic cord leiomyosarcoma is a feasible therapeutic option for small, single and not infiltrating lesion., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Purpose: We report time to erectile function (EF)-recovery data from a multicenter, randomized, double-blind, double-dummy, placebo-controlled trial evaluating tadalafil started after bilateral nerve-sparing radical prostatectomy (nsRP)., Methods: Patients ≤68 years were randomized post-nsRP 1:1:1 to 9-month double-blind treatment (DBT) with tadalafil 5 mg once daily (OaD), 20 mg tadalafil on demand ("pro-re-nata"; PRN), or placebo, followed by 6-week drug-free washout (DFW) and 3-month open-label OaD treatment. Secondary outcome measures included Kaplan-Meier estimates of time to EF-recovery (IIEF-EF ≥ 22) during DBT (Cox proportional hazard model adjusting for treatment, age, and country)., Results: A total of 423 patients were randomized to tadalafil OaD (N = 139), PRN (N = 143), and placebo (N = 141); 114/122/155 completed DBT. The proportion of patients achieving IIEF-EF ≥22 at some point during DBT with OaD, PRN, and placebo was 29.5, 23.9, and 18.4 %, respectively. DBT was too short to achieve EF-recovery (IIEF-EF ≥ 22) in >50 % of patients; median time to EF-recovery was non-estimable. Time for 25 % of patients to achieve EF-recovery (95 % CI) was 5.8 (4.9, 9.2) months for OaD versus 9.0 (5.5, 9.2) and 9.3 (9.0, 9.9) months for PRN and placebo, respectively. Showing a significant overall treatment effect (p = 0.038), the probability for EF-recovery was significantly higher for OaD versus placebo [hazard ratio (HR); 95 % CI 1.9; 1.2, 3.1; p = 0.011], but not for PRN versus placebo (p = 0.140). Of 57 OaD patients (41.0 %) with ED improved (by ≥1 IIEF-EF severity grade) at the end of DBT, 16 (28.1 % of 57) maintained this improvement through DFW and 27 (47.4 %) declined but maintained improvement from baseline after DFW., Conclusions: Data suggest that the use of tadalafil OaD can significantly shorten the time to EF-recovery post-nsRP compared with placebo.

Objective: To evaluate semen quality of men with proven fertility in Spain over the last 3 decades., Methods: We conduct a retrospective analysis of ejaculate samples of 992 men between 1985 and 2009. All patients had proven fertility as demonstrated by fathering at least 2 children and a semen analysis performed before they underwent vasectomy. A standardized procedure was used for the semen analysis. Semen volume, total sperm count, sperm concentration, motility, and percentage of morphologically normal spermatozoa were assessed. Mean values were calculated by examining microscopic fields of 100 spermatozoa., Results: Statistically significant differences were found in all semen parameters analyzed. For the periods 1985-1990, 1990-2000, and 2000-2009, the mean (standard deviation [SD]) sperm concentration was 27.7 (22.97), 20.73 (14.79), and 20.18 (20.79) × 10(6) (P <.0001). The mean (SD) progressive motility for each period was 53.19 (20.35), 47.22 (15.84), and 40.57 (15.15; P <.0001). The mean (SD) normal-shaped spermatozoa for each period was 67.69 (10.24), 58.87 (14.67), and 51.02 (15.76; P <.0001). Multivariate analysis using a logistic regression model showed that age had no significant effect in the variation of semen parameters at the cut-points analyzed, except for normal forms at percentile 25 (P = .001). Multivariate analysis revealed a trend for decline of semen in sperm concentration, progressive and nonprogressive motility, and the percentage of morphologically normal spermatozoa (P = .001-.002)., Conclusion: Over the last 3 decades, a decline in semen quality was found in all the parameters analyzed in Spanish men with proven fertility., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: The role of renal mass (RM) biopsy is currently under discussion. As a result of the progressive increase in the incidental diagnosis of RMs (which have a higher percentage of benignity and well-differentiated cancers), new approaches have emerged such as observation, especially with elderly patients or those with significant comorbidity. RM biopsy (RMB) should provide sufficient information for making this decision, but so far this has not been the case. We examine our prospective series of in-bench RMBs after surgery and compare them with the anatomy of the removed specimen., Material and Methods: We obtained (prospectively, in-bench and with a 16-gauge needle) 4 biopsies of RMs operated on in our department from October 2008 to December 2009. These RMs were analyzed by 2 uropathologists and compared with the results of the specimen., Results: We analyzed 188 biopsies (47 RMs); 12.75% were "not valid". The ability of biopsy to diagnose malignancy or benignity was 100%, and the coincidence in the histological type was 95%. The success in determining the tumor grade was 100% when the cancer was low-grade and 62% when high-grade. None of the analyzed data (necrosis, size, etc.) influenced the results in a statistically significant manner., Conclusion: RMB with a 16-G needle enables the differentiation between malignancy and benignity in 100% of cases, with a very similar diagnostic accuracy in the tumor type. Tumor grade is still the pending issue with renal mass biopsy., (Copyright © 2014 AEU. Published by Elsevier Espana. All rights reserved.)

Introduction: Testosterone deficiency syndrome (TDS) is usually suspected on the basis of signs/symptoms. However, some men with low testosterone levels (low T) are asymptomatic or present mild, unnoticed symptoms. Would they have the same cardiovascular risk as symptomatic men?, Aims: This study aims to assess the relationship between presence/severity of low T-related symptoms and the likelihood of metabolic syndrome (MetS)., Methods: Data were taken from a multicenter, cross-sectional study conducted in Spain among men visiting men's healthcare offices aged ≥45 with low T (total T <8 nmol/L or <12 nmol/L and calculated free T <250 nmol/L). Only subjects whose MetS components and symptoms had been assessed were selected. Data available included anthropometrics, toxic habits, comorbidities, and total testosterone (TT) levels., Main Outcome Measures: MetS was defined using the harmonized definition. Erectile dysfunction was classified using the International Index of Erectile Function questionnaire. The Ageing Male Symptoms (AMS) scale assessed symptoms. Symptom severity was classified as "none/mild" and "moderate/severe." Bivariate and multivariate logistic regression analyses were performed to calculate the effect of moderate/severe symptoms on the odds ratio (OR) for MetS., Results: Mean age (SD) was 61.2 (8.1) years. Erectile dysfunction (ED), AMS, and MetS prevalence were 97.4%, 94.9%, and 69.6%. Prevalence of MetS was higher in men with moderate/severe symptoms vs. men with no/mild ones (75.3% vs. 57.9%, P < 0.001). Age and prevalence of TT <8 nmol/L, moderate/severe ED, and obesity were significantly higher in men with moderate/severe symptoms. Multivariate analysis showed that besides obesity and moderate/severe ED, moderate/severe symptoms increased the likelihood of MetS. This effect disappeared in men with severe ED and in the nonobese. Three symptoms showed relationship with MetS after adjusting for all confounding factors., Conclusion: Severity of TDS symptoms may indicate higher cardiovascular risk in men with low T., (© 2014 International Society for Sexual Medicine.)

Objective: To detect current errors within the administration of phosphodiesterase type 5 inhibitors (PDE5is) and evaluate and elucidate what percentage of patients could be recovered for oral therapy with different subtypes of PDE5is through a re-education program., Methods: Two hundred fifty patients remitted to the andrology unit were prospectively analyzed. Patients' chief complaint was erectile dysfunction despite treatment with PDE5i. The International Index of Erectile Function was used to measure erectile function. A structured interview was developed to evaluate the most frequent errors within the administration of PDE5is. A re-education program was offered to patients with incomplete or incorrect use of PDE5is according to the structured interview, classifying them into true nonresponders or false nonresponders. Finally, the percentage of patients who could be recovered for oral therapy with other PDE5is was analyzed., Results: A total of 172 patients (69%) presented some error within drug administration. The most common error was not trying >1 PDE5i (41%). A re-education program was offered to these nonresponders, and 115 (66.9%) accepted. Up to 27 (23.5%) did not respond to the re-education program and were classified as true nonresponders, whereas 88 (76.5%) had a positive response to treatment and were thus included in the false nonresponder group., Conclusion: Two-thirds of patients remitted to our andrology unit and cataloged as nonresponders were in fact using PDE5i in suboptimal conditions. Offering patients more accurate information provided almost 76% with good results using PDE5is and could therefore be successfully treated with these drugs., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: Stopwatch-assessed duration of erection has been proposed as an objective and reliable efficacy end point for erectile dysfunction (ED) treatments., Aim: The aim of this study is to assess vardenafil orodispersible tablets' (ODTs) efficacy in terms of duration of erection and (i) its correlation with other efficacy end points and male and female sexual quality of life (QoL) and (ii) its impact on intercourse duration., Methods: Randomized, double-blind, placebo-controlled, multicenter study comparing the efficacy and safety of vardenafil ODT 10 mg on-demand over 12 weeks in 127 patients with ED was carried out., Main Outcome Measures: Primary efficacy end points were stopwatch-assessed duration of erection (min) at any attempt and when leading to successful intercourse, and the erectile function domain of the International Index of Erectile Function (EF-IIEF) score. Secondary end points were sexual encounter profile (SEP) 3 response rate and male sexual QoL. End points in participating women (N = 46) were stopwatch-assessed duration of intercourse and sexual QoL., Results: At week 12/last observation carried forward, patients taking vardenafil ODT had longer duration of erections (at any attempt or leading to successful intercourse) vs. placebo (least square mean ± standard error 10.2 ± 0.9 minutes vs. 7.9 ± 1.0 minutes, and 10.4 ± 0.8 vs. 8.3 ± 1.0 minutes, respectively), and significant increases in EF-IIEF scores, the SEP-3 response, and all sexual QoL items. An increased duration of intercourse was also observed. Female sexual QoL improved significantly. Both duration end points strongly correlated with EF-IIEF scores, and the three end points correlated well with SEP-3 response. Correlation was good with sexual QoL scores in men and women and with duration of intercourse, with differences between treatment groups only for duration end points. Safety was similar in both groups., Conclusion: This study provides further evidence for the consistency and reliability of the stopwatch-assessed duration of erection as an efficacy end point for ED treatments, with "duration of erection leading to successful intercourse" showing better properties than duration at any attempt., (© 2014 International Society for Sexual Medicine.)

Many aspects of prostate cancer diagnosis and treatment could be greatly advanced with new, effective biomarkers. Prostate-specific antigen (PSA) has multiple weaknesses as a biomarker, such as not distinguishing well between cancer and benign prostatic hyperplasia or between indolent and aggressive cancers, thus leading to overtreatment, especially unnecessary biopsies. PSA also often fails to indicate accurately which patients are responding to a given treatment. Yet PSA is the only prostate cancer biomarker routinely used by urologists. Here, we provide updated information on the most relevant of the other biomarkers currently in use or in development for prostate cancer. Recent research shows improvement over using PSA alone by comparing total PSA (tPSA) or free PSA (fPSA) with new, related markers, such as prostate cancer antigen (PCA) 3, the individual molecular forms of PSA (proPSA, benign PSA, and intact PSA), and kallikreins other than PSA. Promising results have also been seen with the use of the fusion gene TMPRSS2:ERG and with various forms of the urokinase plasminogen activation receptor. Initially, there were high hopes for early PCA, but those data were not reproducible and thus research on early PCA has been abandoned. Much work remains to be done before any of these biomarkers are fully validated and accepted. Currently, the only markers discussed in this paper with Food and Drug Administration-approved tests are PCA 3 and an isoform of proPSA, [-2]proPSA. Assays are in development for most of the other biomarkers described in this paper. While the biomarker validation process can be long and filled with obstacles, the rewards will be great-in terms of both patient care and costs to the health care system., (© 2013 Elsevier Inc. All rights reserved.)

Unlabelled: Elderly patients present testosterone deficit syndrome (TDS) in a prevalent manner. TDS is defined as a clinical and biochemical syndrome with total fasting testosterone below normal levels in two consecutive measurements. A significant relationship with comorbidities such as diabetes mellitus, obesity or metabolic syndrome has been observed in these patients. These latter are recognized risk factors of coronary artery disease (CAD) and arteriosclerosis. It seems logical to think that CAD is more frequent in patients with TDS, and it is supported on multiple works demonstrating the correlation of theses two pathologies. We intend to illustrate the management of patients with TDS and CAD presenting a clinical case and the recommended diagnostic and therapeutic approach. A Sixty-four year old male with hypertension, non-insulin dependent diabetes mellitus and obesity consulted for erectile dysfunction and diminished sexual desire. Fasting total testosterone and glycosylate hemoglobin were determined. IIEF-5 was 12, Erection hardness Score was 2 and IIEF item 12 1 point over 5. His total testosterone was 150 ng/dl, which was confirmed in a second test; HDL cholesterol level was 30 mg/dl. Interrogated again, the patient referred oppressive chest pain appearing after running 50 meters for the last three months that never happened in rest or with minor efforts., Approach: It is a patient with high cardiovascular risk and atypical chest pain so recommendation was given to consult a cardiologist. Stress test was performed. It was a submaximal, evaluable test (reached 80% of his maximum theoretical heart rate) stopped due to angina. Clinically and electrically it was positive at medium charge. Coronary angiogram was indicated showing a severe (85%percnt;%) lesion at the medial third of anterior descendant artery. Balloon angioplasty was performed and a 3.0 x 24 mm drug-coated stent was placed. Cardiologic treatment was prescribed as well as combination therapy for his erectile dysfunction and diminished libido with testosterone and a PDE 5 inhibitor.

Objective: [corrected] New investigations focus on the relationship between benign prostatic hyperplasia, lower urinary tract symptoms, erectile dysfunction and testosterone deficit; giving to this last one a common role in all of them. In this paper, we present a typical patient who complains of symptoms related to BPH, to treat him in terms of micturition quality, sexual function and hypogonadism ., Methods/results: 61 year-old male, with obesity, hypertension and hypercholesterolemia, who complains of long term mixed urinary symptoms, with an IPSS of 12 and IIEF-5 of 22. DRE: II/IVprostate, adenomatous. Blood parameters: PSA 1.9 ng/dl, total testosterone 238 ng/dl, triglycerides 213 mg/dl, glucose 89 mg/dl. Uroflowmetry :total volume 256 ml, maximum flow 12 ml/s, average 5.7 ml/s and post-void volume of 15 ml. Urinary ultra- sound: 5 mm detrusor and prostate volume of 39 cm3. Nowadays, LUTS are considered multietiologic, including testosterone as one of the causes. According to the classic criteria, this patient fits for treatment with combination therapy, as well as for daily PDE5i, recently approved for LUTS therapy. Administration of testosterone to treat LUTS is still controversial. It could restore the patient's levels of testosterone, improving the metabolic syndrome and creating an optimal environment for the 5PDEi. Nevertheless, according to some current scientific evidences, it could help improving LUTS., Conclusions: Given the necessity of larger studies, testosterone supplementation therapy seems to not worsen the evolution of BHP. It could even improve them if the testosterone deficit is documented.

Objective: Recent studies show an inverse relationship between testosterone levels and prostate cancer (PCa). The usefulness of hormonal patterns in PCa diagnosis is controversial. This study aimed to determine the relationship between hormonal patterns and PCa, and to find a cut-off point of hormone levels to assess PCa risk., Material and Methods: A prospective analysis was undertaken of 279 patients referred for first or second prostate biopsy in the Hospital Clínic Barcelona from November 2006 to May 2009. The indication for prostate biopsy was suspicion of PCa based on the results of digital rectal examination (DRE) and/or elevation of serum prostate-specific antigen (PSA). Screening was carried out with a 5+5-core transrectal ultrasound-guided prostate biopsy. Age, prostate volume, DRE (normal or abnormal), biopsy findings (normal or report of PCa), PSA, free-to-total PSA, PSA density, testosterone and sex hormone-binding globulin (SHBG) were also prospectively recorded. Free and bioavailable testosterone were calculated using Vermeulen's formula., Results: In the multivariate analysis, abnormal DRE [odds ratio (OR = 5.46, p < 0.001], SHBG levels ≥ 66.25 nmol/l [OR = 3.27; 95% confidence interval (CI) 1.52 to 7.04, p < 0.002] and bioavailable testosterone levels ≤ 104 ng/dl (OR = 4.92, 95% CI 1.78 to 13.59, p = 0.002) were related to the diagnosis of prostate adenocarcinoma. Age, free testosterone, PSA, testosterone, PSA/testosterone, PSA/free testosterone and PSA/bioavailable testosterone were not related to PCa diagnosis., Conclusions: Low bioavailable testosterone levels and high SHBG levels were related to a 4.9- and 3.2-fold risk of detection of PCa on prostate biopsy owing to PSA elevation or abnormal DRE. This fact may be useful in the clinical scenario in counselling patients at risk for PCa.

Objective: There is controversial evidence regarding preoperative testosterone (T) levels related to poor prognosis factors after radical prostatectomy (RP). The aim of this manuscript is to determine the relationship between preoperative T levels and final pathologic report together to biochemical recurrence after RP., Materials and Methods: We prospectively analysed 143 patients submitted to RP from February 2008 to June 2010 in our centre. Pretreatment T and sex hormone-binding globulin levels were determined as part of our clinical protocol. Free calculated (fT) and bioavailable (bioT) T were calculated using Vermeulen's formula. Low T levels were defined as 346 ng/dL or less. A comparative analysis with variables pTNM, positive margins, tumour burden, Gleason score, multifocality and biochemical recurrence (using both PSA>0.4 ng/dL and PSA>0.2 ng/dL as cut-off values) was performed, according to preoperative levels of T., Results: Variables Gleason score, rate and number of positive margins, tumour burden, tumour multifocality, time to biochemical recurrence and pathological stage were not related to preoperative hormonal levels. Preoperative T<346 ng/dL was not found to be related to PSA recurrence (PSA>0,4 ng/dL log-rank, P=.512), although a trend was observed when PSA>0,2 ng/dL (log-rank, P=.097)., Conclusion: Preoperative T levels were not related to final pathological report or to biochemical recurrence., (Copyright © 2012 AEU. Published by Elsevier Espana. All rights reserved.)

The development of ischemic gangrene of the penis following implantation of prosthesis is unusual, and very few cases are available in the literature. As a result, no established treatment protocol is available. We report our experience within a case of gangrene of the glans following implantation of a three-component prosthesis. We present a 53-year-old male, smoker with diabetes and hypercholesterolemia, who underwent surgery for the insertion of a penile prosthesis with 3 components to correct his erectile dysfunction and severe Peyronie's disease. The procedure was carried out without incidents. During the postoperative period, the patient began to complain from penile and perineal pain. He developed avascular necrosis of the glans. The necrosed area was excised. Four weeks later, he developed fever and perineal pain arriving to the emergency room with the prosthesis extruding through the glans. He had emergency surgery to remove the prosthesis plus surgical lavage and was prescribed broad-spectrum antibiotic therapy. Four weeks later, the penis was completely revascularized and reepithelialized. Ischemic gangrene following penile prosthesis implantation takes place in patients with poor peripheral vascularisation. Diabetes mellitus has been the common denominator to all of the reported cases.

Objective: To investigate whether radical nephrectomy (RN) and nephron-sparing surgery (NSS) for T1 renal cell carcinoma influence renal function, oncological outcome or survival rate., Material and Methods: A retrospective study was performed, including 290 nephrectomies for tumours of a diameter of less than 7 cm; 174 radical nephrectomies were compared to 116 nephron-sparing surgeries. Preoperative and pathological data were compared between the two groups. The glomerular filtration rate was estimated using the abbreviated Modification of Diet and Renal Disease (MDRD4) study equation. The evolution of renal function was analysed from 6 months to 4 years after surgery, and the oncological outcomes were evaluated by means of cancer and non-cancer survival curves., Results: The results showed a major impairment in renal function in the RN group compared to those who underwent NSS (25 vs 7 ml/min/1.73 m², 6 months after surgery), a difference that was maintained over time. Moreover, patients undergoing RN had a greater chance of developing renal failure. Overall, the survival curves showed a higher mortality rate for the RN group (p = 0.034), although the cancer-specific mortality rate did not show any statistically significant differences (p = 0.079)., Conclusions: For stage T1 renal cortical tumours, NSS should, whenever possible, be regarded as the primary therapeutic option, given that it obtains similar oncological outcomes to RN and preserves renal function, which seems to translate into a lower overall mortality rate.

Introduction: The Erection Hardness Score (EHS) is a one-item questionnaire that assesses rigidity on a 4-point scale., Aim: To perform a validation of a Spanish version of the EHS by comparison with the International Index of Erectile Function (IIEF) questionnaire., Methods: Validation of the EHS included: (i) professional translation of the scale; (ii) scientific evaluation of the translation from four independent urologists; (iii) assessment on five individuals to test correct comprehension and idiomatic adequacy (iv) validation of the EHS by a cross-sectional, multicenter comparison with the IIEF., Main Outcome Methods: Patients were required to respond to a Spanish version of the EHS and IIEF. Statistic correlation was carried out between the EHS score and IIEF-erectile function domain (EF) score., Results: A total of 125 patients were recruited. Overall prevalence of erectile dysfunction (ED) by the EHS questionnaire was of 80.2% patients (n=97). Mean EHS was 2.74±0.97. Mean IIEF-EF score was 17.4±9.5. The EHS showed good reliability. The rate of missing responses to the EHS questionnaire was 0%. A one-factor analysis of variance was performed between the EHS and EF subdomain of IIEF (P=0.000). Pearson's correlation coefficient between EHS and EF subdomain of IIEF was 0.834, P<0.01., Conclusions: The EHS is a reliable tool to test ED and its Spanish version was satisfactorily understood by patients and correlated with IIEF-EF., (© 2010 International Society for Sexual Medicine.)

Introduction: Radical nephrectomy has traditionally been considered as the standard treatment for renal tumors. Nephron-sparing surgery was introduced two decades ago. Its excellent oncological and functional results have led to widespread use of this procedure. This procedure was first performed at our institution in 1991. Our experience with open partial nephrectomy is reported., Materials and Methods: Our series of 83 open partial nephrectomies performed from 1991 to date for oncological purposes is analyzed. The demographic, intraoperative, postoperative, oncological, and functional results are reported. A survival analysis and renal function evaluation is also provided., Results: Thirty-four of the 83 open partial nephrectomies (42%) were non-elective. Mean tumor size was 36 mm (12-120). Fifty-two percent of tumors were exophytic and 38% endophytic. The most relevant intraoperative variables included a median surgery time of 160 min, an ischemia time of 15 min, a blood loss of 500 mL, and a 9-day hospital stay. Twenty-four percent of patients experienced complications, of which fistula was the most common, occurring in 6 patients (8.8%). The pathological study revealed clear renal cell carcinoma in 57% of patients and benign tumors in 25%. Stage at diagnosis was pT1A in 61% of patients, pT1B in 27%, pT2 in 3%, and pT3 in 9%. Grade 2 of Furham classification was most common (40%). Positive surgical margins were seen in 4% of patients. Cancer-specific survival rates were 94% at 5 years and 85% at 10 years. A slight increase was seen in median creatinine levels when preoperative and postoperative values were compared: 0.04, 0.11, 0.08, and 0.03 at 6, 12, 24, and 36 months respectively. A minimum, statistically significant increase was found in mean creatinine levels 6, 12, 24, and 36 months after surgery as compared to preoperative values., Conclusions: Open partial nephrectomy is a feasible procedure routinely used in our standard practice. Its oncological results are satisfactory and consistent with those reported in the literature. The procedure also has a low complication rate and an excellent functional outcome, and is therefore the procedure of choice for a wide spectrum of patients when performed by experienced surgeons.

Purpose: In a nonrandomized prospective fashion we compared the oncological, functional and morbidity outcomes after laparoscopic and retropubic radical prostatectomy., Materials and Methods: Between January 2003 and December 2005 a total of 1,430 consecutive men with clinically localized prostate cancer underwent radical prostatectomy, laparoscopic in 612 and retropubic in 818. The surgical approach was selected by the patient. Preoperative staging, respective surgical techniques, pathological examination and followup were uniform. Functional outcome was measured by patient completed health related quality of life questionnaire., Results: Positive surgical margin rates (11%) and freedom from progression (median followup 18 months) were comparable between laparoscopic and retropubic radical prostatectomy (HR 0.99 for laparoscopic vs retropubic radical prostatectomy, p = 0.9). We found no significant association between operation type and time to postoperative potency (HR 1.04 for laparoscopic vs retropubic radical prostatectomy; 95% CI 0.74, 1.46; p = 0.8). Patients who underwent laparoscopic radical prostatectomy were less likely to become continent than those treated with retropubic radical prostatectomy (HR 0.56 for laparoscopic vs retropubic radical prostatectomy; 95% CI 0.44, 0.70; p <0.0005). Laparoscopic radical prostatectomy was associated with less blood loss (mean ml +/- SD 315 +/- 186 vs 1,267 +/- 660) and lower overall transfusion rate (3% vs 49%). No significant difference was noted in cardiovascular, thromboembolic and urinary complications. Emergency room visits and readmissions were higher after laparoscopic radical prostatectomy (15% vs 11% and 4.6% vs 1.2%, respectively)., Conclusions: At our institution and during the study period laparoscopic radical prostatectomy and retropubic radical prostatectomy provided comparable oncological efficacy. Laparoscopic radical prostatectomy was associated with less blood loss and a lower transfusion rate, and higher postoperative hospital visits and readmission rate. While the recovery of potency was equivalent, that of continence was superior after retropubic radical prostatectomy.

Introduction: The optimal outcome of radical prostatectomy is to cure cancer with the least impact on quality of life. The aim of this paper is to review the existent literature and attempt to compare the results of the retropubic (RRP) with the laparoscopic (LRP) approach., Methodology: Extensive Medline literature search for terms "radical retropubic prostatectomy" and "laparoscopic radical prostatectomy" from 1980 to 2006 to compare cancer control, functional outcomes and morbidity for both groups. Only full length English language articles including 100 or more patients were considered., Results: The 5-year biochemical recurrence rates range from 70-92% for the RRP vs. 82-91% for the LRP. The global positive surgical margin rates are 12-20% for the RRP and 17-30% for the LRP. The continence rate for the RRP varies from 70-93%; the LRP varies from 82-95% for 12 months. Considering potency 12 months after surgery, the rates are 17-75% for the RRP vs. 52-78% for the LRP. The blood loss for the RRP ranges from 818 to 1,500 ml and 220 to 1,100 for the LRP., Conclusions: The concurrent literature lacks randomized trials comparing the different surgical techniques. No definitive conclusions can be drawn.

Objectives: With regard to oncological outcomes and perioperative morbidity, surgical treatment of localized prostate cancer has proved to be an excellent treatment option. At present, there are three different approaches, open, laparoscopic and robotic. Open radical prostatectomy remains the "gold Standard" due to accumulated experience and long follow up of series. But, without a doubt, laparoscopic and robotic groups are contributing with a far from negligible experience. Looking carefully at outcomes we will have to elucidate amongst advantages and disadvantages of each one of them. In this study we have performed a review of the literature trying to compare the three techniques, focusing in available surgical morbidity and oncological outcomes., Methods: We performed a systematic search in the following data bases: PubMed; EMBASE; Cochrane; SCOPUS; Science Citation Index, from January 1990 to January 2007 for terms: "radical retropubic prostatectomy"; "open radical prostatectomy"; "laparoscopic prostatectomy"; "laparoscopic radical prostatectomy"; "robotic prostatectomy"; "robotic radical prostatectomy"; "treatment outcome", "oncologic outcome"; "outcomes morbidity"; "mortality" and "minimally invasive treatment". We analyzed the most representative series (finished learning curve) in each one of the three approaches regarding perioperative morbidity and oncological outcomes., Results: To be able to perform an objective and truthful comparison of the three techniques, there is an absence in randomized studies in the literature. In this scenario we have analyzed the most representative individual series. With respect to the analyzed perioperative results, it seems to be no clear differences regarding surgical time, intraoperative complications, and catheter and hospital stay days. Otherwise, the endoscopic approach (laparoscopy and robotics) show a more favorable results in respect of blood loss and less postoperatorive analgesic. The short-term oncological outcomes (surgical margins) seem to be comparable amongst the three approaches. We only have long-term data (more than 10 years) on open series biochemical recurrence., Conclusions: The open surgery has become a reference for all comparisons. The laparoscopic surgery is being replaced (specially in North America) by robotic surgery which is constantly expanding. It is necessary the publication of randomized and prospective studies to be able to objectively compare the three techniques.

Objectives: Radical prostatectomy is worldwide accepted as treatment for clinically localized prostate cancer. Its oncological results are excellent, so nowadays the functional outcomes: continence and potency, have become essential factors when evaluating the results. Open radical prostatectomy (ORP) is the gold standard against the new techniques, Laparoscopic (LRP) and robotic (RRP) must be compared. A systematic review of the literature is done to evaluate functional outcomes between the three approaches., Methods: Systematic review in the databases: PubMed; EMBASE; Cochrane; SCOPUS; Science Citation Index for: "radical retropubic prostatectomy", "open radical prostatectomy"; "laparoscopic prostatectomy"; "laparoscopic radical prostatectomy"; "robotic prostatectomy"; "robotic radical prostatectomy and functional assessment"; "continence"; "urinary function"; "incontinence"; "erectile function"; 'sexual function"; "quality of life"; "functional assessment"; "minimally invasive treatment was performed"., Results: The lack of randomized trials for this issue forces us to evaluate the functional results comparing the most important series of each approach, so the value of the results are very limited. Accepting 0 pads per day as continence definition and evaluated 12 months following surgery, the continence rates for each approach ORP, LRP and RRP are respectively: 8 1% (60-93%); 87% (82-95%) and 91% (84-98%). For erectile function admitting the capability for intercourse as potency definition, with or without the use of oral drugs and evaluated 12 months following surgery; the potency rates for each approach are: 68% (62-75%), 69% (52-78%) y 60% (20-97%)., Conclusions: Due the lack of randomized trials, we have to evaluate the most important contemporaneous series. The lack of homogeneity in evaluating and reporting results is evident in the urological community. With the limitations of the data available it seems to exist no differences between the three groups for functional outcomes. It is mandatory to develop randomized trials and achieve a consensus for the criteria at the time of evaluating the functional outcomes.

Introduction: Urolithiasis in the pediatric age is a growing problem. In the developed world they are of calcium oxalate and in the upper urinary tract. It is very similar to the presentation of lithiasis in adults, so we have to make an effort to apply the experience in this age to the children. The shock wave lithotripsy is admitted as the first treatment for this pathology in the pediatric population already. The endourological approach must be use as a common approach in this group. We present our technique and experience., Material and Methods: A retrospective, descriptive study of the children diagnosed of lithiasis in the upper urinary tract that were treated by an endourological technique in our centre between January 1992 and January 2005. We gathered data on: 1.) Preoperative: age, sex, clinical manifestations, size (mm) and position of the lithiasis (we divided the upper urinary tract in: renal, proximal third, medial third and distal third) 2.) Operative variable: endourological technique: percutaneus neprolithotomy or ureteroscopy. Reconversion to open surgery. 3.) Postoperative variables: time since surgery, complications and the current state of the patient (ultrasonography and renal function)., Results: Seven children, 4 boys and 2 girls with an age range of 2,5 to 14 years, underwent operation using an endourological technique. Lumboabdominal pain was the main clinical manifestation (4/7). The lithiasis size was 4-7mm, with the exception of a staghorn calculis. The calculis were: 5 ureteral proximal, 1 ureteral distal and one in the kidney (staghound stone). We performed one percutaneus neprolithotomy for the staghorn calculi. We removed completly the stone and had no complications. The 6 other procedures were ureteroscopies. In 3 of them we removed the calculi (4/7 success rate of 57%). The rest procedures we needed to transform in open surgery. With a following time of 1-13 years all of them are asymptomatic, and with ultrasonography and renal function in the normal limits. We did see no complications., Conclusion: The endourological treatment for urolithiasis in pediatric patients is possible but must be individualized in each case. With the development of new endourological material and more surgical experience this technique will be to the reach of the most of the urologists.

Robotic is an antique concep. The first robots used in surgery were precise path systems in the 80's. Stereotactic neurosurgery was the first field applying this devices. Based on these more complex devices were built: AESOP and Endoassist help the surgeon during the surgery. The surgical assistant will not fatigue and there will be no tremor of the camera. Finally the master-slave devices were developed. They are the most commenly used all around the world. They are involved many types surgery in. To evaluate the cost-effectiviness of robotics in surgery is our responsability. Robotics provides many advantages but also has a few disadvantages including expense.

Unlabelled: Endourological treatment of pelviureteric junction obstruction in paediatric patients: our experience., Introduction: Pelviureteric junction (PUJ) obstruction is the most common cause of hydronephrosis in the infancy. The gold standard of treatment is open pyeloplasty, but there is an ever greater tendency towards minimally invasive procedures. We present our serie of paediatric patients with endourologically treated PUJ obstruction, together with a review of the literature., Material and Methods: Retrospective, descriptive study of the children diagnosed of PUJ obstruction who were treated by an endourological technique in our centre between January 1988 and January 2005. We gathered data on 3 periods of time: 1st. Presurgical: age, sex, previous treatment, ultrasound (USS) and nuclear medicine (MAG-3) studies; 2nd. Surgical: type of procedure; 3rd. Surgical: recurrence or not and its treatment, and the current state of the patient., Results: Seven children, with an age range of 13 months to 14 years, underwent operation using an endourological technique. The treatment was secondary in five of these patients, after open pyeloplasty, and was primary in 2 cases. The preoperative USS showed grade III dilatation in 3 and grade IV dilatation in 4, and the MAG-3 study showed type II curves in 6 and a type IIIb curve in 1. Three percutaneous endopyelotomies were performed and, by the retrograde approach, 3 balloon dilatations and one Acucise. With a mean follow-up of 37 months, 2 cases of recurrence (both in patients receiving secondary treatment) have been observed, one in whom a retrograde technique (balloon dilatation) was used and the other in a patient treated by an antegrade technique. The remaining five patients are asymptomatic and show no evidence of recurrence (71% of the patients)., Conclusion: The endourological treatment of PUJ obstruction in paediatric patients is possible but must be individualised in each case. Larger, prospective studies need to be performed in order to reach conclusions.

Unlabelled: Transrectal biopsy is one of the most frequent procedures in urological practice. Generally, transrectal biopsies have been practiced without anesthesia, because of a supposed good tolerance. Nevertheless, it is not infrequent to find patients with a high level of pain and adverse effects attributable to such procedure., Objectives: In the present article the effect of transrectal local anesthesia in order to significantly diminish the perception of pain by the patient is evaluated., Methods: A total of 131 consecutive patients undergoing transrectal prostate biopsy are included in the study. After randomization, 76 patients were biopsiated with anesthesia and 55 represent the control group. Cases and control groups do not differ in age or prostate volume. Anesthesia consisted on a periprostatic nerve blockage with injection of 5 cc of 1% mepivacaine solution in the angle between prostate and seminal vesicles bilaterally. A visual analogical scale for pain was used; it was given to the patient at the end of the procedure., Results: Mean pain value was 2.41 with a median of 2.0 in the group with anesthesia, and 4.02 with a median of 4 in the control group. A Student's t test comparing the means showed a statistically significant difference of 1.61 (p < 0.0001). Pain in the scale was 66% greater in the control group., Conclusion: The use of anesthesia in the performance of transrectal biopsies significantly diminishes the perception of pain by patients. This effect, along with the tendency to increase the number of biopsies, will result in short time in a more generalized use of local anesthesia.

The megalourethra is an uncommon congenital anomally. It is a consecuence of the abnormal development of the corpus spongiosum and, occasionally, also the abnormal development of the corpora cavernosum. It is specially common in association with the Prune-Belly syndrome, and with upper tract abnormalities. We present a bizarre case because of its association with a VACTER syndrome.

The Brucellosis is a zoonotic and unfrequent infection but it is endemic in Spain. It is a well documented cause of fever of unknown origin with varied and nonspecific symptoms. The onset of symptoms of brucellosis may be abrupt or insidious, developing over several days to weeks. Virtually any organ system can be involved with brucellosis and localization of the process may cause focal symptoms. The most frequent focal presentation is the osteoarthicular. Some times it can complicates with para-perivertebral abscess. The unilateral psoas abscess(PA) is uncommon and the bilateral afection is exceptional. The manifestations of PA usually are insidious, the classic tiad of: feber, lumbar pain and functional impotence is rare. For the diagnosis the serology c tests and cultures are necesary. The imaging techniques like: Ultrasonography and Tomography have improved the diagnosis and treatment of this pathologies' complications. The recommended therapy is the use of doxycicline and streptomicine. Some times the use of percutaneous drainage or open surgery is necessary.

Adenocarcinoma of the bladder is an uncommon neoplasm. Depending on its origin it is classified in: primary, secondary and urachal. Generally it grows to the density of the wall, so its clinical appearence is delayed, with the subsequent delayed diagnosis and although an agressive treatment is performed, it frequently has a very bad prognosis. Since there are very few publications of this kind of neoplasm in the literature the lines of actuation in this pathology are not well established. We report the eleven cases of adenocarcinoma neoplasm of the bladder treated in our centre and review the literature.