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The Coronavirus (COVID-19) pandemic, typified as such in March 2020 by the World Health Organization (WHO), has exceeded the capacity of health systems to aid victims, and triggered a radical change in medical research, and in the monitoring of the enrollment for clinical trials in urologic fields around the world. Last year, almost 90% of clinical sites closed patient enrollment, while at the same time, researchers around the world initiated almost 1000 COVID-19 clinical trials. This catastrophic pandemic has allowed us to expand our medical knowledge exponentially. The global urological community has created and published an infinity of scientific articles: establishing guideline reactions for diagnosis, treatment, and follow-up of the different urologic conditions across all areas of the field, reporting the experiences at urology services, and putting forward new strategies. The Confederación Americana de Urología (CAU) has promoted international collaborative projects that have led to gaining insight into how the Latin American Urology Services faced the pandemic, including the challenges, strengths, and the areas of opportunity for urologic care. It also allowed us to increase the number and quality of publications. Also, we have created new virtual platforms and international networks to exchange our knowledge. We have as well transformed this social, economic and health crisis brought upon us by COVID-19, into a source of opportunities for the growth and promotion of research in Latin America. Urologic patients, require researchers to work on favoring their goals. A collaborative network, the established and coordinated protocols, the safety of patients and researchers, assertive and constant communication, and effective technology use, are the essential tools to resume institutional investigation under these critical conditions.

Context Prostate-specific membrane antigen (PSMA) positron emission tomography/magnetic resonance imaging (PET/MRI) is a novel imaging technique with several potential applications in the prostate cancer (PCa) setting. Objective To perform a systematic review of the current evidence regarding the diagnostic performance of PSMA PET/MRI in patients with primary and recurrent PCa. Evidence acquisition A comprehensive bibliographic search on the MEDLINE and Cochrane Library databases was performed in October 2020. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies were deemed eligible if they assessed patients with primary or recurrent PCa (P) undergoing PSMA PET/MRI (I) with or without comparison with other imaging techniques (C) in order to evaluate its diagnostic performance (O). Retrospective and prospective primary clinical studies were included. Results of previous meta-analyses were reported. Evidence synthesis A total of 23 original articles and three meta-analyses were included. Limited evidence on PSMA PET/MRI is available, especially in the setting of partial gland ablation. PET/MRI can be an effective imaging modality for detecting primary PCa, showing higher accuracy than multiparametric MRI alone. It provides accurate local staging of primary PCa; however, there are contradictory results in this context when its performance is compared with other imaging techniques. PET/MRI also shows high performance for restaging and detecting tumor recurrence, even at low prostate-specific antigen levels. Conclusions PSMA PET/MRI could represent a valuable tool in the management of patients with primary and recurrent PCa. No specific recommendations can be provided. Patient summary Encouraging data regarding the benefits of prostate-specific membrane antigen positron emission tomography/magnetic resonance imaging in patients with prostate cancer are emerging from the literature.

The Peyronie’s Disease Questionnaire (PDQ) is a 15-question self-reported questionnaire that evaluates the severity and physical and psychosexual issues of Peyronie’s disease (PD) symptoms in three scales: “psychological and physical symptoms,” “penile pain,” and “symptom bother.” Previous studies validated the PDQ US version and confirmed its test–retest reliability and responsiveness. The aim is to translate and validate the Spanish version of the PDQ to be used in the clinical practice and in PD research studies in Spain. A non-interventional, observational study with 160 PD patients was conducted. Patients included from four healthcare centers in Spain and completed the PDQ in two study visits separated for a period of 4–7 days from March 2018 to June 2019. Patients received no type of treatment or intervention. Different statistical tests were applied to the data in order to validate the structural and construct of the PDQ, as well as its internal reliability, temporal stability reliability, reliability between observers, and test–retest reliability. Cronbach’s alpha over 0.9 showed good internal consistency. We found an ICC agreement of 0.82 (test–retest) for the three scales of the Spanish version of the PDQ, which demonstrates good reliability. When comparing Visit 1 and Visit 2 questionnaires mean scores, the PDQ showed non-significant differences, as expected because no intervention or treatment was administered to the patients between visits. Translation and validation of the PDQ for the Spanish population makes available a valid, useful, and reliable tool to properly evaluate quality of life of men suffering PD.

Phosphodiesterase type 5 inhibitors (PDE5Is) are the first-line therapeutic option for erectile dysfunction (ED), while second-line therapy includes the alprostadil. Due to the different pharmacodynamic mechanism of PDE5Is and alprostadil, a synergistic action is conceivable when they are administered in combination. The aim of present study was to evaluate the efficacy and safety of combination therapy with PDE5I and topical alprostadil in patients with ED non-responders to PDE5I alone. We designed a prospective, two-arm, open-label, non-randomized study. Patients over 18 years old, with a stable sexual relationship for at least 6 months, and ED non-responders to PDE5I monotherapy were included in the study. At baseline the variables assessed were 5-item version of the International Index of Erectile Function (IIEF-5), and Sexual Encounter Profile Questions 2 and 3 (SEP-2 and SEP-3). In addition, all subjects underwent penile dynamic duplex ultrasonography. All patients were assigned to the monotherapy group (Group A) or combination therapy group (Group B) based on their preference. Topical alprostadil 300 mu g/100 mg (Virirec (R)) was the treatment assigned to Group A, while the combination therapy with the last PDE5I taken (at the maximum recommended dose) plus topical alprostadil 300 mu g/100 mg (Virirec (R)) was assigned to Group B. After 3 months from assignment to groups were evaluated IIEF-5, SEP-2 and SEP-3 regarding the last sexual intercourse, and Global Assessment Questionnaire-Questions 1 and 2 (GAQ-1 and GAQ-2). All adverse events (AEs) that occurred during the study period were recorded. A total of 170 patients were included in the study (72 in Group A and 98 in Group B). Fifty-two patients were previously treated with sildenafil 100 mg (30.6%), 6 with vardenafil 20 mg (3.5%), 56 with tadalafil 20 mg (32.9%), and 56 with avanafil 200 mg (32.9%). No significant differences among the study groups were found at baseline (p > 0.05). The mean IIEF-5 score increased significantly in Group B after treatment compared to baseline (12.4 +/- 3.4 vs. 17.1 +/- 4.5; p < 0.001), conversely patients in Group A showed no significant increase (12.2 +/- 2.5 vs. 12.7 +/- 3.1; p = 0.148). The number of affirmative responses to SEP-2 was significantly higher after treatment compared to baseline only in Group B (57 vs. 78; p < 0.001). The number of affirmative responses to SEP-3 was significantly higher after treatment compared to baseline in both groups (p < 0.001). The number of affirmative responses to GAQ-Q1 and GAQ-Q2 was significantly higher in Group B compared to Group A (p < 0.001). A total of 59 (34.7%) patients experienced AEs. They were mild, self-limited, and did not cause discontinuation of treatment. No episode of priapism was recorded. No statistically significant difference was recorded between the AEs of the two groups, except for facial flushing that was reported only in Group B (p = 0.021). The combination therapy with topical alprostadil and PDE5I seems to be more effective than topical alprostadil alone without worsening the safety of the treatment.

Background A xenograft consisting of equine collagen coated with human fibrinogen and thrombin (TachoSil; Baxter, CA) has recently been introduced in grafting procedures for Peyronie’s disease (PD). Aim To describe the results of a multicenter prospective registry on patients with PD undergoing plaque incision or and grafting (PIG) or plaque excision and grafting (PEG) with collagen fleece TachoSil, to evaluate the efficacy and safety of this procedure. Methods A prospective non-controlled multicenter study of patients with PD was performed between May 2016 and March 2018. Patients from 10 centers with stable PD for at least 3 months, difficulties in sexual intercourse, normal erectile function with or without pharmacological treatment, curvature >45°, and/or penile shortening and/or complex deformities were included. All patients underwent PIG/PEG with collagen fleece TachoSil. Outcomes The main outcome measure of this study were penile curvature correction (intraoperative), penile shortening (intraoperative), erectile function with the 5-item version of the International Index of Erectile Function (IIEF-5) and the Erection Hardness Score, subjective patient outcomes with non-validated questionnaires, and complications. Results A total of 52 patients were enrolled in the study. The mean (SD) preoperative penile curvature was 72.8° (17.0). PIG was the preferred technique (80.8%). Intraoperatively, complete curvature correction was achieved in 92.3%, and no significant penile shortening was recorded in 80.8% of subjects. Subjective penile shortening was reported in 83.3% of patients at 6 months. No objective measurement of penile curvature and length was recorded during follow-up. No statistically significant difference from the baseline was found in IIEF-5 and Erection Hardness Score at 3 or at 6 months, although 16.7% of men experienced a worsening of IIEF-5 scores and 14.3% required de novo phosphodiesterase type 5 inhibitor use. 6 months after surgery, 78.5% of men were satisfied with intervention. Swelling and ecchymosis/hematoma were the most common perioperative complications (40.4%). 2 cases (3.8%) of wound infection were recorded. At 6 months, 35.7% of patients reported mild penile hypesthesia. Clinical implications Our results confirm the high success rate of grafting with TachoSil, and the surgeon perceived low percentage of penile shortening. Strength & Limitations This is the first multicentre study on patients with PD undergoing grafting with TachoSil without concomitant placement of penile prosthesis. The main limitations are the short follow-up and the relatively small sample size. Conclusion Grafting with TachoSil after PIG/PEG in patients with PD is an effective and safe procedure. Among the main advantages of this technique, there are ease of use of the graft and reduced operative time.

Objectives To analyze the impact of South Asia’s first cadaveric hands-on workshop on urologists’ training in inflatable penile prosthesis surgery. Methods A total of 72 urologists/andrologists participated in the 2019 South Asian Society for Sexual Medicine Pre-congress Penile Prosthesis hands-on workshop. The workshop included 4 h of lectures and 2 h of hands-on cadaveric laboratory experience using three-piece inflatable penile prosthesis. The Shapiro–Wilk test was used on self-rated procedural confidence levels, which proved the normality. A non-parametric McNemar test was used to examine the change in the number of correct answers. Results Of those who attended the cadaver laboratory, just 45 who answered the survey both before and after the workshop were included for analysis. Significant objective improvements were noted in procedural knowledge test scores (44.30 ± 0.027 vs 72.44 ± 0.024, P < 0.05) and median surgical confidence levels (4 vs 3 and 2, P < 0.001) of the urologists after the completion of the workshop. Conclusions Cadaveric hands-on workshop training improves urologists’ procedural knowledge and surgical confidence levels in carrying out three-piece inflatable penile prosthesis surgery. The feasibility of such workshops should be considered in increasing the surgical expertise of general urologists in prosthetic urology. pre-print 905 KB

The aim of this study was to study the clinical effectiveness of a structured home modeling (HM) protocol in Peyronie’s 9 disease (PD) patients who have residual curvature up to 45° after inflatable penile prosthesis (PP) placement. A total of 92 10 patients with PD and coexistent refractory erectile dysfunction received inflatable PP. If residual curvature after manual 11 modeling (MM) was more than 45°, incision–grafting was performed. If curvature was

Introduction The use of biomarkers in the detection of prostate cancer (PC) can decrease overdiagnosis and overtreatment of non-significant PC. We analyze the usefulness and applicability of the SelectMDx® marker in a routine clinical practice setting. Material and methods Retrospective study of 48 patients evaluated by the SelectMDx® test between July 2017 and April 2019. Patients were stratified into two groups according to the risk estimated by the clinically significant CP test (CS-PC): 2%. Results were expressed based on previous prostate biopsy (PB) and MRI outcomes. Results Patients with negative PB and normal/doubtful MRI had 2% risk presented CS-PC. Of the 14 patients with no previous PB or MRI, 9 had 2%. The number of patients in the remaining subgroups is too small to draw any conclusions. In all cases with pathological digital rectal examination, the test showed a >2% PC risk. Conclusion SelectMDx® is a promising test for detecting patients with a very low risk of CS-PC, especially in patients with suspected PC, with or without negative PB, with normal/doubtful MRI. The presence of a pathological digital rectal examination may condition the result of the test.

Aim To evaluate whether positron-emission tomography/computed tomography with 68Ga-PSMA (68Ga-PSMA PET/CT) influences the therapeutic management of patients with primary or recurrent prostate cancer (PCa). Background Although 68Ga-PSMA PET/CT is one of the best options for staging or restaging patients with PCa, its availability is still very limited in Spain. The present study reports the results of the first group of patients in Spain who underwent 68Ga-PSMA PET/CT imaging. Materials and methods All patients (n = 27) with a histological diagnosis of PCa who underwent 68Ga-PSMA PET/CT prior to the definitive treatment decision at the only centre with this technology in Spain during 2017–2018 were included. Two nuclear medicine physicians and a radiologist reviewed the imaging studies. The clinical impact was assessed from a theoretical perspective, based on the treatment that would have been applied if no data from the 68Ga-PSMA PET/CT were available. Results Most patients (n = 26; 96%) had persistent disease or biochemical recurrence after radical prostatectomy, radiotherapy, or combined treatment. One patient underwent 68Ga-PSMA PET/CT imaging to stage high-risk PCa. Overall, 68Ga-PSMA PET/CT was positive in 19 patients (70.4%). In 68.75% of these patients, none of the other imaging tests—MRI, CT, or bone scans—performed prior to the 68Ga-PSMA PET/CT were able to detect the presence of cancerous lesions. Overall, the findings of the 68Ga-PSMA PET/CT led to a modification of the therapeutic approach in 62.96% of the patients in the study. Conclusions 68Ga-PSMA PET/CT alters the therapeutic approach in a substantial proportion of patients with PCa. Sin financiación No data JCR 2020 0.367 SJR (2020) Q3, 253/354 Oncology No data IDR 2020 UEM

Penile prosthesis (PP) has undergone significant innovation since its first inception in the early 1970s. Urologists are gradually embracing prosthetic urology practice by attending live surgical and cadaveric workshops. Knowing which PP to choose in a particular patient and what to counsel are vital to have a satisfied patient after the procedure. Modifiable risks factors such as diabetes, smoking and obesity should be optimised before the surgery. PP implantation in special scenarios such as solid organ transplant recipient, neurological impairment, HIV-positive status and synchronous artificial urinary sphincter placement have been addressed in this chapter. Involving both the patient and the sexual partner before the surgery in most of the discussions will alleviate their apprehension and expectations. Psychosexual counselling may be preferred in CURSED patients (Compulsive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial and Psychiatric) planning for PP. Majority of the papers published on PP are based on devices from Boston Scientific and Coloplast which are the major players in PP division. There are differences in antibiotic coating, material of the cylinders, axial rigidity of cylinders, lock-valve mechanism and shape and sizes of reservoirs and pump. Understanding on how to select the right device for a right patient is what this chapter offers to its readers.

INTRODUCTION AND OBJECTIVE:Infectious complications, like urosepsis represent unfortunate harm associated to transrectal biopsies (TRBx), occurring in 1 out 25 procedures. By contrary, Transperinea...

INTRODUCTION AND OBJECTIVE:The American Cancer Society estimates that 248,530 men (1 out of every 8) will be diagnosed with prostate cancer during 2021. MR/US has brought precision a in diagnosis a...

The arrival of Pfizer's blue pill Sildenafil in 1998 brought a great relief both to patient and physician signalling the start of a great era of medical therapy in sexual medicine. Since then the sexual medicine experts have been prescribing sildenafil in erectile dysfunction with acceptable minor adverse events. But the use of sildenafil in premature ejaculation (PE) is still debated. 2018 being the 20th anniversary of sildenafil, we have compiled interesting facts about the role of sildenafil in PE from various original articles, systematic reviews, meta-analyses, economic brochures and sexual medicine committee guidelines. The major issues in most of these studies were the heterogeneity in the definition of PE and estimating the exact ejaculatory latency time. This perspective article highlights the positive role of sildenafil in the management of PE (even without ED) with acceptable adverse events. Now that we have a standardised definition of PE from International Society of Sexual Medicine (ISSM) and a psychogenic component in PE definition, more randomised placebo-controlled studies are required to further establish its role.

Introduction Patients with Peyronie’s disease (PD) and erectile dysfunction (ED) concomitant with shortening or other malformations benefit from prosthesis implantation and penile lengthening procedures. Aim To evaluate the safety and efficacy of a multi-incisional technique with penile prosthesis implantation with multiple corporeal incisions and collagen grafting for the surgical management of complex cases of PD with ED and severe penile shortening. Methods From February 2015–May 2018, 43 consecutive patients with complex PD were treated using this technique. Implantation of a penile prosthesis (malleable or inflatable [IPP]) together with multiple relaxing tunica albuginea incisions and grafting with a self-adhesive collagen-fibrin fleece (TachoSil, Baxter Healthcare) was performed in all patients by a single surgeon (J.I.M.S.). Main Outcome Measure Penile length and curvature correction, operative time, and incidence of postoperative complications were recorded as outcome measures. Functional outcomes were measured with questionnaires (International Index of Erectile Function-5, Erection Hardness Score, modified Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire, PD Questionnaire) before and 3 and 6 months after surgery. Results With a median follow-up of 21 months (range 10–31), mean postsurgical penile lengthening was 2.5 (range 1–5) cm, with an improvement in the Bother domain of the PD Questionnaire of 4.4 (range 2–5) points. The average operative time was 86.7 and 71.6 minutes for the IPP and malleable penile prosthesis procedure, respectively. No glans ischemia was recorded; however, 1 IPP infection and 1 delayed distal corporeal erosion were recorded. Hematoma or bruising was observed in 23.2% of patients. The modified Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire was completed by 39 (90.7%) patients. Overall, 89.7% would recommend this surgery. Patient satisfaction with straightness and length was 94.9% and 82.1%, respectively. Clinical Implications The described technique helps restoration of penile length and erectile function in patients with complex PD. Strengths & Limitations The strength of the study is that it offers a simple, easy-to-apply technique for surgeons to correct shortening and other malformations in patients with ED and complex PD. The study is limited by the small number of patients, the short follow-up period and the performance of the technique by a single high-volume implanter. Conclusion The implantation of a penile prosthesis (malleable or inflatable) together with multiple incisions of the plaque/tunica albuginea and grafting with a collagen fleece is a safe and efficient treatment for patients with complex PD in addition to ED and significant shortening.

The Peyronie's Disease Questionnaire (PDQ) is a 15-question self-reported questionnaire that evaluates the severity and physical and psychosexual issues of Peyronie's disease (PD) symptoms in three scales: "psychological and physical symptoms," "penile pain," and "symptom bother." Previous studies validated the PDQ US version and confirmed its test-retest reliability and responsiveness. The aim is to translate and validate the Spanish version of the PDQ to be used in the clinical practice and in PD research studies in Spain. A non-interventional, observational study with 160 PD patients was conducted. Patients included from four healthcare centers in Spain and completed the PDQ in two study visits separated for a period of 4-7 days from March 2018 to June 2019. Patients received no type of treatment or intervention. Different statistical tests were applied to the data in order to validate the structural and construct of the PDQ, as well as its internal reliability, temporal stability reliability, reliability between observers, and test-retest reliability. Cronbach's alpha over 0.9 showed good internal consistency. We found an ICC agreement of 0.82 (test-retest) for the three scales of the Spanish version of the PDQ, which demonstrates good reliability. When comparing Visit 1 and Visit 2 questionnaires mean scores, the PDQ showed non-significant differences, as expected because no intervention or treatment was administered to the patients between visits. Translation and validation of the PDQ for the Spanish population makes available a valid, useful, and reliable tool to properly evaluate quality of life of men suffering PD.

Background Several studies reported high satisfaction rates (> 90%) for patients and their partners after penile prosthesis (PP) implantation. Aim To describe and critically discuss the current evidence regarding the assessment of patient and partner satisfaction after penile implant surgery. Methods A critical narrative review of the studies investigating the patient and partner satisfaction after PP implantation was designed. Papers in English-language published until January 2021 were included. Outcomes The main outcome investigated was patient and partner satisfaction after penile implant surgery. Results The International Index of Erectile Function , the Erectile Dysfunction Inventory of Treatment Satisfaction , the Treatment Satisfaction Scale , and the Quality of Life and Sexuality with Penile Prosthesis are the best-known validated tools used to assess satisfaction after PP implantation. Except for Quality of Life and Sexuality with Penile Prosthesis , they were not validated in patients undergoing penile implant surgery. The lack of an “ad hoc” tool has led to the widespread of nonvalidated questionnaires. Several tools can be useful in the preimplantation counseling, such as the mnemonic Compulsive/obsessive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial, and Psychiatric , the Minnesota Multiphasic Personality Inventory, the Brief Sexual Symptom Checklist for Men , the Attitude towards Penile Implant , and the Attitude Attributed to the Partner towards Penile Implant . Clinical Implications Improvement of knowledge regarding the available tools to evaluate the satisfaction after penile implant surgery. Strengths & Limitations Comprehensive and thorough review of all the main validated questionnaires available to assess satisfaction in patients with PP. Lack of a systematic approach and quantitative data analysis. Conclusion Despite the high satisfaction rate reported in the literature, most of the studies used suboptimal or non-validated questionnaires to assess patients undergoing penile implant surgery. Future research is needed to develop and validate a specific, complete and easy-to-use questionnaire. Manfredi C, Fortier E, Faix A, et al. Penile Implant Surgery Satisfaction Assessment. J Sex Med 2021;18:868–874.

Imaging has a central role in the context of focal therapy (FT) for prostate cancer (PCa). Prostate-specific membrane antigen (PSMA) positron emission tomography/magnetic resonance imaging (PET/MRI) is a novel imaging modality that combines the morpho-functional information of MRI with the molecular characterization of PET. Some papers reported the potential advantages of PSMA PET/MRI in different clinical scenarios. Limited evidence on PSMA PET/MRI is available in the setting of FT. PSMA PET/MRI can be an effective imaging modality for detecting primary PCa and seems to provide accurate local staging of primary PCa. PSMA PET/MRI also shows high performance for restaging and detecting tumor recurrence. The higher soft-tissue contrast and the reduction of ionizing radiation are the main advantages reported in the literature compared to PET/computed tomography. PSMA PET/MRI could represent a turning point in the management of patients with PCa in the context of FT. Further studies are needed to confirm its applications in this specific clinical setting.

The COVID-19 pandemic which has affected Spain since the beginning of 2020 compels us to determine recomendations for the practice of Andrology in present times.A web search is carried out in English and Spanish and a joint proposal is defined by experts in Andrology from different regions of Spain.Most diagnostic and therapeutic procedures in Andrology can be safey postponed during the COVID-19 pandemic. Online consultations and outpatient surgeries must be encouraged. Andrologic emergencies and penile cancer management should be considered high priority, and should be diagnosed and treated promptly even in the most severe phases of the pandemic.INTRODUCCIÓN: La pandemia COVID-19 que ha afectado a España desde comienzos de 2020 obliga a definir unas recomendaciones para la práctica de la Andrología en la actualidad.MATERIAL Y MÉTODOS: Se realiza una búsqueda web en inglés y español y se define una propuesta conjunta por parte de expertos en Andrología de distintas regiones de España.RESULTADOS: La mayor parte de los procedimientos diagnósticos y terapéuticos en Andrología pueden ser demorados con seguridad durante la pandemia COVID-19. Se debe fomentar la consulta telemática y la cirugía ambulatoria. Las urgencias andrológicas y el manejo del cáncer de pene deben considerarse una prioridad alta, diagnosticándose y tratándose con brevedadi ncluso en las fases más severas de la pandemia.

Background Some studies showed encouraging results on the efficacy and safety of penile traction therapy after Peyronie's disease (PD) surgery. The early traction therapy (ETT) could be an effective and safe approach to minimize penile shortening in patients undergoing PD surgery. Aim To evaluate the feasibility, efficacy, and safety of a novel penile splint as ETT in patients with PD undergoing grafting techniques. Methods Patients with PD underwent plaque incision and grafting technique; at the end of the procedure, a novel penile splint (ETT) was applied to all patient. The device consisted of 2 10CH intubating stylets, self-adapted to each patient, that kept the penis stretched with the aid of non-absorbable sutures. The total expense for the materials needed to build each penile splint was less than 15 euros. This active traction was maintained for 1–3 weeks; then, we removed the stitches leaving the device on-site for a passive traction. Within 3–4 weeks from surgery, the penile splint was replaced by a standard penile traction device. Outcomes The main outcomes evaluated at 6 months included stretched penile length (SPL), penile curvature, International Index of Erectile Function-erectile function (IIEF-EF) domain, patient satisfaction, and time to first satisfactory sexual intercourse. Results A total of 46 patients were enrolled. The median preoperative IIEF-EF, penile curvature, and SPL were 27 points, 70°, and 13 cm, respectively. The median follow-up was 15 months. The median postoperative IIEF-EF was 25 points (P < .001). The median residual penile curvature was 10° (P < .001). The median postoperative SPL was 13 cm (P = .269). 8 patients (17.4%) lost 1 cm of SPL; no shortening greater than 1 cm was recorded. The median time to first satisfactory sexual intercourse and patient satisfaction score was 6 weeks and 9 points, respectively. Clinical Implications Our results could pave the way for a new line of research, which in turn could lead to an improvement in the postoperative management of the patient undergoing surgery for PD. Strength & Limitations This is the first study evaluating the ETT after PD surgery. The main limitation of this study is the lack of a randomized control group. Other weaknesses are the small sample size and the short follow-up time. Conclusion Our novel penile splint is inexpensive, easy to assemble, and adaptable to the patient. ETT using this novel device, followed by standard traction therapy, seems to be feasible, effective, and safe.

INTRODUCTION AND OBJECTIVE:Hydrogen sulfide (H2S) signaling has been proposed to participate in erectile physiology. L-cysteine (CYS)/H2S pathway stimulation causes cGMP-dependent relaxation of hum...

At the end of December 2019, the existence of a new pneumonia of unknown causes was reported in the city of Wuhan (Hubei, China).1 Only 3 months later, the World Health Organization declared a pandemic caused by a new coronavirus (COVID-19),2 resulting in an unprecedented crisis in most of the world's health-care systems. Many countries have been overwhelmed by this pandemic and have adapted their facilities and staff in record time to fight against it. But, at the same time, many health-care services have been affected, including sexual medicine. In light of this situation, we are faced with a series of challenges to keep on offering continuity in medical care, education, and research. post-print 134 KB

The European urology guidelines have been written since 1996. In 2000, experts included sections on ejaculation disorders and erectile dysfunction.[1] Since then, each year, they are updated with the competition of specialists from different continents. In 2014, authors introduced the term priapism,[2] and they maintained it until 2018. That same year the guidelines were modified based on the new online educational courses designed by the EAU expert panels and a group of young urologists. For the year 2020 and with the consultation of more than 250 experts from 72 countries, the guidelines gathered in a single chapter (Sexual and Reproductive Health) with extensive content that is worth consulting. Among the novelties, there is a complete change in the chapter regarding the hypogonadism. The use of testosterone replacement is recommended in patients with abnormal values and with erectile dysfunction supported by the Sexual Function trial of testosterone trials since experts previously recommended first use of PDE5 inhibitors. Another issue is the explanation of the effects of hormonal replacement on organs such as prostate and breast as well as how this affects the cardiovascular system. The treatment approach for managing erectile dysfunction changed. After an initial evaluation with a detailed medical history, authors suggest identifying the expectations of the patients to make a joint decision and also offer treatment of physical and psychosexual aspects. Psychosexual therapy continues to be an essential tool in the treatment, better if there is a good follow-up. In the case of choosing a behavioral and cognitive therapy (CBT), they suggest considering its combination with pharmacotherapy. Subsequently, there are different treatment alternatives such as intracavernous injections, vacuum devices, oral therapy with a PDE5 inhibitor and topical and intraurethral treatments. All considered as first line of treatments. Shock wave intervention[3] is also recommended as an option in vasculogenic patients with prior informed consent and after previous treatments as the first line of treatment. The management of Peyronie's disease was extensively reviewed, considering the publication of many of the genes involved in its pathophysiology and its relationship with Dupuytren's disease.[4] Only oral non-steroidal anti-inflammatory drugs (NSAIDs) and phosphodiesterase inhibitors are considered as oral therapy and other options previously considered withdrawn. Despite the recent withdrawal from the European market of collagenase of clostridium histolyticum by its marketing company, the results of the most significant studies regarding the improvement of penile curvature based on the IMPRESS study (Investigation for Maximal Peyronie's reduction efficacy and safety studies) were published.[5] The curvature improvement is 34% versus 18.2% in the placebo group. Patients with curvatures between 30 and 60 degrees, IIEF greater than 17, without calcified plaques and a longer duration of the disease, were those who benefited the most from the treatment. A new shorter protocol for administration of collagenase was mentioned.[6] The use of interferon-a-2b is included as a recommended treatment in the stable phase of the disease due to a 20% reduction in curvature in a recent study, and the few side effects it can cause. Experts reviewed other types of treatments, such as traction therapy. Although they mentioned them as a possible safe and effective option, current studies do not support their use as monotherapy. The vacuum devices are also mentioned as a possible mechanism of mechanical straightening of the curvature but with only one study that recommends it as monotherapy. Regarding surgical management, they better described the surgical technique of penile shortening techniques, reporting penile rectification rates greater than 85%. They mentioned techniques with geometric principles as an option and tunic shortening and lengthening procedures, taking into account the latter types of grafts used and the results obtained. In the chapter on ejaculation disorders, they completely described the pathophysiology and possible causes of hematospermia. In addition to mentioning the types of studies that must be performed, they also reported how to investigate the cause in the initial presentation and recurrent cases. In male infertility, experts presented a text with many modifications (the first published in 2001, updated several years and in 2017 expanded to cover areas not previously mentioned). The diagnostic algorithm emphasizes the evaluation with the fragmentation index (DFI). There is a critical correlation of intrauterine insemination and in vitro fertilization (IVF) with the success rate of pregnancy. There is a new complete explanation about assisted reproduction techniques and some of its characteristics. The guidelines emphasize the role of ultrasound in evaluation, mainly for measuring testicular volume, determining abnormalities in the structure of the testicle (testicular dysgenesis or tumors), and seeing possible indirect signs of obstruction. In infertility-related conditions, the possible role of varicocelectomy in patients with non-obstructive azoospermia, hypogonadism, or patients with altered DNA fragmentation is mentioned as a possible alternative. There are also invasive treatment options (they refer to the types of sperm retrieval technique and their success rates and surgical techniques for reconstruction of the seminal tract depending on the site of obstruction or compromise). Besides, there are non-invasive techniques (such as changes in lifestyle, hormonal therapy and antioxidants). Finally, these guidelines, for the first time, reviewed the effects of urological conditions on sexual and reproductive health. There are interesting relationships of varicocele with cardiovascular disease, the psychological effects of prostate cancer on sexual function and the well-known relationship of erectile dysfunction and cardiac conditions. Priapism, male contraception, or vasectomy chapters have no other updates.In conclusion, the European Guidelines of Urology 2020 are mandatory reading for beginners and experts on the subject. There are novel findings that must be consulted by urologists and residents from all over the world. post-print 90,1 KB

There is clinically relevant molecular heterogeneity in prostate cancer (PCa), but this biological diversity has had only a minimal impact on clinical practice. Treatment outcomes in patients with localised PCa are often highly variable, even among patients stratified to the same risk group or disease state based on standard clinical and pathological parameters. In recent years, the development of gene panels has provided valuable data on the differential expression of genes in patients with PCa. Nevertheless, there is an urgent need to identify and validate prognostic and predictive biomarkers that can be applied across clinical scenarios, ranging from localised disease to metastatic castration-resistant PCa. The availability of such tools would allow for precision medicine to finally reach PCa patients. In this review, we evaluate current data on molecular biomarkers for PCa, with an emphasis on the biomarkers and gene panels with the most robust evidence to support their application in routine clinical practice. Sin financiación 6.639 JCR (2020) Q1, 51/242 Oncology 1.818 SJR (2020) Q1, 63/354 Oncology No data IDR 2020 UEM

Introducción y objetivo El tratamiento de elección en pacientes con enfermedad de Peyronie con dificultad para la penetración o disfunción eréctil sin adecuada respuesta a fármacos es la cirugía. Se han descrito múltiples técnicas, y cada una de ellas acarrea posibles complicaciones y secuelas que el urólogo debe conocer para ofrecer al paciente la mejor alternativa posible. Pacientes y métodos Se exponen 3 casos complejos de pacientes con enfermedad de Peyronie. El primero de ellos es un paciente con una secuela tras una plicatura peneana por una curva importante dorsal. El segundo es un paciente con dificultad para la penetración anal secundaria a un problema de dirección de la erección tras una cirugía de incisión de placa con injerto de mucosa oral. El último caso es un paciente con una complicación tardía en el postoperatorio de una colocación de prótesis de 3 componentes con incisión de la placa y parche de colágeno equino. Resultados Se detallan y discuten las posibles opciones quirúrgicas para los 3 pacientes. Los pacientes fueron informados de las diferentes opciones y se decidió de manera consensuada la cirugía definitiva. Conclusiones La cirugía de la enfermedad de Peyronie exige al urólogo la consideración de las esferas funcional, estética y psicológica a la hora de plantear alternativas de tratamiento. Un abordaje sistemático de todas ellas evita complicaciones y secuelas, y mejora los resultados. pre-print 1298 KB

Background andObjective: Plaque formation ordinarily takes place in the acute phaseof Peyronie’s disease. There is no unanimous consent regarding the management of the acute phase ofPeyronie’s disease.The objective of this study was to evaluate the advantages of using a single intralesional injection of collagenase Clostridium histolyticum in patients with the active phase of Peyronie’s disease and to assess its effect on disease progression by reducing penile curvature and ameliorating pain during sexual intercourse. Methods: Sexually active men aged older than 18years with the acute phase of Peyronie’s disease were enrolled. All patients received treatment with a single intralesional injection of collagenase Clostridium histolyticum. The primary outcome of the study was the change in penile curvature after treatment while secondary outcomes were the change in sexual function (International Index of Erectile Function [IIEF-5]) and in the Peyronie Disease Questionnaire (PDQ) and its sub-scores, PDQ-PS (psychological symptoms), PDQ-PP (penile pain) and PDQ-BD (bother disease). Results: Overall, 74 patients were enrolled. Mean penile curvature at baseline was 41.1° ± 12.2°. The mean changes before and at the 3-month evaluation in terms of penile curvature, Visual Analog Scale score at rest, and Visual Analog Scale score during intercourse were − 19.3 ± 8.4 (p < 0.0001), − 0.8 ± 1.1 (p < 0.0001) and − 3.8 ± 0.9 (p < 0.0001) with the benefit persisting also after 6months. Moreover, improvements of mean IIEF-5 score (1.1 ± 0.9, p = 0.03; 0.9 ± 0.5, p = 0.02), PDQ-PS (− 2.7 ± 2.2; − 2.5 ± 2.0, p = 0.01), PDQ-PP (− 1.2 ± 1.6; − 1.1 ± 1.2, p = 0.02) and PDQ-BD (− 3.8 ± 3.4; − 3.5 ± 3.1, p = 0.001) were observed 3 and 6months after the end of treatment, respectively. At the multivariable regression analysis, the time since disease onset (modelled with non-linear terms) and baseline curvature were independently associated with the degree of curvature improvement (coefficient: 0.30; 95% confidence interval 0.16–0.44) after a single intralesional injection (all p < 0.03). Conclusions: Although intralesional therapy with collagenase Clostridium histolyticum is not yet indicated for the acute phase of Peyronie’s disease, thesepreliminary results suggest the effectiveness of this minimally invasive option by improving penile curvature and IIEF-5 and PDQ scores.

Introduction Surgical intervention in Peyronie’s disease (PD) should ideally be delayed until the resolution of acute inflammatory phase. Aim The objective of this review was to highlight the results of penile prosthesis to correct refractory erectile dysfunction (ED) in patients with PD, and the secondary procedures that may be required to correct the penile curvature. Methods A systematic search on PubMed online database using Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations was done using the MeSH terms “Peyronie’s disease” and “erectile dysfunction.” Main Outcome Measure Success and satisfaction rates of various procedures. Results The search yielded 324 language-specific (English and Spanish language) articles and 58 articles were retained for final review. The following variables were assessed in different studies: number of patients, types of secondary procedure to correct the curvature, satisfaction rates, and follow-up period. Conclusion The aim of the surgery in PD should be to achieve a functionally straight penis (

Introduction Cavernous nerve injury (CNI) in rats and radical prostatectomy (RP) in men result in loss of nitrergic function and increased adrenergic-neurogenic contractions of cavernosal tissue. Aim To evaluate the modulation of the α-adrenergic system as a strategy to relieve erectile dysfunction (ED) and functional cavernosal alterations induced by CNI. Methods A non-selective α-blocker (phentolamine 1 mg/kg daily), a selective α1A-blocker (silodosin [SILOD] 0.1 mg/kg daily), or vehicle was orally administered for 4 weeks after bilateral crush CNI (BCNI). Erectile and neurogenic responses of the corpus cavernosum (CC) were evaluated. The acute effects of SILOD also were evaluated in vivo (0.03 mg/kg intravenously) and ex vivo (10 nmol/L). The effects of SILOD and tadalafil (TAD) on nitrergic relaxations were determined in human CC from patients with ED with a vascular etiology or ED secondary to RP. Main Outcome Measures Erectile responses in vivo in rats and neurogenic contractions and relaxations of rat and human CC. Results Long-term treatment with SILOD significantly improved erectile responses and allowed for the potentiation of erectile responses by acute treatment with TAD (0.3 mg/kg intravenously) in rats with BCNI. SILOD partly recovered nitrergic relaxations and normalized neurogenic contractions in CC from rats with BCNI. Long-term treatment with SILOD partly prevented BCNI-induced decreases in neuronal nitric oxide synthase expression. Acute administration of SILOD (0.03 mg/kg intravenously) improved erectile responses in vivo and potentiated nitrergic relaxation and decreased neurogenic contractions ex vivo in CC from rats with BCNI. In human CC from patients with ED with a vascular etiology, TAD (30 nmol/L), SILOD (10 nmol/L), or their combination increased nitrergic relaxations. Potentiation by TAD was lost in human CC from patients with ED after RP but was recovered after co-treatment with SILOD. Conclusion α-Adrenergic modulation, especially selective α1A-blockade, improves erectile and cavernosal functions after BCNI. Modulation of the adrenergic system, mainly in combination strategies, could have a role in the management of ED after RP.

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 H2O2-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 H2O2-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. Keywords: Oxidative stress, Endothelial dysfunction, Nrf2, Ageing, Human vasculature, Erectile dysfunction

OBJECTIVES To compare the efficacy and safety of a combined treatment of percutaneous needle tunnelling (PNT) and a modified collagenase Clostridium histolyticum (CCH) protocol (PNT/CCH) vs the modified protocol alone (CCH) in the treatment of Peyronie's disease (PD). PATIENTS AND METHODS A prospective registry of patients treated with a modified CCH protocol was maintained between June 2014 and February 2018. The last 50 patients received PNT as an adjuvant therapy (PNT/CCH), and their data were compared with those of the other 94 patients treated previously (CCH). PNT involves the creation of multiple holes made percutaneously in the plaque before each injection. The modified protocol consisted of two collagenase injections, at 1-week intervals, followed by penile modelling. Patients used penile traction therapy, tadalafil and pentoxifylline for the next 2 months and were followed up for 6 months. The main outcome was improvement of curvature. Secondary outcomes were improvements in erectile function, PD symptoms, stretched penile length and satisfaction. RESULTS Improvement in curvature was greater in patients in the PNT/CCH group than in the CCH group (mean ± sd 19.2 ± 6.1° vs 12.7 ± 5.0°; P < 0.001 [36.2 ± 12.5% vs 28.1 ± 14.5%; P = 0.001]). Compared with baseline, both interventions were associated with significant improvement in secondary outcomes. The main complications were ecchymosis, bruising and penile pain, with no significant differences between groups. CONCLUSIONS Treatment of PD with CCH using our modified protocol in combination with PNT is safe and more effective than the modified protocol alone, with the potential for improved cost-effectiveness.