Topic: Men’s Health

Priapism: A Management Enigma

Michael Coburn, MD, FACS, Professor and Russell and Mary Hugh Scott Chair of the Department of Urology at Baylor College of Medicine, discusses priapism and the American Urological Association’s (AUA) guidelines on managing the illness. He gives an overview of priapism, outlining differences between ischemic, non-ischemic, recurrent, primary, and secondary priapism, and discusses a range of contributing risk factors. Next, Dr. Coburn reviews study data on the different qualities of ischemic and non-ischemic priapism, explaining that the latter often is chronic and characterized by less rigidity in the penis, while ischemic priapism tends to be characterized by a fully rigid, very painful erection which contains abnormal cavernous gases. He then discusses treatment recommendations for various forms of the disease, ranging from oral medication for intracavernosal-caused priapism to complex specialty treatment for priapism related to underlying medical conditions. Dr. Coburn concludes by recommending that physicians use the AUA guidelines to create a treatment algorithm for priapism, making sure that if a deviation is made that it is well documented and explained.

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When All Else Fails: Holmium Laser Enucleation of the Prostate as Retreatment for BPH

Nicole L. Miller, MD, FACS, Associate Professor of Urology at Vanderbilt University Medical Center, discusses Holmium laser enucleation of the prostate (HoLEP), particularly focusing on the retreatment setting. AUA guidelines have recently been updated and now mirror EAU guidelines which suggest sizing a prostate before determining treatment options. Dr. Miller examines case studies that underscore the effectiveness of HoLEP in removing large prostates after the patients had previously undergone unsuccessful treatments, including transurethral resection of the prostate (TURP) and prostatic urethral lift. She then analyzes outcomes of a study that compared primary HoLEP (pHoLEP) to retreatment (rHoLEP) observing that the retreatment setting patients experienced shorter operative times, shorter length of stay, had less tissue resected, and had a higher rate of urethral stricture and clot retention. In spite of its utility, HoLEP has not been widely adopted and represents 4% of procedures, which Dr. Miller attributes to the steep learning curve associated with HoLEP. Lastly, she enumerates the barriers within the US medical system to physicians undertaking the HoLEP learning process and concludes that while Europe has numerous options for physicians to learn the technique, the American focus on robotic surgery means that fewer students learn open orifices surgical procedures.

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Biologics in Sexual Medicine – Controversy and Therapeutic Potential

Trinity J. Bivalacqua, MD, PhD, Director of Urologic Oncology and R. Christian B. Evensen Associate Professor of Urology and Oncology at the James Buchanan Brady Urological Institute of Johns Hopkins Medicine in Baltimore, Maryland, discusses studies on biologics and low-intensity extracorporeal shock wave therapy (Li-ESWT), as well as controversial misinformation surrounding their use in sexual medicine. He reviews the results of a Li-ESWT study which displayed the treatment’s ability to improve symptoms, exercise capacity, and myocardial perforation in patients with severe coronary artery disease without indication for percutaneous coronary intervention or coronary artery bypass graft surgery. He then argues that for-profit stem cell clinics who offer biologic treatment for sexual medicine promise results with no supporting efficacy data, and that the trials these clinics use for support are not well-designed. Dr. Bivalacqua concludes that there is a demonstrated therapeutic potential for biologics, but more research is needed to support their use in sexual medicine and to prove their therapeutic value.

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Evidence-Based Guideline for Management of Priapism: Perspectives from AUA/EAU Guideline Panel

Trinity J. Bivalacqua, MD, PhD, Director of Urologic Oncology at Johns Hopkins Medicine, discusses potential solutions to the issues with bacillus Calmette-Guérin (BCG) as a treatment for high-risk non-muscle invasive bladder cancer (NMIBC). Intravesical BCG is more effective than chemotherapy for NMIBC, but approximately ⅓ of high-risk patients are BCG-unresponsive, and there is also a BCG shortage. Dr. Bivalacqua lists potential solutions to both these problems, including early cystectomy, increasing the availability of BCG by using alternative strains, and enhancing immunotherapy. He concludes by discussing research intended to characterize immune cell expression among patients with NMIBC treated with BCG which found that immune checkpoint inhibition with BCG may be beneficial in a subset of patients who experience tumor recurrence after BCG.

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Changing Paradigms in Prosthetic Urology

Steven K. Wilson, MD, FACS, FRCS, explores paradigm shifts in the materials and techniques used for inflatable penile prosthesis implants (IPP) and artificial urinary sphincters (AUS). He focuses on how urologists have improved the standard of care through the use of new technology and a clearer understanding of the negative effects of these procedures. 

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Disease Modification and Erectile Dysfunction: Stem Cells, Shockwave, and PRP

Mohit Khera, MD, MBA, MPH, discusses the shifting paradigms in modern erectile dysfunction (ED) treatment, as reflected by the 2018 American Urological Association ED guidelines. These paradigms focus on shared decision-making, lifestyle modifications, and the concern for cardiovascular risk. He then describes mechanisms of and initial data on experimental regenerative techniques for treating ED, including low-intensity shockwave therapy, stem cell therapy, and platelet-rich plasma (PRP) therapy.

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Testosterone and PSA—A Critical Relationship

John P. Mulhall, MD, discusses the results and implications of a study evaluating the relationship between testosterone and PSA levels in men with prostate cancer. He suggests that these findings indicate that in men with documented prostate cancer, the presence of a pretreatment PSA value below 2 should raise questions about a patient’s testosterone level.

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