Zugail AS, et al. Investig Clin Urol. 2019 Jan;60(1):35-39. https://doi.org/10.4111/icu.2019.60.1.35

Thirty per cent of cases of erectile dysfunction (ED)/male impotence are resistant to oral treatment. Half of these cases are due to blood drainage from the corpora cavernosa occurring too soon, due to cavernovenous leakage (CVL). The aim of this study was to report on an innovative treatment scheme combining pre- and post-operative haemodynamic assessment, venous embolisation, and open surgery for drug resistant ED caused by CVL. An analysis of prospectively collected data, with clinical and haemodynamic pre- and post-operative assessment, was carried out. Forty-five consecutive patients operated on for drug resistant ED caused by CVL were evaluated pre-operatively and three months post-operatively by pharmacologically challenged penile duplex sonography (PC-PDS), pharmacologically challenged Erection Hardness Score (PC-EHS), and pharmacologically challenged computed caverno tomography (PC-CCT). Follow up consisted of patient interview, PC-PDS, PC-EHS and if needed PC-CCT. Mean patient age was 43.9 ± 12.0 years (range 20-67). Forty-nine per cent of patients had primary ED. Patients with diabetes, a smoking habit, hypercholesterolaemia, and hypertension were 18%, 11%, 9%, and 4%, respectively. Three months post-operatively, PC-EHS increased from 2.0 ± 0.7 to 3.1 ± 0.74 (p < .001), with an EHS of 3 being the threshold allowing for penetration. Deep dorsal vein velocity, a haemodynamic marker of CVL, decreased from 14.2 ± 13.0 to 0.9 ± 3.5 cm/s (p < .001). After a 14.0 ± 10.7 month follow up, the primary success rate (clinical EHS ≥ 3, possible sexual intercourse with penetration, no vascular re-operation, no penile prosthesis implant) was 73.3%. Four patients (9%) underwent successful re-operation for persistent ED and CVL. Accordingly, compared with a possible penetration rate of 8.9% before surgery, 37 patients (secondary success rate: 82.2%) were able to achieve sexual intercourse with penetration. Type of ED (primary vs. secondary) and diabetes had no influence on the results. Thirty-two per cent of patients with secondary success achieved penetration with no medication. After a 14 month follow up, pre-operative work up, embolisation, and open surgery during the same procedure allowed patients with ED resistant to oral medical to achieve intercourse with penetration.

Background: Minimally invasive cystectomy is being increasingly performed, however, data comparing laparoscopic radical cystectomy (LRC) and robotic radical cystectomy (RRC) are scarce. We compared 30- and 90-day Clavien–Dindo Classification (CDC) complications between patients undergoing LRC and RRC at our center. Materials and Methods: We retrospectively evaluated 300 patients who underwent minimally invasive radical cystectomy from January 2007 to July 2019 and grouped them into LRC (112 patients) and RRC (188 patients). We compared the two groups for demographic variables, perioperative characteristics, and 30- and 90-day CDC overall, minor, and major complications. Multivariable logistic regression analysis was performed to identify variables that predict perioperative complications. Results: The two groups were comparable for the duration of surgery (270 minutes in LRC vs 265 minutes in RRC) and rate of conversion to open surgery. The RRC cohort had a higher estimated blood loss (EBL) (675 mL vs 500 mL, p = 0.006), but the two groups had a comparable need for intraoperative transfusion. Patients undergoing RRC also had a shorter duration of hospital stay (13 days vs 14 days, p < 0.001). There was no difference between the two groups for 30- and 90-day CDC overall, minor, and major complications. The incidence of rehospitalization within 30 days ( p = 0.1) and surgical reintervention ( p = 0.5) was also comparable between the two groups. On multivariable logistic regression analysis, approach to cystectomy (RRC vs LRC) was not a significant predictor of 30-day CDC overall and major complications. Conclusion: LRC was associated with lesser EBL, whereas the hospital stay was shorter in patients undergoing RRC. The two approaches were comparable with each other for 30- and 90-day CDC overall, minor, and major complications. The choice between the two approaches should depend on availability and surgeon experience and preference, rather than any specific perioperative parameter.

Background: Sleep related painful erection (SRPE) is a rare parasomnia consisting of nocturnal penile tumescence accompanied by pain that awakens the individual. Normal non-painful erections are experienced when awake. No penile anatomic abnormalities are present. No conclusive randomized clinical trial is present in the literature about the management of this rare condition. The aim of this article is to review the current knowledge about the management of SRPE and to suggest an algorithm to help physicians evaluate and manage SRPE. Material and methods: A literature review was conducted through PubMed database using the terms: sleep, pain, painful, penile, and erection. The reference lists of the articles were also reviewed. The search returned 23 references that were published between 1987 and 2019. Results were presented in a descriptive manner. Results: Treatment decision for now is based on reports of the treatment success, the sustainability of remission, the tolerability by the patients and the potential side effects of each medication. From data available in literature, Baclofen is the mostly used medication with a tolerable profile of adverse effects. Phosphodiesterase type 5 inhibitors are considered potential treatments and are already widely used and tolerated for other indications, but so far only 2 successful trials have been reported for SRPE. Cinitapride is very promising, but only one case was studied and no side effects were reported. Clozapine can be very dangerous although highly effective. Conclusion: Based on the limited number of treatment trials and reported cases, the low level of evidence and the lack of randomized clinical trials, no treatment consensus for SRPE can be reached. We suggested a useful tool for clinicians: an algorithm for the management of SRPE to facilitate their access to the literature without exhaustive return to case reports and series upon each case faced.