Challenges in the Practice of Sexual Medicine in the Time of COVID-19 in Spain

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-print134 K

Guías Europeas en salud sexual y reproductiva 2020. ¿Por qué vale la pena leerlas?

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-print90,1 K

Modelo predictivo para la supervivencia y la mortalidad perioperatoria en pacientes con carcinoma renal y extensión venosa tumoral: estudio internacional multi-institucional

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina. La tesis fue realizada en el Departmento del Cirugía de la UAM y el Servicio de Urología del Hospital Universitario Puerta de Hierro-Majadahonda. Fecha de lectura: 17 de Junio de 201

Surgical outcomes after collagenase Clostridium histolyticum failure in patients with Peyronie’s disease in a multicenter clinical study.

In the present study we aimed to investigate the surgical outcomes of patients with persistent penile curvature (PC) after Collagenase Clostridium histolyticum (CCH) intraplaque injections. Data from 90 patients with persistent PC after CCH in a multicentre study from 6 andrological centres were retrospectively reviewed. Three standardized surgical techniques were performed. Group 1: plaque incision grafting (PIG) with penile prosthesis implant (PPI); Group 2: PIG without PPI; Group 3: Nesbit technique. Hospital stay, operative time, postoperative complications and PC persistency/recurrence (> 20°) were evaluated. Overall satisfaction and functional outcomes were assessed through International Index of Erectile Function-Erectile Function (IIEF-EF), Peyronie’s Disease Questionnaire (PDQ), Female Sexual Function Index (FSFI) administered pre and 3 months postoperatively. Of all, 25 (27.8%) patients received grafting procedure + PPI (Group 1), 18 (20.0%) patients belonged to Group 2, and 47 (52.2%) to Group 3. Bovine pericardium graft and collagen fleece have been used in in 22 (51.2%) and 21 (48.8%) patients, respectively. Median penile length after surgery was 13.0 cm (IQR 12.0–15.0). After surgery, Group 1 showed higher increase in penile length after surgery and better improvements in terms of PDQ-PS. In contrast, both IIEF-EF and FSFI scores did not differ among groups. Overall, 86 (95.6%) did not report any complication. 4 (4.4%) patients had PC recurrence; of those, 2 (8.0%), 1 (5.6%) and 1 (2.1%) cases were observed in Group 1, Group 2 and Group 3, respectively. In case of persistent PC after CCH, surgical correction by grafting with or without concomitant PPI or Nesbit technique emerged as a technically feasible, effective and safe procedure, with no significant postoperative complications.post-print1243 K

Home modeling after penile prosthesis implantation in the management of residual curvature in Peyronie’s disease.

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 <45° after MM, patients were 12 instructed to perform HM daily for 6 months, after 4 weeks from PP implantation. The mean preoperative penile curvature 13 was 39.4 ± 5.7° (30–60). Sixteen (17.4%) patients required incision–grafting and the remaining 76(82.6%) patients followed 14 HM protocol. The mean postoperative residual curvature after MM was 29.7 ± 3.2° (5–50). Sixty-five (85.5%) patients who 15 underwent HM had 10° or less residual curvature after 3 months and 72 (94.7%) patients had 10° or less residual curvature 16 after 6 months. Seventy (92.1%) patients responded as satisfied or very satisfied on the questionnaire with the outcome after 17 6 months. HM of the penis over Inflatable PP may straighten the penis without the need for an additional surgical maneuver 18 in vast majority of the PD patients having residual curvature of <45°.pre-print207 K

Clinical Applications of Molecular Biomarkers in Prostate Cancer.

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 di erential 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.post-print789 K

Surgical management of peyronie’s disease with co-existent erectile dysfunction

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 (<20 degree curvature) with good erection. Patients with refractory ED in PD are candidates for penile prosthesis. Secondary procedures, like manual modeling, plication, plaque incision, or excision grafting, may be required depending on the degree of penile curvature and penile length. In quest for the best graft, TachoSil graft seems to have gained popularity in Europe. Krishnappa P, Fernandez-Pascual E, Carballido J, et al. Surgical Management of Peyronie’s Disease With Co-Existent Erectile Dysfunction. Sex Med 2019;7:361e370

Casos complejos: Enfermedad de Peyronie: cirugía sin/con implante de prótesis de pene.

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-print1298 K

Cadaveric Penile Prosthesis Workshop training improves surgical confidence levels of urologists: South Asian Society for Sexual Medicine course survey.

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-print905 K

A Novel Penile Splint as Early Traction Therapy After Grafting Techniques for Peyronie's Disease.

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.pre-print449 K