Veno-occlusive Dysfunction Research Articles

(234) How Age and Obesity Influence Erectile Dysfunction: Evaluation Based Upon Penile Color Duplex Doppler Ultrasound

Abstract Introduction Color duplex Doppler ultrasound (CDDU) is an objective and reliable diagnostic tool for documenting penile hemodynamics. Objective vascular testing provides a physiologic diagnosis of erectile dysfunction (ED) and helps direct appropriate therapy even in this age of ED management including oral drugs. Although age and diabetes are known to be the major etiological factors in development of ED, it is not clear whether obesity as such also plays any role or not. Objective The main objective of this study is to retrospectively assess the penile CDDU hemodynamic parameters of obese men with ED in comparison to non-obese ED men in relation to age. Methods A total of 271 men including obese and non-obese who were diagnosed with ED visiting our Andrology clinic were included in this study. Initial ED was determined by using the International Index of Erectile Function (IIEF) score. Penile CDDU data was retrospectively collected from these ED patients, and parameters mainly peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI) were used for analysis. RI (=PSV-EDV/PSV) was calculated, and different types of penile vascular status were established based on our previously published SOP guidelines for standardization of penile CDDU parameters. Statistical analysis was performed using MedCalc statistical software version 22.009 (MedCalc Software bv, Ostend, Belgium). Results Our study results revealed that with advancement of age the occurrence of vascular changes in obese men were higher in comparison to non-obese men with ED. Table 1 summarizes the influence of obesity on the prevalence of penile vascular status in different age groups of obese and non-obese men with ED. Surprisingly, higher number of obese men showed non-vascular, venous and mixed vascular components compared to non-obese ED patients. Among these obese groups of all ages, the venous leakage was prevalent than arterial or mixed components. Conclusions Our current analysis indicates that besides age, obesity is also one of the major risk factors in altering the penile hemodynamics with increased incidence of veno-occlusive dysfunction (VOD) in ED patients. In addition, this demonstrates the utility of performing CDDU and diagnosing the presence of VOD in further understanding the pathophysiology of obesity associated ED, and an important determining factor in such patient care. Disclosure No.

(322) Predictors of Erection Reversal After Penile Doppler Ultrasound

Abstract Introduction Erection hardness (EH) is a physiologic response graded subjectively on the Erection Hardness Grading Scale during penile Doppler ultrasound (PDUS). Objective This study aims to gather data on the reversal rate following persistent EH sufficient for penetration or higher after PDUS and identify associated predictors. Methods The study population consisted of (i) men with poor response to PDE5i and ICI or (ii) who need curvature assessment due to Peyronie’s disease (PD), (iii) and underwent penile duplex Doppler ultrasound (PDUS), (iv) using a vasoactive agent redosing schedule were included and reviewed retrospectively. Patients with incomplete data were excluded. We performed a descriptive assessment of demographics and comorbidities, including a history of cancer, PD, depression, or anxiety. EH was evaluated by a sexual medicine-trained physician for each case and reported before and 30 minutes after PDUS. EH was assessed on a scale between 0 (no erection) to 10 (erection hard as a rock), with 6 being good enough for penetration. We also described the number of injections, the dose, and PDUS hemodynamic parameters, including peak systolic velocity (PSV) and end-diastolic velocity (EDV). Arterial insufficiency (AI) diagnosis was made with PSV values ≤25 cm/sec bilaterally and corpora veno-occlusive dysfunction (CVOD) with EDV values ≥5 cm/sec bilaterally. We also reported a reversal procedure rate performed due to persistent erection after PDUS, and predictors were assessed. Factors entered into the model included: patient age, EH for PDUS (8 or greater), and dose of vasoactive agent used (Table 1). A p-value ≤0.05 was considered statistically significant. Results 2439 individuals were included. The median age of 59 (50,67) years. 12% had diabetes, 13% reported ≥ 3 comorbidities, 44% had prostate cancer, 17% had a history of depression, and 14% had a history of anxiety. 44% described PD. The vasoactive agent used for PDUS was Trimix 86% and 14% others. The median dose used was 20 (10, 50), and the median of injections applied was 2 (1, 2). The EH median was 8 (6, 9) for PDUS, and 65% had an EH of 8 or greater. The PDUS diagnosis was normal in 62% of the patients; 8% had AI, 29% had CVOD, and 1% had AI+CVOD. The reversal procedure rate was 41%. In the MVA, significant predictors of erection reversal were higher vasoactive agent dose used, age 50 years or younger, and EH 8 or greater for PDUS (Table 1). Conclusions Erection reversal in our redosing PDUS was highly prevalent; predictors of reversal were younger age, greater EH for PDUS, and higher vasoactive agent dose. Disclosure No.

Microsurgical penile revascularization for ischemic erectile dysfunction:Cumulative effective rate over time and factors affecting surgical outcomes.

This study aimed to clarify the cumulative effectiveness of microsurgical penile revascularization over time and factors that affect surgical outcomes. This study analyzed 114 men with a median age of 30.5 years. They had localized arterial lesions on the internal pudendal artery by angiography. They underwent the anastomosis of the distal end of the inferior epigastric artery to the dorsal artery of the penis with 11-0 sutures. The final cumulative effectiveness rate calculated by the Kaplan-Meier method was 92.5%. The 1- and 3-year cumulative effectiveness rates were 58.0% and 92.5%, respectively. Twenty-one patients were not cured during the study. Age was a factor significantly affecting the surgical outcomes (p=0.018), and the peak systolic and end-diastolic velocities on Doppler ultrasound, corporal veno-occlusive dysfunction, and venous ligation were less significant (p=0.290, p=0.559, p=0.054, and p=0.732, respectively). The final cumulative effectiveness rate of penile revascularization was 92.5%. Latency was observed until cure, half of the cases were cured in approximately 10 months. Cavernous function appears to be reversible and cavernous dysfunction was not a significant factor in surgical outcome. J. Med. Invest. 71 : 219-224, August, 2024.

Investigating the risk factors of penile arterial insufficiency and veno-occlusive dysfunction in patients with erectile dysfunction.

To investigate the risk factors for penile arterial insufficiency (PAI), which is a known cause of erectile dysfunction (ED). Patients who attended our urology clinic complaining of ED for more than 6 months were prospectively enrolled in this study over 1-year period. Patient consent was taken and ethical committee approval. Complete medical history and thorough general and local examination including body mass index (BMI), Peyronie's disease (PD) and penile size measurements (length and girth) were done for all of them. Laboratory tests included testosterone, lipid profile and glycated haemoglobin (HA1c). A penile duplex ultrasound study (PDU) was done for all patients after intracavernosal injection (ICI) with alprostadil. Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were measured after 15 min. Statistical analysis was done using SPSS. A total of 440 patients were enrolled in this analysis. The mean age was 48(23-81), and the mean BMI was 30 (18-51). Older patients had lower PSV (r= -0.361, P= 0.000) and higher EDV (r= 0.174, P= 0.001), and both correlations were highly statistically significant. Diabetics had lower PSV (r= -0.318, P= 0.000) and higher EDV (r= 0.139, P= 0.008), which were also highly statistically significant. Smokers had lower PSV (r= -0.140, P= 0.008) and higher EDV (r= 0.178, P= 0.001), which were highly statistically significant. Men with larger penises measured skin to tip had lower EDV (r= -0.119, P= 0.024), which was less significant. Interestingly, there was neither a significant correlation between BMI and PSV (0.16, P= 0.745) nor a significant correlation between testosterone and PSV (0.029, P= 0.552). Also, there was no correlation between PSV and both dyslipidaemia and penile PD. Ageing, tobacco consumption, DM and hypertension seem to have a negative impact on penile haemodynamics, which was statistically significant. In our patients, there was no statistically significant effect on penile haemodynamics in patients with increased BMI, low testosterone or PD or according to the size of the penis.

(165) Role of Penile Veno-occlusive Dysfunction in Peyronie’s Disease Patients with Erectile Dysfunction

Abstract Introduction The incidence of Peyronie's disease (PD) is 4% in the U.S. male population. Many PD patients also suffer from erectile dysfunction (ED). The etiology of ED incidence in PD men is not known, although veno-occlusive dysfunction (VOD) is often suggested. It is important to appreciate the influence of VOD in PD patients with ED, especially in regard to successful PD treatment. Objective The main objective of this study is to assess the penile hemodynamic response to intracavernous injection (ICI) of a vasoactive agent in order to evaluate the incidence of VOD in PD patients with or without ED. Methods A total of 333 men, diagnosed either with PD (n=202) or ED (n=68) or both PD and ED (n=63), visiting our Andrology clinic were included in this study. Initial ED was determined by using the International Index of Erectile Function (IIEF) score, whereas patients with penile curvature ≥30° were categorized as having PD. Penile color duplex Doppler ultrasound (CDDU) data was retrospectively collected from these patients, and parameters such as peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI) were used for analysis. RI (=PSV-EDV/PSV) was calculated, and VOD was confirmed when PSV ≥30 cm/sec, EDV ≥6 cm/sec, and RI <0.8 based on previously published guidelines for standardization of penile CDDU parameters. Statistical analysis was performed using MedCalc statistical software version 20.019 (MedCalc Software bv, Ostend, Belgium). Results Table 1 summarizes the CDDU results of all 333 patients. Age of the study subjects was 55.6 ± 11.3 years, with no difference between groups. Incidence of penile VOD was higher in patients with ED without PD (58.8%) or with PD (52.4%) compared to PD alone (44.6%). RI values of PD patients without ED were higher (>0.8) compared to PD patients with ED having VOD (<0.7) (P<0.001). Conclusions The current study results indicate that lower RI values suggest a higher incidence of VOD in PD patients. VOD plays an important role in the onset of ED in men with PD. Furthermore, this demonstrates the importance of performing CDDU and diagnosing the presence of VOD in further understanding the pathophysiology of PD. Disclosure No

(533) Penile Venous Stripping for Treating Patients with Erectile Dysfunction Secondary to a Minimally Invasive Prostatectomy

Abstract Introduction A minimally invasive prostatectomy becomes a treatment of choice in patients with operable prostate cancer. However, it is not uncommon to encounter patients with erectile dysfunction (ED) secondary to this procedure. Objective Although there are many ED treatment strategies, we want to report a physiological penile venous stripping surgery to those patients whose ED was secondary to prostatectomy and refractory to all medical treatments in the recent decade. Methods From 2012 to 2021, 15 consecutive patients, aged 62 to 79, sustained erectile dysfunction (ED) following a minimally invasive prostatectomy for treating prostate cancer. Meanwhile, their ED was refractory to contemporary varied treatment strategies, including one 70-year-old patient non-responsive to 800 mg sildenafil. All patients received dual cavernosography in which the penile venous anatomy was shown by a pilot cavernosograpy, PGE-1 test in-between, and a veno-occlusive dysfunction (VOD) was documented by pharmaco-cavernosography. Eventually, they underwent a physiologically penile venous stripping surgery (PVSS) for erection restoration from VOD. The ambulatory basis was unexceptionally conducted under acupuncture-assisted local anesthesia. PVSS begins with a circumferential approach, followed by degloving those tissues superficial to the Colles' fascia until the penile base. Next, it entailed stripping a deep dorsal vein and two cavernosal veins while fixing every emissary's vein with 6-0 nylon closest to the outer tunica. In contrast, the two pairs of para-arterial veins were only segmentally ligated. The abridged 5-item version of the International Index of Erectile Function (IIEF-5) score system and corporeal radio-opacity assessed erection restoration. Additionally, the erection hardness scale (EHS) confirmed improvement. Results The prostatectomy was performed in laparoscopic (n=7) and Da Vinci surgical system (n=8) elsewhere. The average follow-up period was 5.3±0.4 years. It was unexceptionally pronounced on the radiopacity of the corpora cavernosa to the femoral cortex, denoting the intracorporeal retention established in the corpora cavernosa after PVSS. It was statistically significant between the preoperative and postoperative IIEF-5 scores (5.9±1.8 vs. 11.8±2.6, P<0.01). The EHS improved at least one scale. Surprisingly, two patients reported gratifying outcomes although they were committed to Parkinsonism. Overall, just 42.9% (9/21) of patients reported unaided sex. The remaining patients required medication aid every five men depending on 20 mg sildenafil and 5 mg vardenafil, respectively. Eventually, four resorted to malleable penile implants, which firmly declined preoperatively. Conclusions PVSS is beneficial in managing some groups of males whose ED is secondary to a minimally invasive prostatectomy, although the sample size is limited. Disclosure No

(097) A Novel Therapeutic Strategy for Recovery from Cavernous Veno-Occlusive Dysfunction through Chronic Administration of Hepatocyte Growth Factor and a JNK Inhibitor in a Rat Model of Cavernous Nerve Injury

Abstract Introduction Structural alterations of penis including cavernosal apoptosis and fibrosis induce venous leakage in the corpus cavernosum or cavernosal veno-occlusive dysfunction, a key pathophysiology of erectile dysfunction (ED) after radical prostatectomy. Objective We aimed to determine if JNK inhibition in combination with intracavernosal administration of hepatocyte growth factor (HGF) would completely restore cavernosal veno-occlusive function (CVOF) in a rat model of ED induced by bilateral CN crush injury (CNCI). Methods A total of forty-two male Sprague-Dawley rats were randomly assigned to sham control (S), CNCI (I) and CNCI treated with combination of JNK inhibitors and HGF (J+H) for 5 weeks after surgery. All rats in each group were evaluated by dynamic infusion cavernosometry (DIC), caspase-3 activity assay, Masson’s trichrome staining, immunohistochemical staining of α-smooth muscle actin (α-SMA) and immunoblotting at 5 weeks after surgery. Results Regarding CVOF, Group I showed a decreased papaverine response, an increased maintenance and drop rates compared to Group S. Group J+H showed significant improvements in the three DIC parameters compared to Group I. There were no differences in papaverine response and drop rate between Group J+H and Group S. Regarding the structural integrity of corpus cavernosum, Group I had an increased caspase-3 activity, decreased SM/collagen ratio, decreased content of SM, decreased protein expression of PECAM-1, and decreased phosphorylation of c-Jun and c-Met. Group J+H had significant alleviation in the histological and molecular derangement compared to Group I. There were no differences in caspase-3 activity, SM content, PECAM-1 protein expression, c-Jun phosphorylation and c-Met phosphorylation between Group J+H and Group S. Conclusions Our data indicate that chronic administration of JNK inhibitors and HGF may restore CVOF to the level comparable to sham control level through preservation of structural integrity of the corpus cavernosum. Combination of JNK inhibition and HGF might be a potential therapeutic option for recovering from CVOD. Disclosure No

(124) Investigating the Risk Factors of Penile Arterial Insufficiency and Veno-occlusive Dysfunction In Patients with Erectile Dysfunction

Abstract Introduction It was reported that a more generalized peripheral atherosclerotic process is associated with a severer penile arterial insufficiency (PAI), and this in turn was correlated well with decreased blood supply in more important arteries like the coronary and carotid arteries. Objective We investigated the risk factors for PAI which is a known cause of erectile dysfunction (ED Methods Patients who attended our urology clinic complaining of ED for more than 6 months, were prospectively enrolled in this study in one year period. Patient consent was taken and ethical committee approval. Complete medical history and thorough general and local examination including body mass index (BMI), Peyronie’s disease (PD) and penile size measurements (length and girth) were done for all of them. Laboratory tests included testosterone, lipid profile, and glycated haemoglobin (HbA1c). Penile duplex ultrasound study (PDU) was done for all patients after intra-cavernosal injection (ICI) with Alprostadil. peak systolic velocity (PSV) and end diastolic velocity (EDV) were measured after 15 minutes. Statistical analysis was done using SPSS. Results A total of 440 patients were enrolled in this analysis. The mean age was 48 (23-81), and the mean BMI was 30 (18-51). Older patients had lower PSV (r=-0.361, P=0.000) and higher EDV (r=0.174, P=0.001) and both correlations were highly statistically significant. Diabetics had lower PSV (r=-0.318, P=0.000) and higher EDV (r=0.139, P=0.008) which were also highly statistically significant. Hypertensive patients had lower PSV (r=-0.296, P=0.000) which was highly statistically significant. Smokers had lower PSV (r=-0.140, P=0.008) and higher EDV (r=0.178, P=0.001) which were highly statistically significant. Men with larger penises measured skin to tip, had lower EDV (r=-0.119, P=0.024) which was less significant. Interestingly there was neither significant correlation between BMI and PSV (0.16, p=0.745) nor significant correlation between testosterone and PSV (0.029, p=0.552). Also, there was no correlation between PSV and both dyslipidaemia and penile PD. Conclusions Our study highlights key risk factors - Increased age, tobacco consumption, DM and hypertension - are factors that have a statistically significant negative impact on penile haemodynamics. Of these, tobacco consumption, good diabetic control and hypertension are potentially modifiable and should form part of any treatment plan for erectile dysfunction. Other risk factors – increased BMI, low testosterone, PD and penile size – had no statistically significant impact on penile hemodynamics. This allows for targeted advice that can be given to patients who present with this very common problem. Ultimately, good vascular health goes hand in hand with good erectile function. Disclosure No

(532) An Innovative Combination of Penile Corporeal Girth Enhancement and Erection Restoration

Abstract Introduction It has been controversial in penile venous surgery for erection restoration and penile enhancement across three centuries thus far. Objective Based on the De Novo penile fibro-vascular assembly, we report an anatomy-physiology-based combination of a physiological penile corporeal diameter expansion and erection restoration surgery in recent decades. Methods From 2012 to 2022, intractable impotence and subjective micropenis prompted 23 men to seek penile venous stripping (PVS) and factual penile enhancement (TPE). All patients received dual cavernosography demonstrating penile venous anatomy and veno-occlusive dysfunction. PVS entailed the venous stripping of one deep dorsal vein and two cavernosal veins after every emissary's vein was double ligated 0.3 cm apart closest to the outer tunica with a 6-0 nylon suture. In addition, the para-arterial veins were just segmentally ligated. In TPE, a longitudinal incision was performed bilaterally over 3 and 9 O'clock positions along the pendulous penis. Every tunic defect was then water-tight sutures with a 7x3 cm rectangle venous stripe as an inner tunica bilaterally, subsequently covered with a piece of 7x3 venous wall, fascia tense lata, or a controlled tissue integration material sheet for surrogating the outer layer bilaterally. On penile girth and glans penis, the diameter was measured preoperatively and postoperatively in six months when a cavernosography was conducted, if available. Radio-opacity was used to compare the femoral cortex and the penile crus on preoperative and postoperative cavernosography. Additionally, the abridged 5-item version of the International Index of Erectile Function (IIEF-5) score system and the erection hardness scale (EHS) was used to confirm improvement preoperatively and postoperative follow-up yearly either by telephone or INTERNET. Results The average follow-up period was 5.3±0.8 years. The operation time was 7.2±1.8 hours. The material of outer patches was fascia tense lata (n=3), Surgifrom (n=6), penile vein (n=8), internal spermatic vein (n=3), and cephalic vein (n=3). The radiopacity was unexceptionally enhanced postoperatively. It was a significant difference between the preoperative and postoperative IIEF-5scores (9.7±2.8 vs. 20.8±2.3; P<0.01). The EHS improved at least one scale. The diameter of the glans and distal penile shaft is increased from 2.78±0.33 cm and 3.41±0.41 cm (n=18) to 2.98±0.32 cm and 3.49±0.31 cm, respectively. Although the satisfaction rate is only 70.0% (16/23), the intracorporeal retention and erection quality improvement were unexceptional. Conclusions This novel combination strategy of factorial penile enhancement and erection restoration is feasible. However, it requires a more significant sample size and longer-term follow; the surgery technology is conspicuously challenging. Disclosure No

(439) Penile Revascularization Utilizing The Lateral Femoral Circumflex Artery After Pelvic Fracture Urethral Injury

Abstract Introduction Pelvic fracture urethral injury (PFUI) is associated with erectile dysfunction (ED) in up to 62% of patients, often due to decreased arterial inflow. For select healthy patients with isolated arterial insufficiency, penile revascularization utilizing the inferior epigastric artery to either the cavernosal or dorsal penile artery has been shown to be an effective treatment ED. The patient originally presented with a PFUI after a motor vehicle collision. He underwent suprapubic tube placement and selective embolization of a right internal pudendal artery pseudoaneurysm. Four months later, he underwent a posterior urethroplasty with corporal splitting and inferior pubectomy. During follow-up, he reported no erectile function following his initial trauma with no prior history of erectile dysfunction. He was trialed on PDE5is which were ineffective and ICI which was discontinued due to pain and minimal efficacy. Penile Doppler ultrasound with ICI showed bilateral arterial insufficiency with peak systolic velocities of 11.3 and 18.8 cm/second and no evidence of veno-occlusive dysfunction with end-diastolic flows of 2.85 and 4.66 cm/second of the cavernosal arteries (Figure 1). Bilateral inferior epigastric arteriography demonstrated 20-30% ostial stenosis with left traumatic occlusion of the internal pudendal and complete occlusion of the right internal pudendal artery post-embolization. The dorsal penile arteries filled in a delayed fashion via small-caliber collaterals. Objective We present this case to demonstrate use of an alternative arterial donor vessel for penile revascularization. Methods An infrapubic incision was made to expose the right dorsal penile artery. Another incision was made from the right anterior superior iliac spine to just above the patella tendon. The rectus femoris and vastus lateralis were atraumatically split and the descending branch of the lateral femoral circumflex artery was exposed. Small branches were clipped (Figure 2). The most distal branch to the rectus femoris was divided to become the donor vessel, leaving the proximal branch to maintain muscular perfusion. The donor branch was mobilized and passed via a subcutaneous tunnel into the infrapubic incision (Figure 3). Using an operating microscope the dorsal penile artery was ligated and the distal end was anastomosed to the donor artery and an end-to-end fashion using 8-0 nylon interrupted sutures. A drain was placed in the thigh wound, and both wounds were closed in two layers. Results The patient was started on 325mg of daily aspirin and remained on bed rest for two days. He was discharged on postoperative day two and his thigh drain remained in place for two weeks. He was restricted to less than 30-degree abduction of the right thigh for four weeks. Four months postoperatively the patient was achieving erections with 7/10 rigidity using only 5mg of tadalafil as needed. His SHIM was 17. At six months postoperatively he had increased his tadalafil dose to 20mg and was achieving erections with 8/10 rigidity from his pre-injury baseline. Conclusions This case demonstrates an excellent result from penile revascularization utilizing the lateral femoral circumflex artery. This artery can be considered an alternate donor for penile revascularization procedures following pelvic fracture urethral injury when there is a contraindication to the use of the inferior epigastric artery. Disclosure No

Chronic treatment with a combination of hepatocyte growth factor and JNK inhibitor ameliorates cavernosal veno-occlusive dysfunction: a rat model of cavernous nerve injury.

Structural alterations of the penis, including cavernosal apoptosis and fibrosis, induce venous leakage into the corpus cavernosum or cavernosal veno-occlusive dysfunction, a key pathophysiology associated with erectile dysfunction after radical prostatectomy. We hypothesized that the effect of JNK inhibitors on reducing apoptosis and hepatocyte growth factor (HGF) on inducing tissue regeneration could be another treatment mechanism of erectile dysfunction after radical prostatectomy. To investigate whether JNK inhibition combined with intracavernosal administration of HGF can completely preserve cavernosal veno-occlusive function (CVOF) in a rat model of erectile dysfunction induced via bilateral cavernosal nerve crush injury (CNCI). A total of 42 male Sprague-Dawley rats were randomly assigned to sham control (group S), CNCI (group I), and CNCI treated with a combination of JNK inhibitor and HGF (group J + H) for 5weeks after surgery. Rats in each group were evaluated via dynamic infusion cavernosometry (DIC), caspase-3 activity assay, Masson trichrome staining, immunohistochemical staining of α-smooth muscle actin, and immunoblotting at 5weeks after surgery. Regarding CVOF, group I showed decreased papaverine response, increased maintenance, and drop rates of DIC when compared with group S. Group J + H showed significant improvement in the 3 DIC parameters vs group I. No differences in the 3 DIC parameters were found between group J + H and group S. Regarding the structural integrity of the corpus cavernosum, group I showed increased caspase-3 activity, decreased smooth muscle (SM):collagen ratio, decreased SM content, decreased protein expression of PECAM-1, and decreased phosphorylation of c-Jun and c-Met. Group J + H showed significant attenuation in histologic and molecular derangement as compared with group I. There were no differences in caspase-3 activity, SM content, SM:collagen ratio, PECAM-1 protein expression, c-Jun phosphorylation, and c-Met phosphorylation between groups J + H and S. Our results suggest that antiapoptotic and regenerative therapy for the corpus cavernosum is a potential mechanism of penile rehabilitation after radical prostatectomy. This study provides evidence that combination treatment of JNK inhibitor and HGF preserves erectile function by restoring corporal SM and endothelium. However, additional human studies are needed to confirm the clinical effect. Chronic treatment with JNK inhibitor and HGF may preserve CVOF to levels comparable to sham control by preserving the structural integrity of the corpus cavernosum and so represents a potential therapeutic option for preventing the development of cavernosal veno-occlusive dysfunction.

Accumulation of Adipocytes in Penile Corpus Cavernosum May Contribute to Venous Leakage and Veno-Occlusive Dysfunction in Patients with Testosterone Deficiency and Erectile Dysfunction

In 2005, we reported that, in the animal model, androgen deprivation resulted in significant changes in the structural elements of the penile corpus cavernosum (CC), including: (1) atrophy of the trabecular smooth muscle, (2) increased deposition of connective tissue, and (3) accumulation of adipocytes in the sub-tunical region. These structural alterations, together with reported decreases in the expression and activity of endothelial nitric oxide synthase (eNOS) and neural nitric oxide synthase (nNOS), are believed to contribute to reduced blood inflow and increased blood outflow, contributing to veno-occlusive dysfunction and erectile dysfunction (ED). More recently, several clinical studies have documented accumulation of adipocytes in the sub-tunical region of the corpora cavernosa from patients with ED, supporting findings reported in the animal models. Here, we summarize the observations from basic and clinical research and advance the hypothesis that testosterone deficiency contributes to significant changes in the structural integrity of the CC, resulting in atrophy of the trabecular smooth muscle and contributing to reduced vascular smooth muscle relaxation and diminished blood inflow into the penis, resulting in a failure to fill. In addition, atrophy of the trabecular smooth muscle, accumulation of adipocytes in the sub-tunical region, and increased deposition of connective tissue contribute to veno-occlusive dysfunction and a failure to maintain erection. It is postulated that testosterone treatment in men with testosterone deficiency may reverse the structural alterations in the CC and improve erectile function.

Prospective Cross-Sectional Evaluation of Penile Helicine Circulation by Power Doppler During Dynamic Ultrasound in Veno-Occlusive Erectile Dysfunction

ObjectiveTo evaluate the usefulness of Power Doppler to improve the diagnostic work up of veno-occlusive erectile dysfunction patients. Materials and MethodsPatients affected by erectile dysfunction, mean IIEF 5 = 13.5 (12-17) for at least 6 months, were enrolled in a prospective cross-sectional study. All patients underwent Dynamic Power Doppler after intracavernous injection of vasoactive drugs (PGE1 20 mcg and Papaverine 6 mg). Poor responders’ patients subsequently underwent to cavernosometry to get a full assessment of the vascular framework. Results202 patients (mean age 46 years), were included in the study. 96 subjects (47.5%) who did not adequately respond to the intracavernous injection -test, subsequently underwent to cavernosometry. In 42 of 96 patients (43.7%) cavernosometry was positive for veno-occlusive dysfunction. In a total of 160 patients who did not have veno-occlusive dysfunction (54 with negative cavernosometry + 106 intracavernous injection-test responders), the Power Doppler was normal in 126 (78.8%) and pathological in 34 (21.3%) in terms of steric conformation of “low flow” vessels corresponding to the Cavernosal Terminal Unit. The diagnostic sensitivity of Power Doppler towards veno-occlusive dysfunction was found to be 52.4% (Positive Predictive Value: 39.3%), the specificity was 78.8% (Negative Predictive Value: 86.3%) and the total diagnostic accuracy was equal to 73.3%. ConclusionCollected data evidenced that patients who reported altered morphological features of the Cavernosal Terminal Unit had an approximately 4-fold greater risk of having veno-occlusive dysfunction compared to patients who had normal Power Doppler features (OR = 4.076; 95% CI: 1.996-8.327).

Penile implants in Japan

ABSTRACT Introduction In Japan, APSSM's founding president Shirai developed a silicon single rod that is inserted into the outside corpora in 1971. In the 1990s penile prostheses started to be sold in Japan. However, sales stopped in 2007. Since then, it has been up to doctors to order them individually. Objective we performed 141penile prothesis surgeries between 1992 and 2019.9. Age is 25-81 years average 62 ± 8 years old. the causes of ED are Diabetes 57 cases, arteriosclerosis (hypertension) 24 cases, failure of prosthesis surgery 17 cases, intrapelvic surgery (prostate ca, bladder Ca, rectal Ca) 16 cases, brain disease (bleeding, infarction, Parkinson, meningitis) 12 cases, Renal failure 7 cases, Peyronie ’s disease 5 cases, priapism 2 cases, wrong masturbation habit 1 case. Diabetes was the most common cause. Diagnosis is vasculogenic and neurogenic 88 cases, vasculogenic 54 cases, vasculogenic and curvature 3 cases, neurogenic 6 cases. Methods Anesthesia method is local anesthesia (penile block) 128 cases, general anesthesia 13 cases. Penile prostheses were AMS 700CXM 6 cases, Titan OTR narrow base (Coloplast) 2 case, hydroflex 1 case, AMS Dura II 26 cases, AMS 600 17 cases, Genesis (Coloplast) 84 cases, Koken (Japan) 5 cases. We have used AMS since 1992, The sale of penile protheses in Japan was halted in 2007. Since 2008, Our University doctors have been ordering Coloplast prostheses Implanted penile prosthesis size is 11-19.5cm length average 15.9cm, median 16cm. The diameter is Dura II 1cm (26 cases), AMS 600 0.95cm (15 cases) 1.15cm (2 cases), Genesis 1.1cm (28 cases), Genesis 0.95cm (56 cases). Day surgeries are popular therefore 94% of patients prefer a non-inflatable prosthesis. We devised a single-implant procedure and performed surgery for the following indications:1. Narrow cavernosum because of congenital abnomarity or re-operations. 2. Small penis. 3. Uncontrolled diabetes. 4. ED caused by corporal veno-occlusive dysfunction (CVOD) in a young man. 5. Patient preference for a warm erect penis (with a PDE5 inhibitor). Single implant surgery has a high satisfaction rate of 98% with no complications, but there are still many enlargement operations and use of PDE5 inhibitors. Results Intercourse was possible 137 cases (97.0%) and impossible 4 cases (3.0%). Ejaculation was possible 100cases (77%), impossible 32 cases (24%) (prostate or rectal surgery, retrograde ejaculation due to DM). Complication rate is 7.8%, exposure of one side prosthesis to urethra 2.8%, exposure of one side prosthesis to skin 0.7%, Exposure of tube (AMS700CXM) 0.7%, persistent pain 2.1%, infection 1.4%. Satisfaction rate is 95.0% Conclusions The penile prosthesis is still considered to be the surgical gold standard for treatment of ED. All other available treatments for ED should be compared with the results of penile prosthesis surgery. In Japan, 95% of day surgeries use non-inflatable prostheses. Disclosure Work supported by industry: no.

The Role of LIM Kinase in the Male Urogenital System.

The LIM kinases (LIMK1 and LIMK2), known as downstream effectors, and the Rho-associated protein kinase (ROCK), a regulator of actin dynamics, have effects on a diverse set of cellular functions. The LIM kinases are involved in the function of the male urogenital system by smooth muscle contraction via phosphorylation of cofilin and subsequent actin cytoskeleton reorganization. Although LIMK1 and LIMK2 share sequence similarities as serine protein kinases, different tissue distribution patterns and distinct localization during cell cycle progression suggest other biological functions for each kinase. During meiosis and mitosis, the LIMK1/2–cofilin signaling facilitates the orchestrated chromatin remodeling between gametogenesis and the actin cytoskeleton. A splicing variant of the LIMK2 transcript was expressed only in the testis. Moreover, positive signals with LIMK2-specific antibodies were detected mainly in the nucleus of the differentiated stages of germ cells, such as spermatocytes and early round spermatids. LIMK2 plays a vital role in proper spermatogenesis, such as meiotic processes of spermatogenesis after puberty. On the other hand, the literature evidence revealed that a reduction in LIMK1 expression enhanced the inhibitory effects of a ROCK inhibitor on the smooth muscle contraction of the human prostate. LIMK1 may have a role in urethral obstruction and bladder outlet obstruction in men with benign prostatic hyperplasia. Moreover, LIMK1 expression was reduced in urethral stricture. The reduced LIMK1 expression caused the impaired proliferation and migration of urethral fibroblasts. In addition, the activated LIMK2–cofilin pathway contributes to cavernosal fibrosis after cavernosal nerve injury. Recent evidence demonstrated that short-term inhibition of LIMK2 from the immediate post-injury period prevented cavernosal fibrosis and improved erectile function in a rat model of cavernosal nerve injury. Furthermore, chronic inhibition of the LIMK2–cofilin pathway significantly restrained the cavernosal veno-occlusive dysfunction, the primary pathophysiologic mechanism of post-prostatectomy erectile dysfunction through suppressing fibrosis in the corpus cavernosum. In conclusion, the LIM kinases–cofilin pathway appears to play a role in the function of the male urogenital system through actin cytoskeleton reorganization and contributes to the pathogenesis of several urogenital diseases. Therefore, LIM kinases may be a potential treatment target in urogenital disorder.

EFFECT OF SATVAVAJAYCHIKITSA (COUNSELLING AND ASSURANCE) AND SHIRODHARA IN THE MANAGEMENT OF PSYCHOGENIC ERECTILE DYSFUNCTION: A CASE STUDY

Any stimulus (intrinsic or extrinsic) that triggers a biological response is known as stress. Stress can exert various negative effects on the body ranging from alterations in homeostasis to life-threatening effects and death. Erectile dysfunction can be a manifestation of chronic stress. ED is the most common male sexual dysfunction that affects 10-25% of middle-aged and elderly men. ED may result from many etiologic factors like psychogenic, endocrino- logic, neurogenic, arteriogenic or venoocclusive dysfunction. These factors are not mutually exclusive and multi- ple factors contribute to ED in many patients. According to modern science Psychogenic factors frequently coex- ist with other etiologic factors and should be considered in all cases. A patient aged 35 years came to the OPD of A&U Tibbia college with complaints of inability to initiate and maintain erection along with abnormal vision, dizziness, retrosternal burning, indigestion, heaviness in chest and disinterest. He was advised for Shirodhara along with counselling (Satvvajaychikitsa) and after a couple of days, there was a significant improvement in pa- tient. In this case study, we are trying to highlight the contribution of stress & psyche on male sexual dysfunction and its management through Satvavajaychikitsa (counselling) and Shirodhara. Keywords: Erectile dysfunction, Satvavajaychikitsa, Shirodhara.

PD30-07 THE COMBINATION OF BLOOD FLOW VELOCITY AND VASCULAR DIAMETER: THE FLOW INDEX IS BETTER IN THE EVALUATION OF ARTERIOGENIC ERECTILE DYSFUNCTION

You have accessJournal of UrologySexual Function/Dysfunction: Evaluation II (PD30)1 Sep 2021PD30-07 THE COMBINATION OF BLOOD FLOW VELOCITY AND VASCULAR DIAMETER: THE FLOW INDEX IS BETTER IN THE EVALUATION OF ARTERIOGENIC ERECTILE DYSFUNCTION Wei-Lun Huang, Chi-Shin Tseng, Sheng-Yung Tung, Tzung-Dau Wang, Wen-Jeng Lee, Shih-Ping Liu, Hong-Chiang Chang, Yi-Kai Chang, and Yu-Hsiang Yang Wei-Lun HuangWei-Lun Huang More articles by this author , Chi-Shin TsengChi-Shin Tseng More articles by this author , Sheng-Yung TungSheng-Yung Tung More articles by this author , Tzung-Dau WangTzung-Dau Wang More articles by this author , Wen-Jeng LeeWen-Jeng Lee More articles by this author , Shih-Ping LiuShih-Ping Liu More articles by this author , Hong-Chiang ChangHong-Chiang Chang More articles by this author , Yi-Kai ChangYi-Kai Chang More articles by this author , and Yu-Hsiang YangYu-Hsiang Yang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002031.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The dynamic duplex sonography (DUS) measures the blood flow velocity but not the volumetric flow rate of blood, which is the blood volume infused per unit of time. In our experience, some patients with normal DUS result still have vasculogenic erectile dysfunction (ED), indicating that current measurements may be incomprehensive. In our study, a new parameter, the Flow Index (FI), was introduced for evaluating arteriogenic ED. METHODS: Patients receiving DUS and computed tomography angiography (CTA) for evaluation of ED were enrolled. ED was defined based on observed EHS after intracavernous injection of PGE1 during DUS exam. Patients with veno-occlusive dysfunction were excluded. Pelvic arterial (PLA) stenosis and cavernous arterial (CA) stenosis were measured by CTA. The volumetric flow rate of blood was velocity*π*radius2. We defined FI=PSV*(1-arterial stenosis%)2. FI of PLA (FIPLA) and CA (FICA) were calculated. Correlations between parameters were assessed. RESULTS: Eighty-three patients were included. Compared with PSV, FI had better correlations with EHS (Table) and better area under the receiver operating characteristic curve (AUC) for arteriogenic ED (Figure). Compared with patients without arteriogenic ED, patients with arteriogenic ED who had normal DUS had more severe PLA stenosis (62.50% vs 30.00%, P=0.02) and lower FIPLA (12.03 vs 42.17, P=0.01), while the PSV was not different (37.50 cm/s vs 39.90 cm/s, P=0.54). In patients with PLA stenosis, the odds of ED was higher (OR=4.88) and the FI was lower (56.00 vs 67.60, P=0.03 for FICA; 10.22 vs 58.53, P<0.01 for FIPLA), however, the PSV was not significantly different (35.00 cm/s vs 38.25 cm/s, P=0.38). CONCLUSIONS: FI is more comprehensive than PSV in evaluating arteriogenic ED, and PLA patency is one of factors determining penile perfusion. However, PSV may not be suitable for diagnosing arteriogenic ED in patients with PLA stenosis. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e534-e535 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wei-Lun Huang More articles by this author Chi-Shin Tseng More articles by this author Sheng-Yung Tung More articles by this author Tzung-Dau Wang More articles by this author Wen-Jeng Lee More articles by this author Shih-Ping Liu More articles by this author Hong-Chiang Chang More articles by this author Yi-Kai Chang More articles by this author Yu-Hsiang Yang More articles by this author Expand All Advertisement Loading ...

PD48-10 MULTIPLE TRANSVERSE INCISIONS PATCHED WITH TACHOSIL® IN PEYRONIE’S DISEASE: PRELIMINARY DATA OF AN ONGOING, PROSPECTIVE, NON-RANDOMIZED STUDY

You have accessJournal of UrologySexual Function/Dysfunction: Peyronie's Disease (PD48)1 Sep 2021PD48-10 MULTIPLE TRANSVERSE INCISIONS PATCHED WITH TACHOSIL® IN PEYRONIE’S DISEASE: PRELIMINARY DATA OF AN ONGOING, PROSPECTIVE, NON-RANDOMIZED STUDY Afonso Castro, Miguel Fernandes, Miguel Miranda, Pedro Simões Oliveira, Natalia Martins, José Palma dos Reis, and Francisco E. Martins Afonso CastroAfonso Castro More articles by this author , Miguel FernandesMiguel Fernandes More articles by this author , Miguel MirandaMiguel Miranda More articles by this author , Pedro Simões OliveiraPedro Simões Oliveira More articles by this author , Natalia MartinsNatalia Martins More articles by this author , José Palma dos ReisJosé Palma dos Reis More articles by this author , and Francisco E. MartinsFrancisco E. Martins More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002070.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Peyronie’s disease (PD) can be both physically and psychologically distressing to the patient. Although invasive, surgery remains the most reliable and effective treatment option. However, complications are not negligible. We present our preliminary data of an ongoing, prospective, non-randomized study of potent patients with PD who underwent multiple transverse incisions (MTI) covered with Tachosil®. Severe dorsal/dorsolateral deformity and/or further penile shortening were the primary therapeutic endpoints. METHODS: Between January 2018 and February 2020, patients with dorsal/dorsolateral deformity and stable PD were included in this analysis. All patients underwent a penile duplex ultrasound study (PDUSS) and SHIM-5 (Sexual Health Inventory for Males) questionnaire to assess erectile function both objectively and subjectively before and after surgery. PGI-I (Patient Global Impression of Improvement) was used to assess patient satisfaction. RESULTS: 23 patients underwent MTI+Tachosil® (median 4 incisions; range 3-6) after ≥12 months of deformity duration and without evidence of progression. Median age was 66 years (range 49 - 76). Median preoperative compound curvature was 60 degrees (range 30-90), 19 (83%) had dorsal curvature, 3 patients (13%) had dorsolateral deformity and 1 had lateral curvature (4%). Total straightness was achieved in 20 patients (87%) and residual curvature was evidenced in 3 (13%). Erectile rigidity sufficient for penetrative intercourse was maintained in all patients at last follow-up, not displaying erectile dysfunction progression. There were no significant changes in PDUSS scores post-operatively. SHIM-5 scores improved from 13 (range 12-16) pre-operatively, to 19 (range 18-21) post-operatively. Median postoperative PGI-I scores were 2 (much better). No penile length reduction was observed. One patient experienced self-resolution of penile hematoma, 5 patients noted transient glandular hypoesthesia with only 1 developing prolonged sensation impairment. CONCLUSIONS: MTI with Tachosil grafting is feasible, well tolerated, easy and quick to perform surgical technique for the treatment of PD. It avoids creation of large tunical defects with subsequent veno-occlusive dysfunction, and provides additional hemostasis, while preserving erectile function. Most complications were minor and transient (Clavien-Dindo I or II). Source of Funding: The authors received no specific funding for this work © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e842-e842 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Afonso Castro More articles by this author Miguel Fernandes More articles by this author Miguel Miranda More articles by this author Pedro Simões Oliveira More articles by this author Natalia Martins More articles by this author José Palma dos Reis More articles by this author Francisco E. Martins More articles by this author Expand All Advertisement Loading ...

X-ray endovascular methods for the treatment of veno-occlusive erectile dysfunction

The results of surgical treatment of 59 patients with veno-occlusive erectile dysfunction and follow-up of 8 years are presented. The age of patients is 18-48 years old (average age is 29.3 ± 7.6). Five of them had hemodynamic and clinical signs of arteriovenous erectile dysfunction in the stage of subcompensation, 16 patients underwent simultaneous treatment in the form of sclerotherapy of testicular veins in connection with the secretory type of male infertility, 5 underwent simultaneous surgical treatment to eliminate veno-occlusive and arterial insufficiency of the cavernous bodies of the penis by stenting of the internal iliac or pudendal arteries, 2 patients underwent delayed stenting of the iliac veins due to May-Turner syndrome, the remaining patients underwent surgical treatment aimed at eliminating venous erectile dysfunction. The diagnosis was established on the basis of a clinical and urological examination, including physical examination and questioning according to the IIEF-5 (International Index of Erectile Function), ultrasound Doppler examination of the cavernous bodies of the penis with intracavernous pharmacotest, dynamic computer pharmacocavernosography with 3D reconstruction, with veno-occlusive arteries with suspected arteries, or computer tomography arterial insufficiency of the cavernous bodies of the penis. All types of endovascular and hybrid operations on the venous collectors of the penis were analyzed. Priority surgical techniques for the treatment of pathological venous drainage have been identified, which are 75 % effective in the long-term postoperative period. Based on the presented experience of the authors and analysis of foreign literature, the expediency of revising the European and Russian recommendations for venous surgery of the penis towards the priority use at the first stage of minimally invasive X-ray surgical treatment in a category of young patients has been proved.

Metabolic Syndrome and Erectile Dysfunction

Metabolic syndrome (MetS) is considered a risk factor for erectile dysfunction (ED), and ED is almost three times more prevalent in men with MetS. Vascular pathologies are a significant factor for the development of ED, and many experts suggest endothelial dysfunction (EnD) as a likely explanation for the association between ED and MetS. Studies also show that corporal vascular and trabecular smooth muscle dysfunction leads ultimately to corporal veno-occlusive dysfunction. Different functional system abnormalities, such as nervous degenerations, hormonal insufficiencies, and metabolic factors (e.g., hyperlipidemia, advanced glycation end products), are also likely involved in the pathophysiological pathways. Autonomic neuropathy is also commonly encountered in patients and animal models of MetS. From another perspective, low testosterone levels may be predictive of MetS. Several studies concluded that components of MetS, such as high blood pressure, obesity, hyperinsulinemia, T2DM, hyperglycemia, hypertriglyceridemia, elevated C-Reactive protein, and low HDL levels, were all associated with decreased serum testosterone levels. Lifestyle modification, such as exercise and diet, are the first-line treatment for MetS. Studies have found that a 10% weight loss has been shown to significantly increase IIEF-5 scores. Exercise was also shown to increase endothelial-derived NO and decrease oxidative stress, resulting in a lower risk of developing ED in physically active men. Metformin combined with PDE5 inhibitors is a promising treatment approach, although with limited research.