3rd Annual Jefferson Urology Symposium: Men’s Health Forum

© The Canadian Journal of Urology TM : International Supplement, August 2020 Short termcomplications related to IPP implantation include bleeding, bruising, hematoma, wound separation, and severe pain, while long-term complications include erosion or cylinder extrusion, mechanical failure, and changes in penis length. Infection is the most serious AE, which may occur typically within the first 3 months or maybe as a late complication. It usually requires the removal of the prosthesis. However, infection rates have been reduced to 1%-2% after the development of antibiotic and hydrophilic coatings, aswell as improvement in surgical techniques. 34 Penile prosthetic surgery should not be performed in the presence of systemic, cutaneous, or urinary tract infections. The penile prosthesis may be considered as a first- line therapy; however, it is typically reserved for patients who have not responded to less-invasive ED treatments. Other ED treatments after prosthesis explantation generally are not successful. Given the invasive and essentially irreversible nature of penile prosthesis implantation surgery, thorough counseling regarding short and long term postoperative expectations (including possible penile length loss associated with ED) is essential. Penile vascular surgery Penile arterial reconstruction surgerymay be considered for young patients who do not have any veno-occlusive dysfunction, evidence of generalized vascular disease, or other co-morbidities that could compromise vascular integrity. 8 There have been numerous controversies due to the absence of large prospective and well-controlled studies. Also, the long term success of the procedure is not well-established. Penile arterial reconstruction surgery would potentially be beneficial to an otherwise healthy patient aged < 55 years with arteriogenic ED. Occlusion of common penile or cavernosal arteries should be documented by penile duplex Doppler ultrasound or cavernosography and selective internal pudendal arteriography. The surgical principle of penile arterial reconstruction surgery includes an anastomosis of the inferior epigastric artery to dorsal penile arteries in an end-to- side fashion or to the deep dorsal vein with additional proximal and/or distal vein ligation. 35 Penile venous ligation surgery is proposed to correct veno-occlusive ED; however, long term success is unlikely achievable for the management of ED. 8 It is currently considered investigational due to inaccurate or deficient methods for diagnosing and correcting the relevant defect. Extracorporeal shock wave therapy Extracorporeal shock wave therapy (ESWT) on penile tissue is thought to be effective. due to microtrauma that upregulates the angiogenic growth factors and activates some factors for tissue restoration and repair. In addition to angiogenesis and tissue restoration, previous animal studies reported that ESWT improves erectile function in a rat model of cavernous nerve injury by inducing nerve generation via increasing brain-derived neurotrophic factor (BDNF) expression and neuronal nitric oxide synthase (nNOS)-positive nerves and activating Schwann cells. 36,37 ESWT has not been approved by the FDAand is still considered investigational. Several studies had reported its efficacy and safety in mild to moderate vasculogenic ED when PDE5i treatment failed. 38-40 However, well- designed prospective randomized clinical trials are limited in the literature. The duration of treatment efficacy, optimal treatment parameters, such as dosing frequency, energy flux density settings, and the number of shocks, and the selection of device types (linear versus focused shock wave) are not well-established. Randomized controlled studies with larger sample sizes are needed to determine its long termefficacy and side effects using a validated and standardizedprotocol. Intracavernosal stem cell therapy In recent years, there has been an increase in the use of SCT for ED treatment. Currently, mesenchymal stem cells isolated from adipose tissue are the most frequently used cells in studies. These stem cells are capable of differentiating into a variety of cells, such as cavernosal smooth muscle cells, endothelial cells, or neuron cells, that can promote cell growth and survival, angiogenesis, and immunomodulation via a variety of growth factors. 41-44 Previous animal studies using SCT have shown improvement in erectile function indiabetic ED, cavernosal nerve injury, and prostate radiation models. 42,45,46 There are several clinical trials in small study groups that have shown promising results using SCT without significant adverse effects in diabetic and post-prostatectomy ED. 47,48 However, stem cells’ differentiation capability as a progenitor cell presents safety concerns for the risk of malignant proliferation as well as potential immune response. In addition to these concerns, the long term efficacy of SCT is uncertain, as are the optimized source and dose of stem cells. Further randomized controlled studies are warranted with long-term follow up periods, standardized protocols, and larger study groups. Karakus AND Burnett 32