Sexual Function/Dysfunction: Mixed results with CCH in Peyronie's

Ryan P. Terlecki, MDSexual function/dysfunction topics discussed at the 2016 AUA included the findings of multiple studies on the effects of collagenase clostridium histolyticum (Xiaflex) treatment for Peyronie's disease, causes and treatments for ED, along with a study on patient satisfaction with implantable penile prostheses.  The Sexual Function/Dysfunction discussions were presented by Ryan P. Terlecki, MD of Wake Forest University, Winston-Salem NC.

Mixed results were seen with several small clinical experiences with collagenase clostridium histolyticum (CCH [Xiaflex]) in Peyronie’s disease. In one study, 66 patients who received 1-4 series of injections noted a mean curvature improvement of 22°, with 80% of men finding their change to be meaningful. In a study of 78 men who completed four treatment cycles, a 16.5° change in curvature was reported. Six men had restoration of ability to engage in intercourse, and 33% of patients reported glans hypoesthesia. In a retrospective study, corporal rupture following injection was reported by 3.6% of patients. Thirty-four percent of surveyed surgeons reported witnessing this complication in practice, typically around 5 days after the last injection. A cost-analysis model found that CCH treatment was nine times more expensive than plication.

Working second or third shift and sleeping poorly may contribute to erectile dysfunction (ED).

Hypofractionated and conventional radiology for prostate cancer confer a comparable risk of ED.

Low-dose brachytherapy is associated with ED in a majority of patients, becoming most noticeable after 3 years. Another group noted that 75% of men with normal function before brachytherapy and who were younger than 60 years of age at treatment could have penetration 10 years later.

External beam radiation therapy commonly causes sensory disturbances in the penis, morphologic changes, and orgasmic dysfunction.

Low testosterone was observed in nearly 24% of patients with new-onset ED.

Continue to the next page for more take-home messages

• Neoadjuvant androgen deprivation therapy prior to radical prostatectomy was associated with worse postoperative erectile function.

• High-intensity focused ultrasound was associated with a 65.6% de novo ED rate at 1 year, which was superior to radical prostatectomy, high-dose-rate brachytherapy, and cryoablation.

• Potency was preserved in 75% of patients undergoing prostate capsule- and seminal vesicle-sparing cystectomy with neobladder.

• Realignment for urethral disruption was associated with significantly higher rates of ED (81.8% vs. 47.3%).

• Only two of 12 patients with pelvic fracture urethral distraction defect with concurrent rectal injury retained normal erectile function.

• A prospective study of 80 patients with abdominal aortic aneurysm (AAA) found that the detriment to International Index of Erectile Function-5 scores was significantly more profound with open AAA repair than with endovascular repair.

Next: Testosterone replacement results with testosterone undecanoate

• Testosterone replacement with testosterone undecanoate (Aveed) in hypogonadal men with prediabetes led to significant improvement in erectile function, sustainable weight loss, and better glycemic control.

• Regular low-dose sildenafil citrate (Viagra) appears to reduce venous leak after radical prostatectomy.

• Multiple agents demonstrated favorable effect on premature ejaculation, including daily sildenafil, on-demand silodosin (Rapaflo), and on-demand dapoxetine with or without additional sildenafil.

• Primary care providers are poorly informed about data regarding satisfaction and complication rates for implantable penile prostheses.

• A cadaveric study showed ectopic submuscular reservoir placement of the inflatable penile prosthesis via the inguinal ring led to inconsistent results and unintentional intraperitoneal placement.

• A review of 546 implantable penile prostheses showed an autoinflation rate of 5.5%, with predictors including absence of lockout valve, complete reservoir filling, and use of the space of Retzius for reservoir placement.

Next: Revision rate following penile prosthesis surgery in ftm transsexuals

• Female-to-male transsexuals had an approximate 46% revision rate following penile prosthesis surgery but a 5-year device-survival rate of 78%.

• The Charlson Comorbidity Index is a significant predictor of need for revision after penile prosthesis implantation.

• Long-acting bupivacaine liposomal suspension (Exparel) showed potential to reduce postoperative pain following prosthesis implantation.

• An analysis of data from a penile prosthesis registry showed an 88% satisfaction rate, independent of device type or penile length.

• Investigators in a small clinical trial of self-adhering equine hemostatic graft for Peyronie’s disease found the grafting technique to be feasible, fast, and safe when used at the time of penile prosthesis implantation.

• Peyronie’s disease was not associated with any differences in operative time, outcomes, or satisfaction in men receiving an AMS 700.

• More than 60% of men had full recovery of stretched penile length after radical prostatectomy. Predictors of recovery included younger age, higher preoperative sexual function, and consistent use of a phosphodiesterase-type-5 inhibitor but not cardiovascular morbidities or use of nerve-sparing surgery.

More AUA 2016 take-home messages:

Female Urology: Improvements in OAB therapy

Minimally Invasive Surgery: Study shows huge variance with RALP cost

BPH: Current, forthcoming modalities show efficacy