BACKGROUND:Three-piece penile prosthesis implantation (PPI) is the gold standard treatment for refractory erectile dysfunction. Although infection rates have declined with improved surgical techniques and antibiotic prophylaxis, postoperative hematoma remains an early complication that may predispose to infection and device malfunction. The role of short-term closed-suction drainage in reducing these complications remains controversial. AIM:To evaluate whether placement of a 24-h closed-suction drain reduces postoperative hematoma, infection, and mechanical complications following primary three-piece PPI surgery. METHODS:This retrospective comparative study included 410 patients undergoing primary penoscrotal three-piece PPI between September 2020 and August 2024. Patients were divided into a drain group (n = 149) and a no-drain group (n = 261). Demographics, comorbidities, operative characteristics, and postoperative outcomes were analyzed. Hematoma was assessed clinically and by ultrasonography on postoperative days 3 and 10. Patients were followed for 12 months. Comparative and multivariate statistical analyses were performed. OUTCOMES:Primary outcomes: Postoperative hematoma and infection.Secondary outcomes: Mechanical complications and risk factors associated with hematoma formation. RESULTS:On postoperative day 3, hematoma was detected in 13.4% of the drain group and 8.8% of the no-drain group (P = .143). By day 10, rates were 16.8% and 13.0%, respectively (P = .298). Infection occurred in 2.0% of patients overall, with no difference between groups (P = 1.000). Mechanical complication rates were also comparable (2.7% vs. 4.2%, P = .427). Hematoma formation was significantly associated with infection (postoperative day 3, OR: 29.0; P < .001; day 10, OR: 10.6; P = .002) and prosthesis malfunction (OR: 4.67; P = .014). Smoking and lower body mass index were identified as independent risk factors for hematoma development. CLINICAL IMPLICATIONS:Routine placement of a 24-h closed-suction drain does not appear to be associated with a reduction in postoperative complications after PPI. Preventive strategies should focus on meticulous intraoperative hemostasis and optimization of modifiable patient-related risk factors such as smoking. STRENGTHS AND LIMITATIONS:The study includes a relatively large cohort and standardized ultrasonographic assessment. However, its retrospective design, exclusion of complex cases, and lack of standardized hematoma grading limit generalizability and causal inference. CONCLUSIONS:Routine use of a 24-h closed-suction drain in primary three-piece PPI surgery is not associated with a reduction in hematoma, infection, or mechanical complications. Hematoma formation remains a key determinant of adverse outcomes, emphasizing the importance of careful surgical technique and patient optimization rather than routine drainage.

Abstract Introduction Closed suction drain systems are frequently used in penile prosthesis implantation surgery to prevent postoperative hematoma and fluid accumulation; however, concerns exist regarding a potential increase in infection risk. Objective This study aimed to evaluate the effect of drain usage on outcomes in patients undergoing primary three-piece inflatable penile prosthesis surgery. Methods This study, initially planned prospectively but analyzed retrospectively, included patients who underwent primary three-piece inflatable penile prosthesis surgery at our center between September 2020-August 2024. Patients who had additional surgical interventions such as grafting for Peyronie’s disease or simultaneous Wilson maneuver, or those with severe fibrosis due to priapism, were excluded. Patients were divided into two groups: those who had a closed suction drain placed and removed at 24 hours postoperatively, and those without drain placement. A third group consisted of patients whose drains were retained for more than 24 hours due to daily output exceeding 50 ml. Demographic characteristics, comorbidities (diabetes mellitus, vascular disease, Peyronie’s disease, history of radical prostatectomy), surgical features (operative time, Wilson maneuver, prosthesis type), and postoperative complications (hematoma on postoperative days 3 and 10, infection, mechanical problems) were compared. All patients with a history of anticoagulant use were bridged to low molecular weight heparin five days before the procedure. Prostheses were implanted via either penoscrotal or infrapubic approaches. Statistical analysis used the Mann–Whitney U test, Pearson’s chi-square, and Fisher’s exact test as appropriate. Results A total of 431 patients were analyzed: 149 with drains removed at 24 hours, 21 with prolonged drainage, and 261 without drains. Median age was 60(54–66) years. Comparison between the 24-hour drain group and the no-drain group showed no significant differences in age, operative time, comorbidities, or prior surgical history. However, BMI was significantly higher in the drain group (p=0.035). Although smoking rates were higher in the drain group, the difference was not statistically significant(p=0.062). Rates of hematoma, infection, and mechanical complications on postoperative days 3 and 10 were similar between groups (p>0.05). At 12 months, prosthesis malfunction occurred in 15 patients(3.7%). Early postoperative hematoma on day 3 was identified as a significant risk factor for malfunction (OR:4.67,p=0.014), while the presence of vascular disease was associated with a lower malfunction rate (OR:0.14,p=0.025). Infection developed in 2.0% of patients within the first 3 months, with the strongest predictors being hematoma on day 3 (OR: 29.0, p<0.001) and day 10 (OR: 10.6, p=0.002). Factors influencing hematoma development on day 3 included smoking, which increased hematoma risk by 2.3-fold (p=0.021), and lower BMI, which was also significantly associated (p=0.033). Smoking was the most significant risk factor for hematoma on day 10 (OR:2.11, p=0.017). Among the 21 patients followed with drains retained for more than 24 hours, only 2 developed infections within the first 3 months. Conclusions The use of drains in primary three-piece inflatable penile prosthesis surgery did not increase the rates of postoperative hematoma, infection, or mechanical complications, showing no significant differences between groups. These findings suggest that drain placement neither raises the risk of complications nor provides a clear beneficial effect on postoperative outcomes. Disclosure No

OBJECTIVE:To investigate the role of the protein galectin-3 (Gal-3) and its effect on fibrosis and apoptosis in testicular tissues of patients with idiopathic non-obstructive azoospermia (iNOA). DESIGN:A prospective study. SUBJECT:Male patients who needed testicular sperm extraction for assisted reproductive technology treatments. EXPOSURE:Tissue samples were obtained during microdissection testicular sperm extraction (mTESE) procedures from patients diagnosed as having azoospermia according to two semen analyses. Two groups were determined as sperm non-detected (n = 8, TESE-) and detected (n = 7, TESE+). Germ cells were morphologically evaluated using haematoxylin and eosin-stained sections and Johnsen scores. Immunohistochemical methods were used to evaluate Gal-3 expression and caspase-3-related apoptotic activity. MAIN OUTCOME MEASURES:Gal-3 positivity, apoptosis and fibrosis indexes. RESULTS:Gal-3 expression was significantly higher in the TESE- group (p = 0.024). Gal-3 showed strong positivity in Sertoli Cells and cells in the interstitial area around the seminiferous tubules in the TESE- group. CONCLUSION:This study highlights the potential role of Gal-3 in iNOA and its association with testicular fibrosis and impaired spermatogenesis. The absence of sperm retrieval was associated with increased Gal-3 expression, seminiferous tubule wall thickening, and enhanced apoptosis-related activity. These findings suggest that Gal-3 may contribute to inflammation- and fibrosis-related testicular damage in iNOA. However, further experimental and clinical studies are required to clarify the underlying molecular mechanisms of Gal-3 and determine its potential clinical significance in male infertility.

BACKGROUND:Non-organic erectile dysfunction (ED) and premature ejaculation (PE) are common conditions for which European Association of Urology guidelines lack specific recommendations on penile prosthesis implantation (PPI). AIM:To establish expert consensus on the role of PPI in non-organic ED and PE using the Delphi method. METHODS:A panel of 24 international penile implant surgeons with significant experience in PPI participated in a 3-round Delphi consensus between February and May 2025. Participants were mainly European-based (Italy, n = 16; Turkey, n = 4; United Kingdom, n = 2; Spain, n = 1; Germany, n = 1). Two online questionnaire rounds were followed by a final virtual meeting. Topics included diagnostics, treatment hierarchy, indications for PPI, ethical concerns, surgical risks, patient satisfaction, partner's involvement, and follow-up strategies. Consensus was defined as ≥75% agreement or disagreement on Likert-scale items. OUTCOMES:Expert consensus was reached on all 53 items, including the ones regarding the appropriateness of PPI in non-organic ED and PE. RESULTS:Experts agreed on the importance of thorough psychosexological assessment, standardized diagnostic tools, and exhausting conservative treatments before considering PPI in non-organic ED. Seventy-five percent supported PPI as a last-resort option in non-organic ED, provided psychological evaluation and informed consent protocols are in place. In contrast, the panel rejected PPI as a treatment for pure PE due to insufficient evidence and lack of clinical experience. Emphasis was placed on ethical safeguards, long-term follow-up, and partner involvement in decision-making. CLINICAL IMPLICATIONS:These findings suggest that, under strict conditions, PPI may have a role in treatment-resistant non-organic ED but not in pure PE. STRENGTHS AND LIMITATIONS:Limitations include the inherent subjectivity of the Delphi methodology and the restricted representativeness of the panel, which was mainly European-based and composed exclusively of urologists specializing in penile implants. CONCLUSION:Selective use of PPI in non-organic ED is supported by expert consensus, while its use in pure PE is not; updated guidelines and further research are warranted.

BACKGROUND AND OBJECTIVE:Despite the consensus that diagnosis of male hypogonadism requires both biochemical and clinical criteria, important uncertainties remain regarding preanalytical conditions, assay selection, and the role of free testosterone (T) and sex hormone-binding globulin (SHBG) measurements. To address these issues, this study provides a summary of the European Association of Urology Guidelines on Sexual and Reproductive Health (SRH) recommendations for the measurement of total T and biochemical diagnosis of male hypogonadism. METHODS:For the 2026 guidelines on SRH, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Database searches included MEDLINE, EMBASE, and the Cochrane Library. Recommendations within the guidelines were developed by the panel to prioritize clinically important care decisions. The strength of each recommendation was determined according to a balance between the desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences. KEY FINDINGS AND LIMITATIONS:Key recommendations emphasize the importance of measuring total T in a fasting state and in the morning (7:00-10:00 AM). Immunoassays remain clinically acceptable for total T measurement when liquid chromatography-tandem mass spectrometry is unavailable. A T level of ≤12 nmol/l continues to be the recommended threshold for diagnosing symptomatic male hypogonadism in clinical practice. Emerging evidence supports broader use of SHBG to prevent misdiagnosis of male hypogonadism. Calculated free T, derived from total T, SHBG, and albumin levels, should be considered in conditions known to affect circulating SHBG levels. CONCLUSIONS AND CLINICAL IMPLICATIONS:Accurate biochemical confirmation of male hypogonadism requires standardized sampling procedures and validated assays. Total T remains the cornerstone of diagnosis; however, SHBG and calculated free T are essential in men with altered binding protein levels. Recent data, although based on limited evidence, support the use of calculated free T even in healthy individuals and not just in patients with conditions associated with potential alterations in SHBG levels. PATIENT SUMMARY:This paper explains how testosterone (T) should be measured to diagnose low T (male hypogonadism). Testing should be done in the morning and after fasting. In some cases, additional measurements such as SHBG and calculated free T may help improve diagnostic accuracy, although current evidence supporting their use is limited.

INTRODUCTION:Male genital emergencies involving the penis are uncommon and necessitate immediate medical attention as well as surgery. The term "priapism" refers to a persistent erection caused by malfunctioning mechanisms that control rigidity, flaccidity, and penile tumescence. Identification of the underlying hemodynamics is necessary for a prompt and accurate diagnosis of priapism. OBJECTIVES:To discuss the epidemiology, pathophysiology, and classification of priapism, as well as to give healthcare professionals up-to-date clinical evidence on the management of the priapism. METHODS:The members of the Fifth International Consultation for Sexual Medicine (ICSM) Committee 22 have conducted a review of the peer-reviewed scientific literature to present an objective, comprehensive analysis regarding the diagnosis and management of priapism. This report reviews the literature from 2010 to 2025 on priapism and concentrates on guidelines that have been written in the last ten years. Every relevant article was examined critically and discussed. RESULTS:This manuscript provides evidence-based diagnostic and treatment recommendations for ischemic, non-ischemic, recurrent ischemic priapism, and priapism in patients with sickle cell disease. The role of imaging, laboratory testing, early urologists' involvement when a patient presents to the emergency room, the discussion of conservative therapies, improved data for patient counseling regarding the risks of erectile dysfunction and surgical complications, specific recommendations regarding intra-cavernosal phenylephrine with or without irrigation, the inclusion of novel surgical techniques, and early penile prosthesis placement are all covered in this recommendation. CONCLUSION:Every patient with priapism should have an emergency evaluation to determine whether they have acute ischemic or non-ischemic priapism, and those who have experienced an acute ischemic event should receive early intervention when necessary. Treatment for NIP must be based on the goals of the patient, the resources at hand, and the experience of the clinician; it is not an emergency.

Purpose To evaluate the effects of intracavernosal stromal vascular fraction (SVF) on erectile function and tissue-level changes in an ischemic priapism model. Methods Male Wistar rats (n=24) were randomized to Sham, Priapism, or Priapism+SVF (n=8 each). Priapism was induced with a penile base constrictor for 60 min. Autologous SVF from peritesticular fat was injected at band removal. At 4 weeks, cavernous nerve–stimulated intracavernosal pressure (ICP) and mean arterial pressure (MAP) were recorded; penile tissue underwent histology, immunohistochemistry, and qRT-PCR. Results Two rats died before model creation; analyses included Sham (n=8), Priapism (n=7), and Priapism+SVF (n=7). Baseline ICP and MAP were similar (p=0.105; p=0.911). Priapism lowered ICPmax, ICPmean, and ICP/MAP versus Sham (all p<0.001). SVF improved ICPmax and ICP/MAP versus Priapism (p=0.002; p=0.013) but did not reach Sham. ICPmean difference was not significant between Priapism and SVF groups (p=0.079). qRT-PCR showed no differences in NGF, TGF-β1, VEGF, or BDNF (all p>0.05). Histology showed more inflammation, fibrosis, cellular injury, hypoplasia, and loss of elastin in Priapism; with SVF these changes shifted to milder grades and elastin partially recovered (all p=0.001). Immunohistochemistry: VEGF unchanged; Bcl-2 higher in Priapism and intermediate after SVF (extent p=0.035; intensity p=0.001). eNOS reduced in Priapism and partially restored with SVF (extent p=0.006). nNOS elevated in Priapism and attenuated with SVF (both p=0.001). iNOS remained higher in both Priapism arms compared to Sham (both p=0.003). The muscle-to-fibrosis ratio did not differ (p=0.561), whereas the type I/type III collagen ratio did (p=0.003). Conclusions Intracavernosal SVF conferred partial protection in ischemic priapism. Its minimally processed, point-of-care profile supports feasibility after detumescence, and its endothelial, antifibrotic, and neurotrophic actions make it promising for broader erectile dysfunction phenotypes. Larger preclinical and controlled clinical studies should define optimal dose/timing and establish long-term efficacy and safety.

To investigate the relationship between polyunsaturated fatty acids and biochemical hypogonadism in aging males with a cross-sectional NHANES data. A total of 1165 men aged ≥ 65 years old, who had complete data on total testosterone levels and erythrocyte membrane fatty acid composition measurements, were included from the National Health and Nutrition Examination Survey (NHANES) 2021–2023 dataset. Biochemical hypogonadism was defined as total testosterone ≤ 300 ng/dL. Age, body mass index (BMI), waist circumference, diabetes mellitus (DM), fatty acid enzyme activities, HDL, LDL, triglycerides, and total cholesterol were also recorded. A total of 1,165 men were analyzed, of whom 859 had complete total testosterone data. In multivariate logistic regression analysis using continuous variables, higher arachidonic acid levels were independently associated with lower odds of biochemical hypogonadism (OR 0.80, 95

High-flow priapism (arterial) is a prolonged erection caused by irregular cavernous arterial flow, often resulting from blunt perineal or penile trauma, or iatrogenic needle injury. This condition leads to the formation of an arteriolacunar fistula, causing unregulated arterial blood flow into the sinusoidal spaces of the penis. Unlike low-flow priapism, high-flow priapism typically presents with a partially erect, non-painful penis. The diagnosis is confirmed through characteristic findings on color Doppler ultrasound, which reveals turbulent high-velocity flow pinpointing the fistula’s location. Blood gas analysis typically reflects arterial values, helping to differentiate high-flow priapism from its low-flow counterpart. Although high-flow priapism was historically considered non-urgent, recent evidence suggests that delayed treatment may increase the risk of erectile dysfunction. Therefore, prompt intervention by urologists is crucial. The primary goal is to close the fistula, and the treatment plan should be individualized based on the severity and duration of the condition. Urologists play a critical role in managing this condition, offering a range of therapeutic options. These include conservative approaches, such as observation and compression, medical therapy, arterial embolization, and, in some cases, surgical intervention. The choice of treatment depends on the patient’s condition, the fistula’s location, and the resources available. By ensuring timely and appropriate management, urologists can minimize complications and preserve erectile function.

BACKGROUND AND OBJECTIVE:To present a summary of the updated 2025 European Association of Urology (EAU) Guidelines on Sexual and Reproductive Health (SRH) on male infertility, providing practical recommendations on the clinical work-up with a focus on diagnosis, treatment and follow-up. METHODS:For the 2025 SRH guidelines, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences. KEY FINDINGS AND LIMITATIONS:Key recommendations emphasise the importance of a thorough urological assessment of all men seeking medical help for fertility problems to ensure appropriate treatment. The guidelines also stress the clinical relevance of a parallel investigation of the female partner during the diagnostic and management work-up of the infertile couple, to promote shared-decision making in terms of timing and therapeutic strategies. Furthermore, the guidelines recommend to counsel all infertile men and men with abnormal semen parameters on the associated health risks. Key changes in the male infertility guidelines for 2025 include: the addition of two new sections addressing exome sequencing and probiotic treatment; and significant update of the evidence base and recommendations for the diagnostic work-up of male infertility. CONCLUSIONS AND CLINICAL IMPLICATIONS:This overview of the 2025 SHR guidelines offers valuable insights into the diagnosis, classification, treatment and follow-up of male factor infertility and are designed for effective integration into clinical practice.

PURPOSE:Non-obstructive azoospermia (NOA), defined as the absence of sperm in the ejaculate due to testicular failure, is observed in 5% to 15% of infertile men and accounts for two-thirds of azoospermia cases. The management of NOA is marked by significant controversy and global variation in diagnostic and therapeutic approaches, highlighting the crucial need for well-designed and standardized clinical practice guidelines. We present comprehensive graded clinical practice recommendations and statements for diagnosing and treating NOA, aiming to establish standardized strategies that can globally help guide practitioners in their practice. MATERIALS AND METHODS:A comprehensive literature review was conducted to gather evidence on the epidemiological, diagnostic, and therapeutic aspects of NOA. The Global Andrology Forum (GAF) recommendations were developed through the collaboration of a global panel of experts using the Delphi method and surveys to achieve consensus. Statements were graded according to the Oxford Centre for Evidence-Based Medicine "GRADE" classification as either "Strong" or "Weak." Statements receiving at least 80% expert consensus were graded as "Strong," while others were categorized as "Weak." RESULTS:The GAF has formulated a total of 49 recommendations and statements on the diagnosis and treatment of NOA, including 21 for diagnosis and 28 for treatment. The recommendations and statements were evaluated and graded by a panel of 48 GAF experts from 25 countries worldwide. The majority of experts (60.5%) had more than 10 years of clinical experience in managing NOA. CONCLUSIONS:The GAF guidelines address discrepancies in NOA management across diverse clinical settings and provide comprehensive graded recommendations to guide clinicians in its diagnosis and treatment. Developed and graded by a large worldwide panel of experts, the current guidelines present simplified, high-standard strategies that can be seamlessly integrated into the daily global practice, offering practitioners a clear framework for managing NOA.

Malignant neoplasms of the penis are uncommon, the most common being squamous cell carcinoma. Non-Hodgkin's lymphoma occurs in extranodal sites in half of patients, but is extremely rare in the penis. Here, a 24 years old case of a penile mass is reported as non-Hodgkin lymphoma. On physical examination and imaging, two-centimeter lesion was detected on the left distal corpus cavernosum of the penis and extending to the proximal corpus cavernosum. Excisional biopsy from distal left corpus cavernosum performed under general anesthesia. Histopathological examination of the excision material revealed diffuse large B-cell lymphoma with a post-germinal center cell phenotype. Although it is rare in patients presenting with a penile mass, the possibility of lymphoma involvement should be kept in mind. It can mimic Peyronie's disease or corpus cavernosum thrombosis.

OBJECTIVES:Erectile dysfunction (ED) is a common sexual disorder in men, with a notable prevalence among young patients. This study aims to evaluate the clinical characteristics, perioperative parameters, patient satisfaction, and complication rates in men under 40 years old undergoing penile prosthesis implantation (PPI). MATERIALS AND METHODS:A retrospective analysis was conducted on 64 patients under 40 years of age who underwent PPI between 2006 and 2024. Preoperative assessments included history, physical examination, dynamic duplex ultrasound, and injection tests. Perioperative data, including incision type and prosthesis model, were recorded. Postoperative follow-up assessed complications, revision rates, and satisfaction levels using a Likert scale. RESULTS:The mean age was 31.7 ± 5.8 years, and the median duration of ED was 6 years. Vascular causes, including arterial deficiency and cavernosal dysfunction, were identified in 64% of cases. Idiopathic ED was observed in 28.1% of patients. Three-piece inflatable prostheses were implanted, with infrapubic incisions used in 57.8% of cases. During a median follow-up of 7 years, 4.7% of patients required revisions due to mechanical failure or implant erosion. No infections were reported. Satisfaction was high, with 92.8% of respondents rating their experience as "satisfied" or "very satisfied" (mean satisfaction score: 4.5 ± 0.7). CONCLUSION:PPI is an effective and safe treatment for ED in young men, with outcomes comparable to those of the general population. The study highlights the importance of thorough preoperative evaluation and counseling to optimize postoperative satisfaction. Further research is needed to refine patient selection and improve long-term outcomes in this population.