AbstractIntroductionUreteral stricture disease (UTSD) poses significant challenges in reconstructive urology, with recent advances highlighting disparities in healthcare outcomes based on race and ethnicity. This study investigates the impact of race and ethnicity on clinical outcomes following ureteral reconstruction.MethodsWe conducted a single‐centre prospective analysis of 233 patients who underwent ureteral reconstruction for UTSD from 2014 to 2023. Patient demographics, clinical characteristics, surgical details and outcomes were collected. Patients were stratified by race (White vs. non‐White) and ethnicity (Hispanic vs. non‐Hispanic). Statistical analyses included Kruskal–Wallis, Mann–Whitney U tests, ANOVA, Kaplan–Meier analysis and multivariate logistic regression.ResultsOur cohort included 233 patients who underwent ureteroplasty with 108 (46.4%) non‐White patients, and 71 (30.5%) were Hispanic. No significant differences were found in recurrence rates, complications, or stricture‐free survival between racial and ethnic groups. Prior reconstructions were more prevalent among non‐White patients (26.9% vs. 16.0%; p = 0.043). Unadjusted and adjusted regressions showed significant associations between non‐White race (unadjusted β = 0.76, p = 0.008; adjusted β = 0.82, p = 0.008) and Hispanic ethnicity (unadjusted β = 0.70, p = 0.025; adjusted β = 0.79, p = 0.020) with increased stricture lengths.ConclusionThis study highlights that although recurrence and complication rates do not significantly differ by race or ethnicity, disparities exist in clinical presentations, with non‐White and Hispanic patients presenting with longer stricture lengths and higher body mass index. These findings underscore the need for targeted interventions to address underlying disparities in healthcare delivery and access.

Prostate cancer is a widely common and treatable disease, and functional outcomes can greatly affect survivor quality of life. A retrospective review of the SEER-Medicare database was performed to identify patients who underwent prostate cancer treatment between January 1, 2004 and December 31, 2013 and review the rates of diagnosis and treatment of common functional side effects of surgery, radiation, or a combination of the 2 and perform a comparison of the outcomes. A total of 67,527 patients were included in the analysis. Radiation therapy (RT)-only compared to radical prostatectomy (RP)-only had lower rates of diagnosis of erectile dysfunction (30.4%, 95% CI 29.9%-30.9% vs. 56.1%, 95% CI 55.1%-57.04%, P < 0.0001), UI (29.7%, 95% CI 29.0%-30.3% vs. 44.5%, 95% CI 43.3%-45.6%, P < 0.0001), but higher rates of urethral stricture disease (8.44%, 95% CI 8.1%-8.8% vs. 5.35%, 95% CI 4.9%-5.9%, P < 0.0001), cystitis (33.1% 95% CI 32.4%-33.7% vs. 20.3%, 95% CI 19.2%-21.4%, P < 0.0001), and proctitis (14.7%, 95% CI 14.3%-15.1& vs. 2.75%, 95% CI 2.3%-3.3%, P < 0.0001). Compared to either single modality, the RP-then-RT group had higher incontinence medication use (12.0% 95% CI 10.8%-13.2% vs. 9.8%, 95% CI 9.5%-10.1% for RT-only and 8.3%, 95% CI 7.8%-8.8% for RP-only, P < 0.0001), overall incontinence therapy (18.5%, 95%CI 17.1%-20.0% vs. 10.2%, 95%CI 9.9%-10.5% for RT-only and 14.9%, 95% CI 14.3%-15.5% for RP-only, P < 0.0001), and stricture therapy (12.7%, 95% CI 11.5%-13.9% vs. 8.2%, 95% CI 8.0%-8.5% for RT-only and 9.1% 95% CI 8.6%-9.6% for RP-only, P < 0.0001). The RT-then-RP group had higher rates of stricture (25.4% compared to 8.2% for RT-only, 9.1% for RP-only, and 12.7% for RP-then-RT) and fistula (1.0% compared to 0.07% for RT-only, 0.18% for RP-only, and 0.092% for RP-then-RT) treatment than all the other groups. Multimodality therapy is generally associated with higher treatments rates for conditions such as erectile dysfunction , incontinence, urethral stricture disease , irritative cystitis and proctitis in patients older than 65. Radiation therapy followed by prostatectomy is associated with significantly worse functional outcomes. Patients undergoing or anticipating undergoing multimodality therapy for prostate cancer should be counseled regarding the possibility of increased risk of declining functional outcomes.

Purpose/Objective(s) The use of radical prostatectomy (RP) for men with high-risk prostate cancer (PC) is increasing. RP is often utilized as a component of multi-modality therapy, as a method to intensify treatment. Many patients who undergo RP will subsequently require radiation therapy (RT), exposing patients to side effects from both treatments. While the side effects of RT and RP have been directly compared in previous studies, there is limited data comparing side effects of primary RT with those of patients undergoing RP and RT (RP/RT). We hypothesize that patients undergoing RP/RT for high-risk PC will experience significantly higher side effects than those undergoing primary RT. Materials/Methods We used the Surveillance Epidemiology and End Results (SEER) database with Medicare insurance claims to identify patients 66 years or older with primary high-risk PC who underwent RP, RT, or both between January 1, 2004 and December 31, 2013. High-risk PC was defined as disease meeting one or more of the following criteria: stage ≥ T3a, grade group ≥ 4, PSA >20. Outcomes of interest included treatment for urinary incontinence, urethral stricture, erectile dysfunction (ED), proctitis and cystitis at least 1 year after completion of primary prostate cancer treatment, which were captured using diagnosis and procedure codes. Rates of these endpoints were compared using cumulative incidence functions as well as cox proportional hazard models. Patients who were lost to follow up or died were censored at the time of their last encounter. Results The cohort included 17,649 patients, of which 15,399 were treated with primary RT (87.25%) and 2,250 were treated with RP/RT (12.75%). On multivariable analysis, compared to primary RT, RP/RT was associated with an increased risk of incontinence therapy [HR 1.907 (1.679-2.166)], stricture therapy [HR 1.865 (95% CI: 1.589-2.190)] and ED therapy [HR 2.869 (95% CI: 2.046-4.023)] after treatment for prostate cancer. Rates of therapy for cystitis or proctitis were not significantly different between these two groups. Conclusion For men with high-risk PC, treatment with RP/RT was associated with increased utilization of incontinence therapy, stricture therapy, and ED therapy after completion of prostate cancer treatment. With multiple curative treatment options and long duration of survival after treatment, the side effect profile of treatment is a major factor in determining the most appropriate course of treatment for an individual patient. Patients considering primary RP as a component of multimodality therapy for high-risk PC should be informed about the increased risk of side effects. Clinical trials are required to better evaluate this treatment paradigm.

You have accessJournal of UrologyCME1 May 2022MP52-17 RACIAL AND REGIONAL DISPARITIES AND SURGICAL INTERVENTION FOR URINARY INCONTINENCE AFTER PROSTATE CANCER THERAPY: A SEER-MEDICARE STUDY Nishant Garg, Alexandra Muise, Michael Pan, Michael Witthaus, Brent Rose, and Jill Buckley Nishant GargNishant Garg More articles by this author , Alexandra MuiseAlexandra Muise More articles by this author , Michael PanMichael Pan More articles by this author , Michael WitthausMichael Witthaus More articles by this author , Brent RoseBrent Rose More articles by this author , and Jill BuckleyJill Buckley More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002627.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary incontinence after prostate cancer therapy can significantly affect quality of life, with some men eligible for corrective surgery. Our objective is to evaluate the potential racial disparities for surgical management of urinary incontinence in patients who have undergone prior prostate cancer therapy. METHODS: Medicare claims from 2004-2013 were used to identify men aged 66 years or older who met inclusion criteria and underwent either prostatectomy (RP) or radiation (RT). Medicare Part A and B claims for incontinence were captured using HCPCS and ICD-9-CM codes along with the associated codes for the therapeutic surgeries. Differences in the covariates between treatment groups were evaluated using pairwise Chi-Square tests, and time to event analyses for surgery were calculated using Kruskal-Wallis tests. Outcomes were reported as hazard ratios with 95% confidence intervals, with statistical significance being reported as p < 0.05 on SASTM. RESULTS: A total of 63,158 men were identified in the cohort of which 15,143 men underwent RP and 44,694 underwent RT. There was no statistically significant difference in rates of incontinence surgery such as artificial urinary sphincter (AUS) and male sling (MS) between white and black men after either RT or RP. Black men had delayed treatment for incontinence compared to white men (27 vs 25 months for AUS and 27.5 vs 22 months for male sling). Men in the east were more likely to have incontinence after both RP and RT compared to men in the west but were not more likely to have any corrective surgery for this (Table 1). Men from the south were not more likely to have incontinence after RP compared to men from the west, but were more likely to get a MS (1.356 (1.086-1.692), p <0.0071). CONCLUSIONS: There was no difference in overall rates of surgical treatment for incontinence after either RT or RP between white and black men. There was a difference between men in the east vs west. These results may help improve counseling for men eligible for incontinence surgery, including based on region of the country but not stratified by race. Future research is needed in identifying the systems that may be associated with delayed surgical care. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e893 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nishant Garg More articles by this author Alexandra Muise More articles by this author Michael Pan More articles by this author Michael Witthaus More articles by this author Brent Rose More articles by this author Jill Buckley More articles by this author Expand All Advertisement PDF DownloadLoading ...

Radiation therapy is an important treatment option for management of pelvic organ malignancies including urologic, gynecologic, and gastrointestinal cancers (1). Radiation toxicity results from DNA and cellular damage of healthy tissue in the radiation field and can ultimately lead to tissue necrosis or fibrosis. Radiation therapy of abdominal and pelvic malignancies can cause delayed adverse functional and anatomical effects that involve portions of the urinary tract, such as the ureters, bladder, and posterior urethra. These adverse effects are believed to result from damage to urinary tract epithelium and microvasculature (2,3). Ureteral stricture, contracted bladder, rectourethral fistula, bladder neck contracture, and urethral stricture disease are among the long-term toxicities Review Article

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making III (MP23)1 Sep 2021MP23-12 FUNCTIONAL ANALYSIS AFTER RADICAL PROSTATECTOMY, RADIATION THERAPY, OR MULTIMODAL THERAPY FOR PROSTATE CANCER THERAPY USING THE SEER-MEDICARE DATABASE Alexandra C. Muise, Jill C. Buckley, Michael M. Pan, and Brent Rose Alexandra C. MuiseAlexandra C. Muise More articles by this author , Jill C. BuckleyJill C. Buckley More articles by this author , Michael M. PanMichael M. Pan More articles by this author , and Brent RoseBrent Rose More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002014.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior studies have used patient reported outcomes to show the impact of primary radical prostatectomy or radiation therapy on urinary and sexual function after treatment of prostate cancer. We sought to investigate the impact of both primary as well as multimodal therapy on erectile dysfunction (ED) and urinary incontinence therapies among patients in the SEER-Medicare database. METHODS: We used the SEER-Medicare database to identify men aged 66 or older diagnosed with primary prostate cancer in 2004-2013 who received RT, RP, or both. The final cohort was 67,565 after excluding patients with non-continuous Medicare coverage, other malignancy, or missing PSA values. Patients were classified as RT only (n=47,731), RP only (n=16,294), RT then RP (n=300), or RP then RT (n=3,240). Urinary incontinence and ED therapy utilization was captured using Medicare claims. Fine and Gray regression with covariates was used to estimate hazard ratios (HRs) for association between therapy utilization and prostate cancer treatment. RESULTS: Multivariable analysis indicated that patients in the RP only group were 2.03 times as likely to receive any ED therapy (p <0.0001) and 1.73 times as likely to receive any urinary incontinence therapy (p <0.0001) compared to those in the RT only group. The RT then RP and the RP then RT groups were also more likely to receive ED (RT then RP HR: 2.57; p=0.0003 | RP then RT HR: 2.13; p <0.0001) and urinary incontinence therapy (RT then RP HR: 2.47; p <0.0001 | RP then RT HR: 2.21; p <0.0001) compared to the RT only group. Among therapy subtypes, patients in the RP only, RT then RP, and RP then RT groups were more likely to receive a definitive incontinence procedure as well as undergo a penile prosthesis compared to those in the RT only group. CONCLUSIONS: This population-based study demonstrates that, for patients over 66 with Medicare, RT alone is associated with fewer therapies for ED and urinary incontinence compared to RP alone. Patients who undergo multimodal therapy required more treatment for erectile dysfunction and incontinence than patients who undergo a single treatment modality. This is important for patient counseling in the setting of cancer survivorship. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e406-e406 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexandra C. Muise More articles by this author Jill C. Buckley More articles by this author Michael M. Pan More articles by this author Brent Rose More articles by this author Expand All Advertisement Loading ...

As assisted reproductive technologies use increases, the evaluation of male factor infertility has often become overlooked. However, male evaluation remains critically important, with benefits seen in overall health, as well as in natural and assisted pregnancy and birth rates. A comprehensive assessment of the male partner should be offered to all couples seeking infertility care.

Characterized by low serum testosterone levels and diverse symptoms, male hypogonadism is a common condition. Current medical treatment focuses on testosterone supplementation using multiple modalities such as injections, gels and pellets. Interestingly, while testosterone is considered an anabolic androgenic steroid, it has not been saddled with the social stigma that other, similar medications have. The goal of this review is to highlight an anabolic steroid, 19-nortestosterone (i.e., nandrolone, deca-durabolin) and illustrate prospective therapeutic applications for male health. Containing a chemical structure similar to testosterone, nandrolone has a higher myotrophic: androgenic ratio resulting in improved effects on muscle mass. Animal models have suggested application in the improvement of joint healing following rotator cuff repair. Minimal literature exists regarding the use of nandrolone and, as such, further human studies are required.

To compare user performance of four fundamental inanimate robotic skills tasks (FIRST) as well as eight da Vinci Skills Simulator (dVSS) virtual reality tasks with intra‐operative performance (concurrent validity) during robot‐assisted radical prostatectomy (RARP) and to show that a positive correlation exists between simulation and intra‐operative performance.

We demonstrate the construct validity, reliability, and utility of Global Evaluative Assessment of Robotic Skills (GEARS), a clinical assessment tool designed to measure robotic technical skills, in an independent cohort using an in vivo animal training model.

You have accessJournal of UrologyBladder Cancer: Invasive I1 Apr 2015PD31-04 ROBOTIC SALVAGE CYSTECTOMY IS SAFE: MULTI-INSTITUTIONAL PERIOPERATIVE OUTCOMES Neel Srikishen, Andre Abreu, Monty Aghazadeh, Michael Pan, Gus Miranda, Monish Aron, Brian Miles, Inderbir Gill, Mihir Desai, and Alvin Goh Neel SrikishenNeel Srikishen More articles by this author , Andre AbreuAndre Abreu More articles by this author , Monty AghazadehMonty Aghazadeh More articles by this author , Michael PanMichael Pan More articles by this author , Gus MirandaGus Miranda More articles by this author , Monish AronMonish Aron More articles by this author , Brian MilesBrian Miles More articles by this author , Inderbir GillInderbir Gill More articles by this author , Mihir DesaiMihir Desai More articles by this author , and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2089AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Patients requiring cystectomy who have had prior pelvic radiotherapy and/or surgery are typically offered open salvage surgery. Recently, robotic cystectomy has been performed in the salvage setting; however, there are no published data regarding the safety and efficacy of this approach. We present early perioperative outcomes of robotic salvage cystectomy from two centers. METHODS Twenty-three patients underwent robotic salvage cystectomy at two tertiary referral centers from January 2011 to September 2014. Patients who had prior radical prostatectomy and/or received primary pelvic therapy (radiation or ablative treatment) for prostate or bladder cancer were considered salvage cases. Perioperative data were prospectively collected, including demographics, intraoperative data, complications, and oncologic outcomes (when applicable). RESULTS Demographics and perioperative outcomes are summarized in Table 1. Of the 23 patients, 7 (30%) had prior radical prostatectomy, 21 (91%) had prior pelvic radiotherapy, and 5 (22%) underwent both. All but one patient (96%) were male, 19 patients (83%) were ASA class ≥ 3, mean age was 75.4 years (range, 65.2-94.6), and mean BMI was 26.4 kg/m2 (range, 17.7-34.9). Robotic cystectomy was successfully completed in all patients with no intraoperative complications. Intracorporeal urinary diversion was performed in 21 patients (91%). Twenty-two patients (96%) had an ileal conduit and 1 patient (4%) had an ileal neobladder. Mean operative time was 7.4 hours (range, 4.8-12.1). Mean estimated blood loss was 280 mL (range, 50-600). Median length of stay was 6 days (range, 3-36). Three patients (13%) had high-grade complications (Clavien grade ≥ 3) within 90 days. The overall readmission rate was 13% (n=3). At a mean follow-up period of 225 days (range, 0-622) there were no rectal injuries, bowel leaks, or fistulas. One patient developed a ureteral stricture 6 months after surgery. Of the 19 patients undergoing robotic salvage cystectomy for oncologic reasons, 4 (21%) patients experienced a recurrence during the follow-up period. CONCLUSIONS Early perioperative results suggest that robotic salvage cystectomy following primary pelvic therapy is safe and feasible. These promising findings warrant further investigation comparing robotic and open salvage cystectomy. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e699 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Neel Srikishen More articles by this author Andre Abreu More articles by this author Monty Aghazadeh More articles by this author Michael Pan More articles by this author Gus Miranda More articles by this author Monish Aron More articles by this author Brian Miles More articles by this author Inderbir Gill More articles by this author Mihir Desai More articles by this author Alvin Goh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyTechnology & Instruments: Surgical Education & Skills Assessment III1 Apr 2015PD19-08 PROFICIENCY-BASED ROBOTIC TRAINING CURRICULUM YIELDS IMPROVEMENTS IN ROBOTIC CLINICAL PERFORMANCE: A RANDOMIZED CONTROLLED STUDY Monty Aghazadeh, Miguel Mercado, Michael Pan, Neel Srikishen, Brian Miles, Richard Link, Brian Dunkin, and Alvin Goh Monty AghazadehMonty Aghazadeh More articles by this author , Miguel MercadoMiguel Mercado More articles by this author , Michael PanMichael Pan More articles by this author , Neel SrikishenNeel Srikishen More articles by this author , Brian MilesBrian Miles More articles by this author , Richard LinkRichard Link More articles by this author , Brian DunkinBrian Dunkin More articles by this author , and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.707AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The lack of data regarding the impact of training on robotic clinical performance has precluded the adoption of a standardized robotic training curriculum. Our group has previously established and validated task-specific proficiency levels for 5 inanimate skills (IS) and 8 da Vinci Skills Simulator Virtual Reality (VR) exercises. Herein, we evaluate the impact of a standardized proficiency-based training curriculum employing these specific IS and VR tasks on clinical performance. METHODS Twenty urology residents from post-graduate years (PGY) 2-6 were enrolled in the curriculum extending between March 2013 and June 2014. All participants underwent a baseline skills assessment consisting of simulation performance as well as performing the endopelvic dissection of robotic prostatectomy (scored by the Global Evaluative Assessment Robotics Skills [GEARS] assessment tool). Residents were then randomized within their PGY and assigned to either: 1) Training Group (TG), train until proficient on 2 consecutive repetitions for each task, or 2) Standard Access Group (SAG), access to training tools, but no defined curriculum. Skills assessment was repeated at the midpoint and at the end of the curriculum for all participants. Median performance scores were compared between groups using the Wilcoxon Rank-Sum test and changes over time within groups were evaluated using the Paired-Sample Wilcoxon test. RESULTS Seventeen residents completed the required skills assessments, 9 of whom were in the TG. At baseline, no significant differences were noted between TG and SAG on all portions of skills assessments. By the end of the study, both groups saw improvements in performance, but in comparing final scores, the TG significantly outperformed SAG on IS and VR. Clinical performance was also higher in TG, although this was not statistically significant. However, when comparing baseline and final GEARS scores within groups, the improvement over time was significantly different in the TG (p=0.015), but not in the SAG (p=0.091). CONCLUSIONS To our knowledge, this is the first study to evaluate the impact of simulation training on robotic clinical performance over time. We show that a structured proficiency-based robotic curriculum can yield improvements in robotic clinical performance. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e394-e395 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Monty Aghazadeh More articles by this author Miguel Mercado More articles by this author Michael Pan More articles by this author Neel Srikishen More articles by this author Brian Miles More articles by this author Richard Link More articles by this author Brian Dunkin More articles by this author Alvin Goh More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

You have accessJournal of UrologyBladder Oncology/Testis/Transplantation/Trauma1 Apr 2015V8-14 ROBOTIC SALVAGE CYSTECTOMY: TIPS AND TRICKS Neel Srikishen, Michael Pan, Monty Aghazadeh, Brian Miles, and Alvin Goh Neel SrikishenNeel Srikishen More articles by this author , Michael PanMichael Pan More articles by this author , Monty AghazadehMonty Aghazadeh More articles by this author , Brian MilesBrian Miles More articles by this author , and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2138AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic cystectomy has continued to become an increasingly accepted and utilized surgical approach. To our knowledge, there have been no published series of robotic cystectomy in the salvage setting, as patients who have had prior therapy for advanced prostate or bladder cancer are typically offered open salvage cystectomy. METHODS Since 2013, we have performed robotic salvage cystectomies after a variety of prior treatment modalities including cryotherapy, brachytherapy, external beam radiotherapy, and radical prostatectomy. We followed the basic steps of a robotic cystectomy as is done in the non-salvage setting, with particular emphasis being placed on the posterior and urethral dissections. All patients underwent an intracorporeal ileal conduit urinary diversion. RESULTS We performed seven robotic salvage cystectomies at our institution. Mean total operative time was 6.5 hours (range 4.8-8.4 hours) and mean estimated blood loss was 300 mL (range 200-500 mL). There were no bowel injuries or gastrointestinal fistulae. CONCLUSIONS Robotic salvage cystectomy, though challenging, can be safely done after a variety of prior primary therapies. More data is needed to determine long-term oncologic and functional outcomes. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193 Issue 4S April 2015 Page: e719 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.Metrics Author Information Neel Srikishen More articles by this author Michael Pan More articles by this author Monty Aghazadeh More articles by this author Brian Miles More articles by this author Alvin Goh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

An increasing number of men are being diagnosed with hypogonadism. While many benefit from testosterone supplementation therapy, others who do not meet the criteria for hormone supplementation have turned to dietary adjuncts as a way or gaining improvements in libido, energy, and physical performance. These oral adjunct medications include controlled substances such as androstenedione, androstenediol as well as other “over-the-counter” options like DHEA (dehydroepiandrosterone) and herbal remedies like Tribulus terrestris. This review will focus on the use of these adjunct medications in isolation, or in combination with testosterone supplementation therapy as well as the biochemical nature of the supplements, the results of scientific trials as well as the side effects that limit their use. At the end of this review, physicians will have an improved understanding of the popular testosterone adjuncts being used currently as well as the availability of these substances and how they are used.

The paradigm of erectile dysfunction (ED) treatment was fundamentally altered following the introduction of oral phosphodiesterase type 5 inhibitors. Unfortunately, a significant number of men exhibit a suboptimal response and require additional management strategies. One of the novel, minimally invasive strategies being developed is low-intensity extracorporeal shock wave therapy. Used in the hope of delaying placement of an inflatable penile prosthesis, the final phase of ED treatment, low-intensity extracorporeal shock wave therapy is a unique application of an established technology that may hopefully one day expand the medical options for patients with ED. This commentary will highlight the physiology underlying this technique and summarize the most recent studies.

Hypogonadal men are characterized by low serum testosterone and symptoms of low energy, decreased libido, and muscle mass as well as impaired concentration and sexual functioning. Men with prostate cancer (PCa) currently on active surveillance or post-therapy, have traditionally been excluded from management paradigms given the decade-old concern that testosterone caused PCa growth. However, there appears to be little or no relationship between serum testosterone concentration and PCa. Androgen action in the prostate has long been known to be affected by the kinetics of receptor saturation and, as such, testosterone beyond a certain baseline is unable to stimulate prostatic growth due to complete intra-prostatic androgen receptor binding. Given this physiologic concept, many clinical investigators have begun to promote testosterone supplementation therapy (TST) as safe in men with PCa. This review examines the basics of testosterone physiology and summarizes the most recent findings on the use of TST in men with PCa on active surveillance and following treatment with external beam radiotherapy, brachytherapy and radical prostatectomy.

A semen analysis (SA) should be performed on all men of reproductive age prior to the commencement of testosterone supplementation therapy (TST). A baseline SA has numerous benefits including the ability to unmask occult azoospermia, act as a baseline measure of reproductive function, and provide a recovery target for management of TST-induced testicular dysfunction. Physicians treating men of reproductive age with TST should incorporate SA as part of their initial treatment protocol.