Abstract Introduction Epithelioid sarcoma (ES) is a rare, aggressive soft tissue malignancy that typically affects the distal extremities of young adults but can rarely involve the penis. Management usually requires wide excision or partial/total penectomy to achieve negative surgical margins due to high local recurrence and distant metastasis rates. Phallic reconstruction using a radial forearm free flap (RFFF) offers satisfactory cosmetic and functional outcomes. However, inflatable penile prosthesis (IPP) implantation in a neophallus presents unique technical challenges due to the absence of native corpora cavernosa, the need for neurovascular protection, and limited tissue support. Objective To describe the surgical technique and outcomes of IPP implantation in a young male who underwent partial penectomy and radial forearm flap phalloplasty after penile epithelioid sarcoma, emphasizing anatomical considerations, flap preservation, and prosthesis integration. Methods A 20-year-old male with penile ES underwent multimodal therapy including systemic and radiation therapy followed by partial penectomy with negative margins. Eighteen months later, he underwent total phallic reconstruction with a left radial artery–based forearm free flap. The urology team performed urethral anastomosis between the native urethral stump and the flap’s neourethra. Sensory reinnervation was achieved through coaptation of the lateral and posterior antebrachial cutaneous nerves with the bilateral dorsal penile sensory nerves. Six weeks postoperatively, glansplasty was performed using a distally based advancement flap technique. Subsequently, an IPP was implanted through a penoscrotal approach. The proximal corporal remnants were identified and dilated bilaterally. The distal neophallus was carefully dissected and dilated. Two Tutoplast grafts were shaped into windsocks to cover the distal cylinder tips, which were inserted through the neoglans using a Furlow introducer. The prosthesis components were connected and filled with normal saline. Intraoperative Doppler and indocyanine green angiography confirmed adequate flap perfusion. Results The implantation was completed without intraoperative or immediate postoperative complications. The flap maintained excellent perfusion and integrity throughout the procedure. Prosthesis inflation testing demonstrated full cylinder expansion and satisfactory penile rigidity. No ischemia, infection, or device malfunction was observed during the early postoperative period. The patient reported satisfactory cosmetic appearance, scrotal symmetry, and preserved tactile sensation in the neoglans at his six-week post-op follow-up. Conclusions IPP implantation following phallic reconstruction in patients with prior partial penectomy for malignant disease is technically feasible and safe when meticulous dissection and flap preservation are ensured. Key surgical considerations include individualized corporal anchoring, protective distal grafting, and use of intraoperative perfusion assessment to avoid vascular compromise. This case highlights the multidisciplinary collaboration between reconstructive plastic surgery and urology as essential for restoring urinary, sensory, and sexual function in young patients undergoing complex genital reconstruction after oncologic surgery. Disclosure No

Abstract Introduction Inflatable penile prosthesis (IPP) is the gold standard treatment for erectile dysfunction (ED) refractory to medical therapy and is associated with high patient satisfaction rates. Traditionally, the reservoir is placed in the space of Retzius; however, this approach can be technically challenging and may lead to serious complications, particularly in patients with a history of major pelvic surgery. Subscarpal reservoir placement (SRP) is an alternative in select patients with prior pelvic surgery. Objective To examine the efficacy and safety of the SRP of IPP reservoir placement. Methods Retrospective analysis of patients who underwent SRP by a single surgeon between May 2016 and September 2024. Patients were evaluated based on age, etiology of ED, history of radiation therapy (RT), body mass index (BMI), diabetes, hypertension, peripheral vascular disease, smoking status, immunosuppression status, prior abdominal surgery, history of Peyronie’s disease (PD), history of priapism, prosthesis type, surgical approach, postoperative complications, and reservoir-related complications. Patients were also asked whether the reservoir was palpable and to report their subjective level of bother, if any. Results A total of 35 patients were identified with SRP during the study period, with a mean age of 67.6 years (SD 7.6) and a mean BMI of 28.9 kg/m2 (SD 3.8). Of these, 71.4% (25/35) had previously undergone radical cystectomy (RC), while the remaining 28.6% (10/35) had undergone radical prostatectomy, associated with additional risk factors, including a history of oncologic colonic surgeries (6/35), pelvic fracture (1/35), or BMI >35 kg/m2 (3/35). All demographic variables are summarized in Table 1. A penoscrotal approach was used in 97.1% (34/35) of cases. A subcoronal approach was used in one patient due to the need for concomitant PD correction. The mean follow-up duration was 31.1 months (SD 29.5). Notably, there were no reservoir-related complications such as erosion or herniation. One patient developed an infection requiring IPP removal. Two patients experienced urethral erosion, necessitating device removal. Four patients presented with mechanical malfunction and subsequently underwent revision surgery. The response rate to the satisfaction survey was 45.6% (16/35). Among the respondents, 75% (12/16) reported palpable reservoirs; however, only 18.8% (3/16) reported being bothered by it. Conclusions SRP is a viable option for carefully selected patients with a history of major pelvic surgery. This approach is safe and associated with a low incidence of reservoir-related complications, such as herniation or erosion. Although many patients are able to palpate the reservoir, only a small proportion report being bothered by it. These findings underscore the importance of thorough preoperative counseling and expectation management in this high-risk population for reservoir-related complications. Disclosure No

INTRODUCTION:Erectile dysfunction (ED) is a multifactorial condition with psychological, vascular, hormonal, neurological, and systemic risk factors. Four phosphodiesterase-5 inhibitors (PDE5is), sildenafil, tadalafil, vardenafil, and avanafil, have been approved by the United States Food and Drug Administration and the European Medicines Agency for the management of ED. OBJECTIVES:While several meta-analyses have assessed the efficacy of PDE5is in the management of ED, none have focused on dose-specific outcomes. Hence, the study was conducted to compare the dose-dependent efficacy and safety of four FDA/EMA-approved PDE5is in the treatment of ED using on-demand dosages. METHODS:A comprehensive literature search identified randomized, double-blind, placebo-controlled trials. Only on-demand doses of PDE5is were included in the network meta-analysis (NMA), which focused on primary outcomes such as the proportion of participants achieving satisfactory erectile function (EF), defined as an International Index of Erectile Function (IIEF) domain score > 26. A threshold analysis was conducted to evaluate the robustness of treatment recommendations derived from the NMA. RESULTS:A total of 83 studies with 6029 participants (treatment group: 3457 participants; placebo group: 2572 participants) were included. This dose-response network meta-analysis highlighted better efficacy with sildenafil (sildenafil 100 mg: odds ratio [OR] 9.06, sildenafil 50 mg: OR 7.90) in improving EF compared to that with placebo, followed by tadalafil (tadalafil 20 mg: OR 7.13, tadalafil 10 mg: OR 3.14), vardenafil (vardenafil 10 mg: OR 7.78), and avanafil (avanafil 200 mg: OR 3.42, avanafil 100 mg: OR 1.75). Threshold analysis showed a statistically significant improvement in ED with sildenafil 100 mg [OR 2.20; 95% confidence interval (CI) 1.78-2.63] and 50 mg (OR 2.10; 95% CI 1.69-2.50) compared to placebo. This indicated the robustness of the results, with moderate variations unlikely to alter their comparative ranking within the NMA. The odds of treatment-related adverse events were highest for vardenafil, followed by avanafil and sildenafil, and lowest for tadalafil compared to placebo. However, in some instances, the wide CI showed higher variability and potential uncertainty in effect estimates. CONCLUSION:PDE5is are highly effective, with sildenafil showing a significantly greater efficacy compared with the other PDE5is.

BackgroundGremlin-1 (GREM1) is a profibrogenic molecule involved in TGF-β signaling. Recent studies have implicated GREM1 in androgen receptor (AR)-independent signaling and castration resistance in advanced prostate cancer. However, its compartment expression patterns and clinicopathologic significance in primary prostate cancer remain unclear.MethodsGREM1 mRNA expression and clinicopathologic associations were analyzed in the Cancer Genome Atlas (TCGA) prostate adenocarcinoma (TCGA-PRAD), the Memorial Sloan Kettering Cancer Center (MSKCC), and the German Cancer Research Center (DKFZ) primary prostate cancer cohorts. Correlations between GREM1 and genes related to TGF-β signaling, extracellular matrix organization, fibroblast activation, and AR signaling were evaluated by Spearman analysis. GREM1 protein expression was examined by immunohistochemistry in commercial human prostate cancer tissue microarrays (TMAs) using compartment-specific QuPath-based H-scores.ResultsGREM1 expression was relatively elevated in prostate and bladder cancers. Across the three prostate cancer cohorts, higher GREM1 expression was associated with adverse pathologic features and was most consistently correlated with FAP. Inverse correlations were observed with selected AR-related genes, whereas no significant correlation was found with AR itself. Higher GREM1 expression was associated with shorter disease-free survival only in MSKCC but was not an independent prognostic factor after clinicopathologic adjustment. Quantitative immunohistochemistry in 43 patients showed higher epithelial than stromal GREM1 H-scores (median, 3.10 vs 1.41; P < 0.0001), with heterogeneous staining in both compartments. Neither epithelial nor stromal H-scores were associated with Gleason score or pathologic T stage.ConclusionsGREM1 mRNA expression in primary prostate cancer was associated with adverse clinicopathologic features, and a fibroblast-associated transcriptional context but did not demonstrate independent prognostic value. At the protein-level, GREM1 expression was heterogeneous in both epithelial and stromal compartments, with higher epithelial H-scores on average. These findings support further investigation of the biological significance of GREM1 expression in primary prostate cancer.

Radical prostatectomy (RP) is a common treatment for localized prostate cancer, which unfortunately often results in sexual dysfunction, including, but not limited to erectile dysfunction (ED), penile atrophy and penile fibrosis. Various therapies have been used to manage these side effects associated with RP, including vacuum erection devices (VEDs) and penile traction therapy (PTT). This review focuses on the mechanisms, efficacy, and clinical applications of VED and PTT in post-RP patients. VED, a well-established, non-invasive modality, enhances penile blood flow, preserves tissue integrity, and facilitates early engagement in sexual activity. Although VED has been shown to help maintain penile length and improve sexual function, its effectiveness in accelerating spontaneous erectile function recovery remains uncertain. PTT, originally developed for Peyronie's disease, has recently been explored for post-RP patients. Preliminary studies suggest its potential in mitigating penile shortening and supporting functional recovery, though long-term efficacy data remain limited. Both therapies face challenges, including lack of standardized protocols, adherence issues, and encouraging, but limited evidence on their combined use with pharmacological interventions. Additionally, factors such as patient education, treatment accessibility, and psychological support play critical roles in therapy adherence and overall success. Further research is needed to optimize treatment protocols, improve patient compliance, and establish the role of VED and PTT in comprehensive post-RP care through large-scale, well-designed clinical trials.

Background: Fibroblasts are vital for tissue structure, repair, and fibrosis in male reproductive organs, but tools for investigating their localization and distribution are limited. This study employed the collagen type I alpha 2 Cre recombinase estrogen receptor tandem dimer Tomato (Col1a2CreERtdTomato (Tom)) lineage tracing mouse model, enabling tamoxifen-inducible, fibroblast-specific labeling through Cre recombination under the Col1a2 promoter. This system labels collagen-producing fibroblasts with tdTomato, enabling lineage tracing and visualization of their organization in the penis, prostate, and testis. The study aimed to investigate fibroblast distribution and localization in these organs using this model. Methods: Male Col1a2CreERTom mice (n = 5-6) received tamoxifen (1 mg/day/mouse, intraperitoneal, for 5 consecutive days) to induce Cre recombination and label collagen-producing fibroblasts with tdTomato. Wild type (WT) control mice (n = 3) also received tamoxifen. Two days after the last injection, penis, prostate, and testis tissues were harvested, sectioned, and examined through microscopy on tdTomato epifluorescence. Fibroblasts were quantified as the percentage of tdTomato+ cells relative to total cells. Results: Quantification revealed distinct fibroblast distribution patterns among the organs. In the Col1a2CreERTom mouse, tdTomato+ fibroblasts were most abundant in the penis (75.24 f 1.6%), followed by the prostate (26.02 f 1.4%) and testis (13.97 f 0.9%). Within the penis, the subtunical region had the highest density (93.42 f 0.5%). In the prostate, fibroblasts were mainly within the fibromuscular stroma; in the testis, they were in the tunica albuginea and interstitial compartments. No tdTomato+ cells were observed in WT controls. Conclusions: The number and location of collagen-producing fibroblasts differ among the penis, prostate, and testis, and vary within penile compartments. These findings reflect the organ-and region-specific distribution of Col1a2-lineage fibroblasts, as revealed by tamoxifen-induced tdTomato lineage tracing. This study provides a useful tool for further investigation of fibroblast function in male reproductive health.

INTRODUCTION:Vacuum erectile device (VED) is 1 of the main approved therapies for erectile dysfunction (ED). The introduction of phosphodiesterase type 5 inhibitor (PDE5i) for ED significantly changed the roles of VED in contemporary sexual medicine. OBJECTIVE:To provide updated clinical evidence to inform health care providers on best practices with VED. METHODS:A consensus panel was held with leading sexual medicine experts during the 5th International Consultation on Sexual Medicine (ICSM). Relevant peer-reviewed literature was reviewed with focus on research from the last 10 years, but not limited to the last 10 years. The expert panel generated consensus statements based on the quality of evidence and criteria of Grading of Recommendations Assessment, Development and Evaluation. RESULTS:As a primary or combination therapy for ED, VED has been shown to be successful in all populations studied, including difficult to treat cohorts, such as diabetes mellitus, spinal cord injury, and post-radical prostatectomy (RP), but long-term attrition rates are high. Available evidence has shown that VED can preserve or restore penile size for patients after RP, after incision and grafting surgery for Peyronie's disease, before and after penile prosthesis, and after other post pelvic surgeries. However, it has not demonstrated a more rapid recovery of spontaneous erectile function after RP. VED does not increase penile length for subjective short penis. Studies with female specific VED for female sexual dysfunction are very limited. CONCLUSIONS:Since the prior 4th ICSM, more evidence is available to support the new roles of VED in contemporary sexual medicine. Research into the penile pathophysiologic changes with VED therapy and clinical outcomes for various conditions are ongoing. We encourage sexual medicine clinicians to follow the 5th ICSM recommendations, but providers should also use their own judgement and adopt shared decision making with their patients/partners when considering VED for a specific disorder.

Radiotherapy, a standard treatment for prostate cancer, is known to adversely affect erectile function. Assessing the impact of this therapy on penile vascular health and erectile dysfunction management is essential for improving patient outcomes post-treatment. This evaluation can help optimize rehabilitation plans and enhance quality of life for those undergoing prostate cancer therapy. This study aims to explore the effect of radiotherapy on penile Doppler parameters and intra-corporeal injection (ICI) dose requirements, compared with other treatment modalities, in prostate cancer patients. A retrospective analysis was performed using our institution’s database to identify patients who developed erectile dysfunction following radiotherapy. The study included individuals from a single institution who attended the Sexual Medicine clinic, underwent Penile Doppler Ultrasound, received Trimix ICI therapy, and had at least one year of follow-up, during which the ICI dosage required for satisfactory erectile response was monitored. A total of 233 patients, meeting the inclusion criteria between 2021 and 2024, were included in the analysis. Participants were divided into two groups: Group 1 consisted of patients who underwent radiotherapy, while Group 2 included those who received alternative prostate cancer treatments, such as prostatectomy or androgen deprivation therapy. Student’s T-test and Chi-squared test were utilized to compare numerical and categorical variables between the two groups, respectively. Linear regression analysis was performed to explore the impact of demographic and clinical variables on the changes in ICI trimix dose during follow-up. A total of 233 patients were evaluated in this study. Table 1 compares key clinical parameters between two groups: prostate cancer patients treated with radiation therapy (N = 57) and those treated with non-radiation modalities (N = 176). The prevalence of diabetes mellitus (DM) and hypertension (HTN) is comparable between the two groups, with no statistically significant differences (p = 0.53 and p = 0.36, respectively). However, the mean age of patients in the radiation group (63.58 ± 6.87 years) is significantly higher than in the non-radiation group (61.11 ± 7.51 years), with a p-value of 0.029, suggesting a meaningful age difference. No significant differences between both groups were observed in arterial parameters, including pre- and post-in office ICI arterial diameters, as well as peak systolic velocity (PSV) and end-diastolic velocity (EDV). Notably, the increase in the required dose of intra-corporeal trimix injections over time is more pronounced in the radiation group (17.31 ± 19.21) than in the non-radiation group (10.94 ± 15.7), with a p-value of 0.016. Linear regression analysis further confirmed that age (regression coefficient = 0.34, 95% CI 0.04-0.64, p = 0.02) and exposure to radiation (regression coefficient = 5.5, 95% CI 0.34-10.6, p = 0.03) were both independent predictors for an increase in trimix ICI dose during follow-up. The findings of this study suggest that exposure to radiation therapy as well as older age were associated with a greater need for higher doses of injection therapy to achieve satisfactory erectile function in prostate cancer patients. These findings highlight the potential adverse effects of radiation on erectile recovery and underscores the need for individualized rehabilitation strategies for patients undergoing prostate cancer radiotherapy. Further studies are needed to definitively determine its clinical significance and move beyond the current status.

Background: Prostate cancer, a prevalent malignancy in men, often results in erectile dysfunction (ED), particularly following treatments like radical prostatectomy (RP) and radiotherapy, significantly affecting quality of life. Managing ED in prostate cancer survivors is critical. Inflatable penile prosthesis (IPP) implantation is a well-established treatment for ED, yet the literature on satisfaction rates for patients with a history of androgen deprivation therapy (ADT) remains sparse. We aimed to investigate the impact of ADT on satisfaction rates in patients undergoing IPP implantation following RP or radiation therapy (XRT). Methods: A retrospective review of 529 patient charts identified 96 eligible patients who underwent IPP implantation post-prostate cancer treatment and completed the 11-item Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire. Patients were stratified into two groups based on ADT status, and their satisfaction scores were compared. Effect sizes were used to assess clinical relevance alongside statistical significance (p = 0.0344). Results: Patients receiving ADT had significantly lower EDITS scores (p = 0.0344) compared to those not on ADT. RP patients reported higher satisfaction post-IPP compared to XRT patients, even after controlling for ADT. Additionally, coronary artery disease (CAD) was associated with lower satisfaction scores. Conclusion: ADT significantly lowers patient satisfaction post-IPP, with RP patients generally reporting higher satisfaction than XRT patients. These findings highlight the importance of counseling prostate cancer patients on ADT's impact on long-term sexual satisfaction and suggest areas for further research to enhance outcomes.

INTRODUCTION:Penile prosthesis (PP) is one of the main approved therapies for erectile dysfunction (ED). Greater than 50 years of clinical use has led to considerable innovation in PP surgery and patient care. OBJECTIVES:To summarize the current literature and provide updated clinical evidence to inform healthcare providers on best practices with PP. METHODS:A consensus panel was held with leading sexual medicine experts during the 5th International Consultation on Sexual Medicine (ICSM). Relevant peer-reviewed literature was reviewed with focus on research from but not limited to the last 10 years. The quality of each individual study was judged with Oxford levels of evidence (LOE) criteria, but overall LOE were not used as systematic review was not performed. The expert panel generated consensus statements based on the quality of evidence and criteria of GRADE (Grading of Recommendations Assessment, Development and Evaluation). RESULTS:PP provides excellent outcomes for the treatment of ED. The panel developed 35 recommendations building upon previous recommendations. Nine recommendations (4, 5, 11,13,17, 25, 26, 31, and 32) are retained without change from 2015. Twelve recommendations (1, 2, 3, 7, 9,14,16,19,21, 28, 33, and 34) change syntax to make statements more active or change details. Fourteen recommendations (6, 8, 10, 12, 15, 18, 20, 22, 23, 24, 27, 29, 30, and 35) are novel in this update. CONCLUSION:Since the 4th ICSM, new evidence has emerged to guide PP use in modern sexual medicine. While multi-institutional studies are needed to improve outcomes, key challenges remain: reducing infections, enhancing devices, and improving awareness and accessibility. We recommend following 5th ICSM guidelines while emphasizing the importance of clinical judgment and shared decision-making for optimal PP outcomes.

>San Antonio, May 3, 2024—The 16th Annual meeting of the World Chinese Urological Society (WCUS) was successfully held in San Antonio, drawing together experts and scholars from around the globe in the field of Chinese urology. This conference served as a platform for academic exchange, as well as an occasion for medical professionals of Chinese descent to learn from,inspire, and motivate one another. Such events are crucial for advancing research and clinical practice in Chinese urology worldwide, and the success of this conference signals a bright and progressive future for the field.

Introduction In cases of a noninfected malfunctioning inflatable penile prosthesis (IPP) device, surgeons often opt to exchange all of the device rather than the defective component for fear of an increased infection rate and future mechanical dysfunction.Objectives To assess whether partial-component exchange of an IPP device has comparable outcomes to complete explant and replacement of an IPP device with or without a retained reservoir.Methods A systematic review was conducted following the PRISMA 2020 and AMSTAR guidelines. Searches were performed on MEDLINE (Ovid), PubMed, and the Cochrane Library from inception to June 2023, identifying studies reporting outcomes and complications of revision surgery for noninfected malfunctioning IPP devices. Three groups were compared: those undergoing single- or 2-component exchange, those with complete explantation and replacement, and those with replacement of all components while retaining the primary reservoir.Results Analysis included 11 articles comprising 12 202 patients with complete device replacement, 234 with partial device exchange, and 151 with retained reservoirs following revision. Mean ages ranged from 62 to 68 years, with median follow-up times between 3 and 84 months. Partial-component exchange showed a higher infection rate (6.3%) as compared with complete replacement (2.7%) and reservoir retention (3.9%). Similarly, partial exchange had a higher complication rate (23.9%) when compared with complete replacement (11.3%) and reservoir retention (19.6%). Mechanical failure rates for partial exchange were similar across the 3 groups (10%, 2.8%, and 5.8%, respectively).Conclusion Partial-component exchange during IPP revision is associated with higher infection and perioperative complication rates but comparable rates of mechanical failure as compared with complete-component replacement, with or without retaining the original reservoir.