Epidemiology of Sexual dysfunction in Asia compared to the rest of the world

There have been a limited number of epidemiological studies published on sexual disorders in persons from Asia. This paper aims to assess the reports of sexual dysfunction epidemiological studies published in the English language that involved Asian countries. Key points are summarized in this paper from nine epidemiological papers on sexual dysfunction from Asia that were published in the English language. Seven met the criteria for evidence-based studies reaching a Prins score of at least 10 or more. Papers included in this report came from national and regional representative studies in peer review journals. These results for sexual dysfunction in the nine papers are summarized for various sexual dysfunctions in men and women in Asian countries. In three of these, worldwide data were presented in the same paper allowing comparisons with Asian data on prevalence rates. Detailed descriptions from each of these studies are presented in paragraph form. More detailed data on erectile dysfunction （ED） is presented in a tabular form. Collectively, there seems to be a need for country- and population-specific further descriptive and analytical epidemiological studies in all of the sexual disorders from Asia. This critical review paper should help guide these studies for reachinj[ evidence-based literature standards.

The role of photovaporization of the prostate in small volume benign prostatic hyperplasia and review of the literature

Objective:Our objective was to characterize the safety and efficacy of the 180 W XPS-GreenLight laser in men with lower urinary tract symptoms secondary to a small volume benign prostatic hyperplasia(BPH).Methods:A retrospective analysis was performed for all patients who underwent 180 W XPSlaser photoselective vaporization of the prostate(PVP)vaporization of the prostate between 2012 and 2016 at two-tertiary medical centers.Data collection included baseline comorbidities,disease-specific quality of life scores,maximum urinary flow rate(Qmax),postvoid residual(PVR),complications,prostate volume and prostate-specific antigen(PSA).The secondary endpoints were the incidence of intraoperative and postoperative adverse events.Complications were stratified using the Clavien-Dindo grading system up to 90 days after surgery.Results:Mean age of men was 67.8 years old,with a mean body mass index of 29.7 kg/m2.Mean prostate volume as measured by transrectal ultrasound was 29 mL.Anticoagulation use was 47%and urinary retention with catheter at time of surgery was 17%.Mean hospital stay and catheter time were 0.5 days.Median follow-up time was 6 months with the longest duration of follow-up being 22.5 months(interquartile range,3-22.5 months).The International Prostate Symptom Score improved from 22.8±7.0 at baseline to 10.7±7.4(p<0.01)and 6.3±4.4(p<0.01)at 1 and 6 months,respectively.The Qmax improved from 7.70±4.46 mL/s at baseline to 17.25±9.30 mL/s(p<0.01)and 19.14±7.19 mL/s(p<0.001)at 1 and 6 months,respectively,while the PVR improved from 216.0±271.0 mL preoperatively to 32.8±45.3 mL(p<0.01)and 26.2±46.0 mL(p<0.01)at 1 and 6 months,respectively.The PSA dropped from 1.97±1.76 ng/mL preoperatively to 0.71±0.61 ng/mL(p<0.01)and 0.74±0.63 ng/mL at 1 and 6 months,respectively.No patient had a bladder neck contracture postoperatively and no capsular perforations were noted intraoperatively.Conclusion:The 180 W GreenLight XPS system is safe and effective for men with small volume BPH.PVP produced improvements in symptomatic and clinical parameters without any safety concern.It represents a safe surgical option in this under studied population.

Mapping of metastasis suppressor genes for prostate cancer by microcell-mediated chromosome transfer

Aim:To identify the metastasis suppressor genes for prostate cancer.Methods:A copy of human chromosomeswas introduced into the highly metastatic Dunning R-3327 rat prostate cancer cells by the use of microcell-mediatedchromosome transfer.Relationships between the size of human chromosomes introduced into microcell hybrid clonesand the number of lung metastases produced by the clones were analyzed to determine which part of human chromo-somes contained the metastasis suppressor gene(s)for prostate cancer.To determine portions of human chromosomesintroduced,G-banding chromosomal analysis,fluorescence in sim hybridization analysis,and polymerase chain reac-tion analysis were performed.Results:Each of microcell hybrid clones containing human chromosomes 7,8,10,11,12,or 17 showed decreased ability to metastasize to the lung without any loss of tumorigenicity.This demonstratesthat these human chromosomes contain metastasis suppressor genes for prostate cancer.Spontaneous deletion of portionsof human chromosomes was observed in the human chromosome 7,10,11,12,and 17 studies.In the human chromo-some 8 study,irradiated microcell-mediated chromosome transfer was performed to enrich chromosomal arm deletionsof human chromosome 8.Molecular and cytogenetic analyses of microcell hybrid clones demonstrated that metastasissuppressor genes on human chromosomes were located on 7q21-22,7q31.2-32,8p21-12,10q11-22,11p13-11.2,12p11-q13,12q24-ter,and 17pter-q23.KAII and MKK4/SEKI were identified as metastasis suppressor genes from11p11.2 and 17p12,respectively.Conclusion:This assay system is useful to identify metastasis suppressor gene(s)for prostate cancer.

Critical evaluation of unscientific arguments disparaging affirmative infant male circumcision policy

We evaluate recent claims opposing infant male circumcision,a procedure now supported by the evidencebased policy of the American Academy of Pediatrics.We find those criticisms depend on speculative claims about the foreskin and obfuscation of the strong scientific evidence supporting pediatric policy development.An argument that circumcision should be delayed to allow a boy to make up his own mind as an adult fails to appreciate the psychological,scheduling and financial burdens later circumcision entails,so reducing the likelihood that it will occur.In contrast,early infant circumcision is convenient,safer,quicker,lower risk,healing is faster,cosmetic outcome is routinely good and the lifetime benefits accrue immediately.Benefits include reduction in urinary tract infections,inflammatory skin conditions,foreskin problems,and,when older,substantial protection against sexually transmitted infections and genital cancers in the male and his female sexual partners.Some authorities regard the failure to offer parents early infant circumcision as unethical,just as it would be unethical to fail to encourage the vaccination of children.In conclusion,the criticisms of evidence-based infant male circumcision policy are seriously flawed and should be dismissed as unhelpful to evidence-based development and implementation of pediatric policy intended to improve public health and individual wellbeing.

A national survey of lower urinary tract symptoms in Jordan

Objective To determine the prevalence of lower urinary tract symptoms(LUTS)and their severity population in Jordan.Methods This cross-sectional survey was conducted using a paper-based survey between August and September in 2019.The study was carried out in the health care centers or hospitals in three different regions of Jordan:North(Irbid and Jarash),Middle(Amman,Madaba,Salt,and Zarqa),and South(Karak and Aqaba).Results To estimate the prevalence of LUTS,two definitions were used,including the first definition(presence of any LUTS regardless of the degree of severity)and the second definition(presence of any LUTS that occurs half the time or more).According to the first definition,1038(89.9%)reported LUTS(male:47.3%,female:52.7%),while 763(66.1%)reported LUTS according to the second definition(male:45.6%,female:54.4%).According to the International Prostate Symptom Score characterization,73.9%had nocturia and 62.9%reported daytime increased frequency.Conclusion LUTS are highly prevalent among the Jordanian population,and more than half of them have nocturia or daytime increased frequency as most frequently reported symptoms.

Robotically assisted removal of pelvic splenosis fifty-six years after splenectomy: A case report

BACKGROUND‘Splenosis’is defined as the autotransplantation of splenic tissue following trauma or surgery,usually in the form of intraperitoneal nodules.The proliferation of imaging techniques has resulted in increased unexpected discoveries of splenosis nodules,and achieving a differential diagnosis can be challenging.Nuclear medicine studies have been playing an increasingly important role in this process,but the clinical significance of asymptomatic nodules remains uncertain.CASE SUMMARY We present a case of pelvic splenosis in a 73-year-old man diagnosed 56 years after a splenectomy during a computed tomography(CT)follow-up for B-cell lymphoma,presenting intense contrast enhancement of an 18 mm nodule in the right recto-vesical space.18F-fluorodeoxyglucose demonstrated weak metabolic activity.Since histological diagnosis was deemed necessary,the nodule was easily removed with robotically assisted laparoscopy,together with another 6 mm left a paracolic lesion.The latter was previously undiagnosed but retrospectively visible on the CT scan.CONCLUSION In a patient requiring differential diagnosis of splenosis nodules from lymphomarecurrence, the robotic approach provided a safe en bloc removal with shorthospitalization. The Da Vinci Xi robot was particularly helpful because its opticscan be introduced from all ports, facilitating visualization and lysis of multipleintra-abdominal adhesions.

Expertise and Ideology in Statistical Evaluation of Circumcision for Protection against HIV Infection

Aim: To critically evaluate data and arguments by Van Howe defending his stance opposing male circumcision (MC), in particular his meta-regression analyses evaluating the ability of MC to reduce HIV infection risk in heterosexual populations within and outside Africa. Methods: We performed metaregression analysis of log odds of HIV infection between uncircumcised and circumcised men using a single covariate (MC prevalence) in the meta-regression model involving the metareg package in STATA 13 for 103 populations worldwide and for populations within Africa. The meta-regression of log odds and MC prevalence was fitted to a line, as were empirical Bayes estimates resulting from post-estimation. Results: Our critical evaluation of Van Howe’s arguments attempting to undermine the scientific evidence in support of the benefits of MC in protection of men against HIV during heterosexual intercourse, as well as other infections and conditions, together with his use of statistics to support his beliefs, revealed serious flaws, obfuscation and missing data. We therefore performed our own meta-regression analysis using a trivariate model. Doing so revealed that for MC prevalences of 50%, 75% and 100% for general populations within Africa, odds ratios for HIV risk in uncircumcised vs. circumcised men were 1.35, 1.58 and 1.85, respectively. Our meta-regression analysis of data for all countries yielded similar findings. For a general population outside Africa with 100% MC prevalence, OR was 1.5. Van Howe failed to acknowledge that since MC prevalence in US whites (91%) and blacks (76%) exceeds 75% his results support MC having a protective effect in those population groups. Conclusions: The protective effect of MC against HIV infection during heterosexual intercourse applies to populations both within and outside Africa. The debate engineered by MC opponents, and led by Van Howe, now appears to have run its course. The scientific evidence has prevailed.

PSA velocity may not be of value in prostate cancer detection

Prostate cancer is the most prevalent nonskin cancer and is the third leading cause of cancer death in the United States. It is estimated to affect millions of men worldwide and is a significant cause of morbidity and mortality.

Lingual mucosal graft urethroplasty 12 years later: Systematic review and meta-analysis

Objective:To evaluate the functional results and complications of the lingual mucosal graft(LMG)urethroplasty and to sum up the current state of the art of this surgical technique.Methods:A systematic search of PubMed and Scopus electronic databases was performed,according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA)statement.Studies involving male patients treated with LMG urethroplasty for urethral stricture were included.Complete protocol is available at http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017080121.A meta-analysis comparing functional and long-term oral complication outcomes of LMG and buccal mucosal graft(BMG)was performed,calculating the odds ratio(OR)and 95%confidence interval(CI).Results:Twenty original articles were included in the qualitative analysis.Strictures of 1.5e16.5 cm have been treated with LMG urethroplasty,due to the improvement of harvesting technique and very low rate of long-term oral complications.Very good functional results have been reported by different authors for LMG urethroplasty,with lower rate of oral complications than BMG.The meta-analysis included six comparative studies involving 187 and 178 patients treated with LMG and BMG urethroplasty,respectively.An OR of 1.65(95%CI[0.95e2.87],I^2=0%)and 0.18(95%CI[0.03e1.26],I^2=68%)were found for LMG vs.BMG urethroplasty,in terms of success and oral complication rate,respectively.Conclusion:LMG urethroplasty can be reasonably considered a first choice technique for urethral stricture with very good results.Oral complications are temporary and minimally disabling,basically less than those for BMG,and depend mainly on the graft extent.

Does urodynamics predict voiding after benign prostatic hyperplasia surgery in patients with detrusor underactivity?

Objective:We sought to determine if urodynamic study(UDS)predicted voiding outcomes in men with detrusor underactivity(DU)and benign prostatic enlargement(BPE)who underwent photovaporization of the prostate(PVP).Methods:Between September 2010 and July 2015,106 male patients with BPE and DU were identified.All patients underwent PVP.Urinary retention was noted by the preoperative necessity for an indwelling or intermittent catheter.Data collection included comorbidities,quality of life(QoL)scores,prostate volume,prostate-specific antigen(PSA),UDS and perioperative outcomes.UDS parameters included volume at first desire to void,volume at first urge to void,volume of severe urge,volume at capacity,compliance,detrusor contractions,maximum urinary flow rate(Qmax),and postvoid residual(PVR).Results:A total of 106 men were included in this analysis,who had urinary retention with a Foley catheter or clean intermittent catheterization(CIC)at the time of surgery.At baseline we found patients who voided had a detrusor pressure at Qmax(Pdet@Qmax)of 10.05±6.45 cmH2O compared to 16.78±12.17 cmH2O in those who did not void(p=0.071).Postoperatively,96(90.6%,mean age 76.9±26.2 years)of patients voided successfully while 10(9.4%,mean age 80.52±9.61 years)of patients remained in urinary retention.Mean baseline Qmax was 4.895±5.452 mL/s and 2.900±3.356 mL/s(p=0.087)in those who voided and did not respectively.PVR was 319.23±330.62 mL in those who voided and 276.88
263.27 mL(p=0.344)in those who did not void.No UDS parameter predicted who would void postoperatively or improvements in QoL.Conclusions:The patients with DU and BPE might be able to successfully void after undergoing PVP regardless of UDS findings.All men who voided had improved international prostate symptom score and QoL scores compared to baseline and these parameters were durable up to 12 months.

Prolonged penile strangulation with metal clamps

Various different objects have been reported to strangulate the penis,We reported on a patient who used metal radiator clamps for an extended period of time .Workup included history,physical examination and urinalysis.The patient was taken to the operating room for further evaluation with cystourethroscopy and orthopedic wire cutters were used to break the metal bands.（Asian J Androl 2006Jan;8：105-106）

Epithelial-mesenchymal transition in prostate cancer： providing new targets for therapy

The ability of epithelial cells to undergo phenotypic transitions during embryo-genesis, wound healing and malignant pro- gression is now widely accepted as a core biological process termed epithelialmesenchymal transition （EMT）. During cancer progression, the process of EMT has been associated with the acquisition of stemness properties, treatment resistance and metastatic progression, hallmarks of malig- nancy.

Long-term differences in urinary, bowel and sexual function among men treated with surgery versus radiation for prostate cancer

surgery and radiation have both been shown to increase the longterm diseasespecific survival rate for men with din icaUy localized prostate cancer. Although both modalities have demonstrated favor able effects on cancer control, questions regarding quality of life （QoL） and func tional outcomes remain incompletely answered. To date, no randomized prospective trials have been performed comparing the two treatment modalities and so indirect compar isons of longterm functional outcomes have served as a substitute to aid in patient coun seling and decisionmaking. As there is a pau city of longterm data comparing functional outcomes after radical prostatectomy and external beam radiation therapy, a recent art icle by Resnick et al.,1 has attempted to pro vide additional information about this topic in terms of continence, erectile function and bowel function. Utilizing the Prostate Cancer Outcomes Study cohort, a populationbased cohort of men diagnosed with prostate cancer in the pro statespecific antigen （PSA） era, the authors compared rates of urinary incontinence, erect ile dysfunction, and bowel urgency at 2, 5 and 15 years after primary therapy. They showed that men undergoing prostatectomy had higher rates of incontinence and erectile dys function at 2 and 5 years, but these rates were similar to those in the radiotherapy group at 15 years. More specifically, men were approxi mately five times more likely to have urinary continence issues if they underwent prostatec tomv versus radiotherapy and almost three anda half times more likely to develop erectile dys function in the short to intermediateterm following primary treatment. As expected, rates of bowel urgency were higher in the radio therapy group at 2 and 5 years, but not sig nificantly different from the surgery group at 15 years. In addition, the authors note that the rate of incontinence and erectile function pro gressively worsened over time, regardless of primary treatment modality. At 15 years of followup, the prevalence of erectile dysfunc tion was approximately 87% in the prosta tectomy group, and 94% in the radiotherapy group, a nonsignificant difference. Interes tingly, only approximately 40% of patients in either group reported being bothered by this. Without an appropriate control group, it is hard to distinguish the relative contribution of inter vention or age to the overall decline in sexual function. Shortterm studies have shown that men undergoing prostatectomy have larger declines in sexual and urinary function than agematched controls,2 but no such untreated control cohort was present in this study. The effects on sexual, urinary and bowel function are critical issues to address when counseling patients regarding prostate cancer treatment. Rather than looking at specific points in time, the overall decrement in each QoL domain can be evaluated as the area under the curve for each treatment type. Therefore, while values generally are similar at 15 years, men have a cumulative difference in preserved erectile and urinary function over that period that can be compared by area under the curve measurement. A calculation of the relative decrement in each domain over time would be valuable for patient counsel ing, but these are not provided by the authors. In addition, the generalizability of the authors＇ findings may be limited by thedramatic refinement of treatment modalities since study enrollment in the mid1990s. Robotassisted laparoscopic radical prostatect only is now the primary surgical therapy for prostate cancer, with a much smaller propor tion of prostatectomies being performed at lowvolume centers and those not offering robotic surgery.3 As the shift to higher volume surgeons has progressed, it is reasonable to con sider that the improvements in lengths of stay and shortterm outcomes after robotic surgery could be extrapolated to the continence and sexual function domains.4 Additionally, the advent of image modulation in radiotherapy has reduced late toxicity rates and, in the cur rent era, may lower the reported rates of erec tile dysfimction, urinary incontinence and bowel dysfunction reported in this study.5 Any assessment of QoL following prostate cancer treatment merits discussion of the overdiagnosis and overtreatment of clinically insignificant cancers. Less than 10% of patients in either cohort had a Gleason score /〉 8 and less than a third of patients had a PSA level 〉 10 ng ml 1. There has been an increas ing view that some Gleason 6 prostate cancers do not have metastatic potential. As such, active surveillance in men with lowrisk dis ease is an appropriate choice and minimizes treatmentspecific issues with the QoL para meters considered in this study.6 Selection of only those men who have a high likelihood of benefiting from treatment may have the most significant effect in reducing treatment related sexual, bladder and bowel dysfunction.7 The Prostate Cancer Research International Active Surveillance Project is the largest obser vational prospective study evaluating active surveillance as an alternative to radical treat ment for lowrisk prostate cancer. Their data show that surveillance is a feasible strategy that does not compromise cancer cure.

Male Circumcision Does Not Reduce Sexual Function, Sensitivity or Satisfaction

We disagree with Boyle’s recent article questioning our systematic review in Journal of Sexual Medicine in 2013 (Volume 10, pages 2644-2657). In particular, he disputed the quality ranking we assigned to 7 of the 36 articles that met our inclusion criteria. These had been ranked for quality by the Scottish Intercollegiate Guidelines Network (SIGN) grading system. We found that, “the highest-quality studies suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation or satisfaction.” This conclusion was supported by two randomized controlled trials, regarded as high-quality (1++) evidence and the majority of surveys and studies involving physiological measurements comparing uncircumcised and circumcised men. Here we explain why the 2 randomized controlled trials merit a 1++ ranking and why 4 reports that Boyle believes merit a higher ranking only meet the criteria set down for low quality (2?) evidence according to the SIGN system. We therefore stand by our conclusions. These are supported by a meta-analysis of sexual dysfunctions and by a recent detailed systematic review of the histological correlates of male sexual sensation.

阴茎癌改良临床病理肿瘤分期预后意义分析

背景与目的第8版美国癌症联合会-TNM(American Joint Committee on Cancer tumor–node–metastasis,AJCC-TNM)分期基于的是一些回顾性单中心研究。本研究旨在分析分期的预后价值,并探讨加入脉管癌栓的改良的临床病理肿瘤分期能否提高对T2–3期阴茎癌患者预后预测的准确性。方法根据第8版AJCC-TNM分期对2000年至2015年在中国和巴西2个中心接受治疗的411例患者所组成的训练队列进行分期。采用C-indexes一致性系数进行预测模型的评估,Bbootstrap再抽样法(1000次)进行模型验证。采用来自4个大洲15个中心接受治疗的436例患者的数据进行外部验证。结果根据第8版AJCC-TNM分期的T2和T3期患者有存活率重叠(P=0.587)。脉管癌栓是转移和生存的重要预后因素(均P <0.001)。多因素分析显示,仅脉管癌栓对癌症特异性生存(cancer-specific survival,CSS)有显著影响(风险比=1.587,95%置信区间=1.253–2.011;P=0.001)。发生脉管癌栓的T2和T3期患者的CSS显著短于无脉管癌栓的患者(P <0.001)。因此,我们提出一种改良的临床病理分期,将第8版AJCC-TNM分期的T2和T3期细分为如下2个新类别:T2期肿瘤侵犯尿道海绵体和/或阴茎海绵体和/或尿道且无淋巴管侵犯;T3期肿瘤侵犯尿道海绵体和/或阴茎海绵体和/或尿道并有淋巴管侵犯。加入脉管癌栓的改良的分期显示出预后分层改善,各组间CSS差异显著(均P <0.005),患者预后预测的准确性高于第8版AJCC-TNM分期(C-index,0.739 vs. 0.696)。以上结果在外部验证队列中得到了确认。结论 T2–3期阴茎癌是异质性的,加入脉管癌栓的改良临床病理分期比第8版AJCC-TNM分期对阴茎癌患者的预后预测能力更强。

A systematic review and meta-analysis of clinical trials implementing aromatase inhibitors to treat male infertility

Aromatase activity has commonly been associated with male infertility characterized by testicular dysfunction with low serum testosterone and/or testosterone to estradiol ratio.In this subset of patients,and particularly in those with hypogonadism,elevated levels of circulating estradiol may establish a negative feedback on the hypothalamic–pituitary–testicular axis by suppressing follicle-stimulating hormone(FSH)and luteinizing hormone(LH)production and impaired spermatogenesis.Hormonal manipulation via different agents such as selective estrogen modulators or aromatase inhibitors to increase endogenous testosterone production and improve spermatogenesis in the setting of infertility is an off-label option for treatment.We carried out a systematic review and meta-analysis of the literature of the past 30 years in order to evaluate the benefits of the use of aromatase inhibitors in the medical management of infertile/hypoandrogenic males.Overall,eight original articles were included and critically evaluated.Either steroidal(Testolactone)or nonsteroidal(Anastrozole and Letrozole)aromatase inhibitors were found to statistically improve all the evaluated hormonal and seminal outcomes with a safe tolerability profile.While the evidence is promising,future prospective randomized placebo-controlled multicenter trials are necessary to better define the efficacy of these medications.

The pelvic pop:an extremely rare case of internal penile fracture presenting with scrotal hematoma and review of the literature

Dear Editor,Penile fracture is an infrequent urologic emergency with a nationwide incidence of 1 in 100000 men in the United States.1 Blunt trauma during sexual intercourse(penile-perineal impact)is the primary cause of penile fracture,but a variety of alternative mechanisms of injury have been reported in the literature.2 The vast majority of penile fractures occur in the external corpus cavernosum and manifest with the classic“eggplant deformity.”The location of these fractures makes them amenable to repair through a circumcising,degloving incision.

Assessment of SARS-CoV-2 RNA shedding in semen of 36 males with symptomatic,asymptomatic,and convalescent infection during the first and second wave of COVID-19 pandemic in Italy

The severe acute respiratory syndrome coronavirus-2(SARS-CoV-2)receptor,angiotensin-converting enzyme 2(ACE2),has been identified in the human testis,but the risk of transmission of SARS-CoV-2 through sexual intercourse still needs to be defined.The goal of our study was to determine if SARS-CoV-2 is detectable in the semen of patients suffering or recovering from coronavirus disease-19(COVID-19),still testing positive at nasopharyngeal swabs but showing mild or no symptoms at the time of sampling.Detection of SARS-CoV-2 RNA in semen was performed by real-time reverse transcriptase-polymerase chain reaction(RT-PCR)and nested PCR targeting open reading frame(ORF)1ab.Medical history of the enrolled patients was taken,including COVID-19-correlated symptoms,both at the time of diagnosis and at the time of interview.Results of real-time RT-PCR and nested PCR in semen showed no evidence of SARS-CoV-2 RNA in the 36 patients suffering or recovering from COVID-19 but still positive in a nasopharyngeal swab,from over 116 patients enrolled in the study.SARS-CoV-2 detection and persistence in semen would have an impact on both clinical practice and public health strategies,but our results would suggest that SARS-CoV-2 is not present in the semen of men recovering from COVID-19.

A modified clinicopathological tumor staging system for survival prediction of patients with penile cancer

Background:The 8th American Joint Committee on Cancer tumor-node-metastasis(AJCC-TNM)staging system is based on a few retrospective single-center studies.We aimed to test the prognostic validity of the staging system and to determine whether a modified clinicopathological tumor staging system that includes lymphovascular emboliza-tion could increase the accuracy of prognostic prediction for patients with stage T2-3 penile cancer.Methods:A training cohort of 411 patients who were treated at 2 centers in China and Brazil between 2000 and 2015 were staged according to the 8th AJCC-TNM staging system.The internal validation was analyzed by bootstrap-corrected C-indexes(resampled 1000 times).Data from 436 patients who were treated at 15 centers over four conti-nents were used for external validation.Results:A survivorship overlap was observed between T2 and T3 patients(P=0.587)classified according to the 8th AJCC-TNM staging system.Lymphovascular embolization was a significant prognostic factor for metastasis and survival(all P<0.001).Based on the multivariate analysis,only lymphovascular embolization showed a significant influ-ence on cancer-specific survival(CSS)(hazard ratio=1.587,95%confidence interval=1.253-2.011;P=0.001).T2 and T3 patients with lymphovascular embolization showed significantly shorter CSS than did those without lymphovascu-lar embolization(P<0.001).Therefore,a modified clinicopathological staging system was proposed,with the T2 and T3 categories of the 8th AJCC-TNM staging system being subdivided into two new categories as follows:t2 tumors invade the corpus spongiosum and/or corpora cavernosa and/or urethra without lymphovascular invasion,and t3 tumors invade the corpus spongiosum and/or corpora cavernosa and/or urethra with lymphovascular invasion.The modified staging system involving lymphovascular embolization showed improved prognostic stratification with significant differences in CSS among all categories(all P<0.005)and exhibited higher accuracy in predicting patient prognoses than did the 8th AJCC-TNM staging system(C-index,0.739 vs.0.696).These results were confirmed in the external validation cohort.Conclusions:T2-3 penile cancers are heterogeneous,and a modified clinicopathological staging system that incorporates lymphovascular embolization may better predict the prognosis of patients with penile cancer than does the 8th AJCC-TNM staging system.

Updates in penile prosthesis infections

Inflatable penile prostheses are an important tool in the treatment of medically refractory erectile dysfunction.One of the major complications associated with these prostheses is infections,which ultimately require device explanation and placement of a new device.Over the past several decades,significant work has been done to reduce infection rates and optimize treatment strategies to reduce patient morbidity.This article reviews the current state of knowledge surrounding penile prosthesis infections,with attention to the evidence for methods to prevent infection and best practices for device reimplantation.