After the 2013 FDA approval of collagenase clostridium histolyticum (CCH) what was its impact on the use of surgical management of Peyronie Disease (PD) in United State? Dr. Sukumar and cols. from Columbia University hypothesized that with the introduction of CCH, surgery as a primary treatment modality for PD would be used less often. The authors reviewed 547 men with PD registered in Statewide Planning and Research Cooperative System (SPARCS) that provides data on patients in the outpatient, inpatient, ambulatory, and emergency department setting in New York. All patients >18 years old with a diagnosis with PD who received surgical therapy (ST), defined as plaque excision/incision and grafting or plication, or injection therapy (IT) as a primary treatment between 2003 and 2016 were included. Over the study period, surgical management was used less often as the primary procedure with a concurrent increase in use of IT (P < .001). On multivariable modeling, patients more likely to receive IT as treatment for penile curvature were younger, of higher socioeconomic status and presented to a surgeon with a high volume practice. That trend should worry other countries were CCH could be approved? IMPRESS I and II data revealed that men treated with CCH showed a mean 34% improvement in penile curvature, representing a mean-9.3 ± 13.6 degree change per subject (p <0.0001) (1) after eight injections.

and Research Cooperative) database for men who underwent inflatable penile prosthesis and/or artificial urinary sphincter insertion between 2000 and 2014. Compared with men who received a penile prosthesis alone those with a penile prosthesis and an artificial urinary sphincter (not necessarily done at the same surgery) had a higher likelihood of undergoing inflatable penile prosthesis reoperation at 1 year (OR 2.08, 95% CI 1.32-3.27, p <0.01) and 3 years (OR 2.60, 95% CI 1.69-3.99, p <0.01). The authors concluded that combined inflatable penile prosthesis and artificial urinary sphincter insertion portends a higher likelihood of inflatable penile prosthesis reoperation at 1 and 3 years. However, artificial urinary sphincter outcomes remain comparable. These data are in opposition to 2013 publication on Journal of Urology by Dr. Segal and cols. (1) retrospectively reviewed the records of 55 combined procedures that were performed from 2000 to 2011 and concluded that dual implantation (DI) was feasible without an increased risk of adverse outcomes compared to implantation of a single prosthesis. And also contradict a 2019 publication in Urology by Dr. Boysen and cols. (2) where, with the biggest number of cases (all over 65 years old), dual implantation does not adversely affect perioperative complications or device survival relative to placement of either device alone.

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When dealing with a rare condition, it is important to learn from the experience of reference centers. That is the case in this nice paper coming from the biggest public urologic emergency unit in Rio de Janeiro, Brazil (1). Penile fracture (PF) is one of the less frequent urological traumas and generally has sexual intercourse associated with its mechanism. PF of non-sexual etiology is even rarer, at least in Western countries, and this report adds significant information (2, 3). First, as a teaching for less experienced emergency physicians, to the possibility of PF in single men in order to properly conduct the situation since the type of therapy is relevant to the outcomes. This is even more significant when considering that mostly of the affected men were in the fourth decade (3). Secondly, to confirm also in this specific subgroup of PF that its diagnosis is eminently clinical. The typical presentation-the triad of hematoma, detumescence, and snapping sound-is enough to indicate immediate surgical exploration in most cases. Surgical repair of penile fractures was popularized in the 1980s after several studies had demonstrated that long-term complications were reduced from 30% to 4% in surgically treated patients (4, 5). Only in doubtful cases a complementary exam such as an ultrasound or an urethrocystogram (suspicion of urethral injury) shall be performed and justify postpone surgery (6, 7). But would the time interval between trauma and surgery be a significant variable in relation to outcomes? The answer is surprisingly no, accordingly with authors, that stated in another manuscript: "Even with treatment delay of 21 days, we did not identify a statistical difference between the time of PF repair and complications such as erectile dysfunction or penile curvature rates" (3). Third, to highlight the value of knowing the level of energy involved in the trauma, since it is related to the surgical findings. In comparison with sexual PF, authors found that in their sample of non-intercourse nor masturbation etiology, bilateral tunica albuginea tears and urethral lesions were less common. And here, another surprising data emerges: complications were similar among those found in their sample of sexual etiology, possible meaning that lower level of energy and less damage did not decrease odds of fibrosis nor erectile dysfunction. And finally, it is very useful as an alert to properly address the psychological aspect involved in this delicate situation. Most men don't even imagine that their penis can break, especially during sleep. So, it is essential to talk properly before surgery, clarify all doubts and highlight the importance of immediate surgical repair as the best way to minimize sequelae (8). But as this article and others have shown, even with the ideal treatment, problems can arrive. Late complications of around 10% have been reported in large series of immediately surgically treated penile fractures from reference centers (9). So, this should also be taken into consideration when counseling men with pen...

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Dr. Arcangelo Barbonetti et al. published the first meta-analysis exploring the differences in the prevalence of ED and PE between homosexual and heterosexual men.They found that homosexual orientation is associated with higher odds of erectile dysfunction (ED) and lower odds of premature ejaculation (PE) compared with heterosexual orientation. However, considering that only four studies could be included, the non-probabilistic nature of the samples and the use of different non-standardized indicators of sexual dysfunctions, their results should be interpreted with caution.The fact is that homosexual individuals have been excluded from a significant number of important clinical trials. When dealing with non-heterosexual people, the investigation of sexuality is hindered by a methodological issue in that most of the questionnaires and diagnostic tools for the assessment of sexual disorders appear to be heterosexual oriented and have not yet been validated for homosexual populations (1).Authors found that the discussed possible reasons why homosexual men have more chance of suffering with ED and multiple partners (less stability), a sense of competition and what they call: psychological stress -social stigmatization and discrimination against sexual minorities can jeopardize the psychological well-being of homosexuals (2).