Citations

Key Points The kidney microvasculature was quantified reliably in human autosomal dominant polycystic kidney disease early on, using super-resolution ultrasound localization microscopy. Microvascular parameters correlated with structural and functional indices, constituting promising biomarkers to evaluate noncystic parenchyma. Microvascular parameters may serve to assess disease severity and monitor progression from the early stages of the disease. Background In vitro studies in individuals with autosomal dominant polycystic kidney disease (ADPKD) have shown extensive intrarenal microvascular remodeling. However, analyses have been limited to the time of kidney failure because of the invasive nature of current methodologies to assess the intrarenal microvasculature. We hypothesized that super-resolution ultrasound microvascular imaging, known as ultrasound localization microscopy, enabled by high-framerate ultrasound imaging and microbubble localization and tracking postprocessing techniques, would safely, reliably, and reproducibly assess the intrarenal microvasculature in individuals with ADPKD at an early stage of the disease. Methods We prospectively enrolled young (<40 years of age), well-characterized, early-stage (eGFR >90 ml/min per 1.73 m 2 ) individuals with ADPKD, and sex–age 1:1 matched controls ( n =17 each) and assessed the intrarenal microvasculature using ultrasound localization microscopy. We determined the intersonographer reliability, intraobserver repeatability, and interobserver reproducibility of microvascular parameters in both groups, and the day-to-day variability in the control group. Microvascular parameters were correlated with structural (total kidney volume) and functional (eGFR) markers in individuals with ADPKD. Results Ultrasound localization microscopy provided a super-resolved map of the intrarenal microvasculature in ADPKD and matched controls. Intrarenal microvascular parameters ( e.g ., vessel density) were quantified in a safe, reliable (intraclass correlation coefficients, 0.96; 95% confidence interval, 0.91 to 0.98), reproducible (intraclass correlation coefficient, 0.96; 95% confidence interval, 0.93 to 0.98), and repeatable (coefficient of variations, 3.6%) manner. In control individuals, the day-to-day variability of most parameters was low, with coefficient of variation ranging from 1.8% to 10.7%. Microvascular parameters differed in individuals with ADPKD compared with controls, despite preserved eGFR. Interestingly, cortical vessel density and its derived perfusion correlated directly with eGFR, whereas tortuosity indices presented an inverse correlation. Conclusions Ultrasound localization microscopy provided a safe and reliable in vivo assessment of the human intrarenal microvasculature.

Abstract Introduction Peyronie’s Disease (PD) is a fibrotic disorder of the tunica albuginea leading to penile curvature, pain, and sexual dysfunction. Intralesional therapies are a non-surgical treatment strategy aiming to modulate fibrosis and reduce deformity. Intralesional verapamil, a calcium channel blocker, has been used to inhibit fibroblast proliferation and collagen synthesis, but its clinical effectiveness remains controversial. Despite widespread use, existing literature is heterogeneous in design and outcome measures. Objective We aimed to systematically review and summarize the evidence from prospective clinical trials assessing the efficacy and safety of intralesional verapamil. Methods Data extraction was carried out independently by the presenting author and a board-certified librarian. We conducted a structured literature search using PubMed, Scopus, and Web of Science for prospective trials from 2015-2025 evaluating intralesional verapamil use in patients with PD. Inclusion criteria were: [1] prospective study design, [2] adult patients with a clinical diagnosis of PD, [3] use of intralesional verapamil as monotherapy or in combination, and [4] reported outcomes on penile curvature, and sexual function. Data extraction included study design, sample size, outcome measures, and follow-up. Risk of bias and quality assessment was performed using the Cochrane Risk of Bias 2.0 scale. Results A total of 199 studies were screened. A total of 6 prospective trials were selected after excluding trials who were not compliant with our criteria, reporting on 754 patients with 1 to 24 months follow-up. RCTs evaluated were of moderate quality with a low risk of bias, but 3/6 had a high risk of bias. Across randomized trials, verapamil monotherapy resulted in modest improvements in curvature (range mean change in penile curvature -2° to -16°). In contrast, combination therapies or alternative injectables such as collagenase (CCH) and tiocolchicine showed greater curvature improvements (–28° in Chung; ~10° in Toscano). In non-randomized studies comparative studies, verapamil (Ver) demonstrated consistent improvement in penile curvature (~4.5° reduction [Cocci 22]), with sustained results at 24 months. Nevertheless, in these studies HA was superior to Verapamil (~9.5° reduction). Erectile function, measured by IIEF-5, improved modestly across studies, with the greatest gains observed in combination therapy arms or HA groups. Conclusions Intralesional verapamil offers modest improvements in penile curvature and erectile function in Peyronie’s Disease but appears less effective than alternative agents such as hyaluronic acid, collagenase, or combination therapies. Heterogeneity in trial design and moderate risk of bias limit definitive conclusions. Further high-quality, blinded randomized trials are needed to establish optimal intralesional treatment strategies. Disclosure No

Abstract Introduction Down-sized inflatable penile prosthesis (IPP) cylinders are useful in cases with substantial penile fibrosis such as history of priapism or prior infection. Although down-sized IPP cylinders have a clear role in fibrotic corpora, their role in primary implant cases is unclear. Objective To identify factors associated with the use of down-sized cylinders in men undergoing primary IPP placement. Methods We conducted a retrospective analysis of 4,389 patients undergoing primary IPP placement from our multicenter database. Patients were categorized by down-sized (AMS 700 CXR, Coloplast NB) vs. standard sized cylinders (AMS 700 CX, AMS 700 LGX, Coloplast Titan). We collected demographic, intraoperative, and postoperative data. A multivariable analysis was performed to identify factors associated with use of down-sized cylinders Results A total of 4,389 men undergoing primary inflatable penile prosthesis (IPP) placement were included in the study, with a mean age of 62.3 ± 10.3 years. Among them, 1,485 (34%) had diabetes and 2,131 (49%) had hypertension. A total of 406 down-sized cylinders and 3,983 standard cylinders were implanted. Non-infectious complications occurred more frequently with the use of down-sized cylinders (odds ratio [OR] = 2.0, p &lt; 0.001). Specifically, non-infectious complications were reported in 44 out of 185 men (23.8%) with down-sized cylinders, compared to 192 out of 2,727 men (10.9%) with standard cylinders. Cylinder complications constituted 13.9% and 13.0% of the non-infectious complications in the down-sized and standard cylinder groups, respectively. Conclusions The rate of cylinder-related complications were similar between the down-sized cylinder and standard cylinder groups. Urologists should be prepared to place down-sized cylinders during IPP placement in diabetic men and in men requiring serial dilation due to fibrosis. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Intuitive Surgical, Fidelis, Urofill, Boston Scientific, Coloplast, Cynosure, Antares Pharma, Clarus Pharmaceuticals, Acerus Pharma; Endo Pharma.

Abstract Introduction The Penuma ® implant is a medical-grade silicone implant used in the cosmetic augmentation of the penis. Reportedly 3-11% of devices are being removed over time for reasons such as infection, pain, and dissatisfaction with the device. Objective Despite this, there remains a paucity of information demonstrating safe removal of this device. In this video, we outline intra-operative considerations to promote the safe removal of the Penuma device. Methods Sharp and blunt dissection to the level of the capsule is performed via the original incision line. The proximal end of the device is identified via sharp dissection through the capsule. The penis is then everted to expose the distal attachments of the implant, which are subsequently dissected. Superficial and sharp dissection to remove the mesh is performed. We avoid the use of cautery to prevent damage to the nearby neurovascular bundle. Once the mesh and all permanent material is removed, haemostasias is achieved. A drain may be placed. The incision is irrigated and closed in a multi-layer fashion. Results Here we demonstrate a safe and feasible method to surgically remove the Penuma (Himplant) device. Conclusions In conclusion, the Penuma ® implant is a medical-grade silicone implant used in the cosmetic augmentation of the penis that can be safely removed surgically in the event of infection, pain, or dissatisfaction with the device. Disclosure No

Abstract Introduction Traditional vasectomy reversals are performed in the operating room under general anesthesia, which poses logistical, financial, and clinical drawbacks. A shift toward office-based vasectomy reversal under local anesthesia may address these limitations. Objective To demonstrate the feasibility and technical approach of performing microsurgical vasovasostomy in an office-based setting using local anesthesia, without compromising patient comfort or surgical technique. Methods In this video we outline a step-by-step microsurgical vasovasostomy in an office-based setting. Results Office-based vasovasostomy is technically feasible in the office-based setting. Conclusions Office-based microsurgical vasovasostomy is safe, feasible, and well tolerated in the office-based setting, offering multiple patient- and provider-centered advantages. Disclosure No

Abstract Introduction 0.05% Chlorhexidine Gluconate (CHG) has gained popularity as an irrigant for inflatable penile prosthesis (IPP). In vitro data has explored interactions between CHG and minocycline/rifampin impregnated (M/R) IPP surfaces Objective We aimed to assess clinical infection rates between intraoperative CHG use and M/R impregnated IPPs in a large multi-institutional cohort. Methods We conducted a retrospective analysis of 1,604 patients who underwent IPP implantation across 12 referral centers. Data collection spanned from January 1, 2017 to March 1, 2024. Each surgeon contributed patients who underwent IPP implantation with the use of CHG as an irrigant and an equal number of consecutive control patients where CHG was not used. The primary outcome was explant for postoperative infection. Patient demographics were compared using chi squared testing and logistic regression analysis was performed to assess factors associated with infection. Results M/R impregnated devices accounted for 695 cases. The incidence of infection with intraoperative CHG use was 1.7% (5/289) and was not significantly different from the 2.5% (10/406) infection rate in those without CHG (p=0.429). Patients with infection had a higher prevalence of hypertension and history of priapism (Table 1). On logistic regression analysis, only a history of priapism was significantly associated with an increased odds of infection (OR 11.47, 95%CI 2.25-58.40, p=0.003). Intraoperative CHG use was not associated with postoperative infection (OR 0.69, 95%CI 0.2-2.06. p=0.514). Conclusions In a large multi-institutional cohort, there was no difference in infection rate for patients with or without intraoperative CHG use, consistent with prior in vitro findings. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Intuitive Surgical, Fidelis, Urofill, Boston Scientific, Coloplast, Cynosure, Antares Pharma, Clarus Pharmaceuticals, Acerus Pharma; Endo Pharma.

Abstract Introduction There is wide variation in male fertility preservation practices. While physician preference accounts for some of this diversity, practice patterns often reflect multiple extrinsic factors including patient demographics, equipment availability, laboratory protocols, and state law. Objective We sought to characterize national trends in sperm retrieval and storage across reproductive urology practices in the United States. Methods An anonymous 34-item survey characterizing provider demographics, practice settings, fertility preservation procedures, andrology laboratory practices, and cryopreservation expenses was designed. Practicing reproductive urologists were identified using information available through professional societies. Our survey was constructed using the Qualtrics platform and distributed electronically between October 2024 and May 2025. Results 39 responses were received by urologists practicing across 21 states (response rate: 21%, n=189). A majority (74%, n=29) of survey responders practiced at academic medical centers, with others practicing at non-academic hospitals (8%, n=3) and private practices (13%, n=5). The most common indications for fertility preservation reported included oncologic care (42%), gamete storage for planned ART (31%), transgender care (18%), pre-vasectomy sperm banking (10%), and pre-deployment banking for military personnel (5%). Nearly all providers performed microsurgical sperm retrievals (97%, n=38, Figure) and oncologic testicular sperm extractions (85%, n=33) when indicated. More than half of providers offered conventional testicular sperm extractions (72%, n=28), microsurgical epididymal sperm aspirations (59%, n=23), testicular sperm aspirations (56%, n=22), penile vibratory stimulation (54%, n=21), or percutaneous epididymal sperm aspirations (52%, n=20). Fewer providers offered post-mortem sperm retrieval (49%, n=19), pre-pubertal testicular tissue cryopreservation (36%, n=14), or electroejaculation (31%, n=12). Most respondents (62%, n=24) had access to an on-site andrology laboratory. Semen analyses were evaluated using manual (53%, n=20), computer-assisted (11%, n=4), or combinatorial methods (26%, n=10). Though many (37%, n=14) providers were uncertain about institutional costs for semen specimen processing, a plurality of respondents (40%, n=15) reported fees ranging from $100-500 with the remainder (23%, n=9) reporting fees exceeding $500. Respondents most frequently reported semen storage fees ranging between $100-300 per year (39%, n=15), while approximately a third (31%, n=12) estimated these costs to range between $300-600 per year. However, 18% (n=7) of respondents reported higher costs for specimen storage and 13% (n=5) were uncertain about the expense of this service. Conclusions This multi-institutional, geographically diverse survey reveals significant variation in reproductive urology practice patterns and cost associated with semen analyses and storage. Future studies will explore differences in practice patterns to better understand the factors influencing this variation and their effect on male reproductive healthcare. In the absence of society guidelines, reproductive urologists must collaborate, share best practices, and maintain price transparency to ensure sperm retrieval remains accessible and affordable. Disclosure No

Abstract Introduction The optimal antimicrobial prophylaxis strategy for inflatable penile prosthesis (IPP) surgery remains a subject of ongoing investigation. Our institution recently discontinued the use of chlorhexidine gluconate (CHG) and returned to traditional antibiotic-based prophylaxis protocols. Objective To evaluate infection rates following the reinstitution of antibiotic-based prophylaxis after discontinuing CHG in IPP surgery. Methods We conducted a retrospective, consecutive cohort study of patients who underwent Coloplast Titan IPP insertion between May 2024 and May 2025. The antibiotic prophylaxis protocol consisted of rifampin/gentamicin device dipping and vancomycin/gentamicin irrigation. Primary and revision cases were analyzed separately. Results A total of 188 patients underwent IPP insertion during the study period, including 119 primary implantations and 69 revision procedures. Mean patient age was 69.6 ± 11.5 years, BMI was 27.6 ± 4.2 kg/m2, and operative time was 67.1 ± 24.1 minutes. No infections occurred in the primary implantation cohort. One infection (1.4%) occurred in the revision group in a diabetic patient with prolonged operative time (176 minutes). Compared to our previously published data using CHG, infection rates decreased significantly in the revision group (1.4% vs. 9.67%, p &lt; 0.001), while the primary group showed a numerical reduction from 2.22% to 0%. Conclusions The reinstitution of antibiotic following discontinuation of CHG resulted in significantly lower infection rates, particularly in revision cases. These findings support the continued use of antibiotic dipping and irrigation protocols for IPP surgery as a safe and effective strategy for infection prevention. Disclosure No

Abstract Introduction Device malfunction remains a serious concern for patients with inflatable penile prosthesis (IPP), with pump failure being one of leading causes of revision surgery. Complete device replacement has been the traditional approach, but partial device replacement for the pump may offer a less invasive and cost-effective alternative, with potentially lower complication risk. Objective To evaluate the safety, efficacy, and clinical outcomes of pump replacement (with or without obvious tubing leak/fracture), manipulation or fluid addition in patients undergoing IPP revision surgery. Methods A retrospective review was conducted on patients who underwent IPP pump replacement with or without additional component exchange by a single surgeon, between January 2018 and April 2025. Thirty patients met the inclusion criteria. Clinical, intraoperative and postoperative data were collected and descriptively analyzed. Outcomes included postoperative infectious and non-infectious complication rates. Results The median age at revision was 77 years, with a median time to revision of 76 months post-implantation. Most common indications were frozen or pump difficulties (67%), pump + tubing damage (30%) and fluid addition requirement (10%). No intraoperative complications occurred. Postoperative complications were reported in 3 patients (10.0%), all due to mechanical malfunction, with no infections observed. Median time to complication was 24 months (IQR 7–72). One patient progressed to IPP explanation after successive revisions for impending erosion not thought related to pump manipulation. Another underwent complete replacement at 7 months for fluid leak from reservoir. A third required non-exchange revision at 24 months. The majority (91%) received Coloplast pumps. The median operative time was 53 minutes (IQR 43–70). Conclusions Pump replacement appears to be a safe and effective option for select patients, potentially reducing surgical morbidity and preserving viable components. The absence of infection in this series is reassuring, particularly in a revision setting where infection risk is amplified. Consideration of device age and patient specific factors is important in guiding the choice between partial and complete component exchange. Disclosure No

Abstract Introduction Glans ischemia and subsequent necrosis is a rare but devastating complication of inflatable penile prosthesis (IPP) placement. Differentiating true glans ischemia from severe ecchymosis is often difficult to distinguish, yet it remains paramount given the glans ischemia principle: “when in doubt, take it out.” Objective We present several clinical scenarios and associated postoperative images wherein there was concern for post-IPP glans ischemia based on initial clinical examination. In addition, we review pertinent clinical factors that can be used to help distinguish between greater than “average” glans ecchymosis and true ischemia. Methods We present four cases from 2025 and describe clinical factors likely responsible for increased glans discoloration. Results Traditional risk factors for glans ischemia are constrictive IPP wrap, vasculopathy, use of prolonged large bore catheters, and concomitant surgery (circumcision, distal counter-incision, urethral/neurovascular bundle mobilization). Case 1 was a patient with a history of radiation for prostate malignancy who had notably hypervascular corpora intraoperatively. On postoperative day (POD) #1, the urethral meatus was ecchymotic along with patchy ecchymosis throughout the glans. The Kerlix wrap can be seen around the penile shaft up to the corona. Removing the constrictive wrap and increasing room lighting revealed a well-vascularized glans with spotty ecchymosis likely from passage of the Keith needles during deployment. Case 2 was another patient examined on POD1 after uneventful IPP placement under local anesthesia. Note the similar level of ecchymosis involving the scrotum. Case 3 is another patient examined POD1 from a penoscrotal IPP that required multiple firing attempts with the Keith needle. Again, multifocal areas of patchy ecchymosis are interspersed with areas of normal appearing glans. The patient’s skin color was also similar in appearance to the areas of ecchymosis, requiring careful attention to detail to differentiate. Finally, Case 4 is an image on POD0 after uneventful IPP. The patient required several Keith needle passes because Furlow tool severed suture. Notably, decision was made to leave the penile implant in place in all cases. The penile wrap and/or catheter was removed and lighting was optimized to evaluate for clinical change. No patient reported paresthesia or pain out of proportion to the clinical examination. All glans were warm to the touch. Rates of glans bruising at POD3 for 298 implants performed since 2024 under local anesthesia, with bruising scored 0-4, were as follows: 0: 3.7% 1: 48.7%, 2: 25.5% 3: 21.1% 4: 0.3%. This demonstrates high rates of glans bruising with local anesthesia. We speculate that the increased rate of glans bruising may be attributed to the aggressive nature of the local anesthesia block, which can result in vasodilation and ecchymosis due to needle trauma and increased vascular permeability. Conclusions IPP cylinder deployment requiring multiple Keith needle punctures, constrictive post-op penile wrap, hypervascular corpora, exam/images with poor lighting, extensive bruising in other areas, and IPPs performed under local anesthesia appear may contribute to glans discoloration that mimics ischemia. A detailed physical exam and close clinical monitoring are essential when postoperative glans discoloration is observed. Disclosure No