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Key Points Male fertility is controlled by a Zn 2+ -dependent short circuit of the Krebs cycle within prostate epithelial cells Homeostasis of the prostate epithelium is reliant on the intracellular androgen-dependent accumulation of Zn 2+ and citrate Sperm motility requires the coordinated action of the components of the two main fluids in the human seminal plasma: the prostatic fluid, which is enriched with Zn 2+ , citrate and kallikreins, and the semenogelin-enriched seminal vesicle secretion The prostate is the direct target for a number of benign and malignant diseases that are potentially linked to impaired fertility status Prostatitis might be directly linked with changes in fertility The prostate gland is the major male reproductive gland involved in male fertility. In this Review, the authors discuss the reproductive function of the prostate gland, summarizing physiological and molecular mechanisms that connect prostate homeostasis with male fertility and describing how these mechanisms are associated with prostatic diseases. They highlight the central role of Zn 2+ and citrate in regulating activities of the prostate epithelium, discuss the influence of bacteria-related prostate inflammation on male fertility, and note the potential role of prostatic inflammation in the development of prostatic hyperplastic growth and prostate carcinogenesis. Ejaculation is a synchronized cascade of events that has the ultimate goal of activating sperm and enabling them to reach an egg for fertilization. The seminal plasma contains a complex mixture of fluids that is secreted from the testes, epididymis and male accessory glands. The prostate gland has a pivotal role in this process, as prostatic fluid enriched in Zn 2+ , citrate and kallikreins is crucial for the molecular synchronization of the functional cascade triggered by ejaculatory stimuli. The prostate is the target of a number of common diseases that can affect male fertility at different ages. In both young and aged men, prostatic diseases or an unhealthy prostate can affect spermatozoa functioning and, therefore, male fertility. Consideration of prostate physiology emphasizes a number of points: the central role of Zn 2+ and citrate in the regulation of prostate epithelium homeostasis and in ejaculation; the influence of bacteria-related prostatic inflammation on male fertility; and the potential role of prostatic inflammation in promoting the development of prostatic hyperplastic growth and carcinogenesis.

Google Trends (GT) is a free, easily accessible search tool which can be used to analyze worldwide “big data” on the relative popularity of search terms over a specific period of time. To determine worldwide public interest in Peyronie’ disease (PD), erectile dysfunction (ED), premature ejaculation (PE) treatments, their penetrance, variation, and how they compare over time. Worldwide search-engine trends analysis included electronic Google queries from people who searched PD, ED, and PE treatments options from January 2004 to October 2018, worldwide. Join-point regression (JPR) has been performed. Comparison annual relative search volume (ARSV), average annual percentage change (AAPC) and temporal patterns were analyzed to assess loss or gain of interest. Our results showed that for PD it has been a decreased interest for Drug (AAPC: −3.1%, p < 0.01), ESWT (AAPC: −3.1%, p < 0.01), and vacuum therapy (AAPC: −1.2%, p < 0.01). In the field of ED, we observed trends toward an increased interest in prosthetic surgical treatment (AAPC: +1.7%, p = 0.4), for prostaglandins (AAPC: +0.7%, p = 0.7), for traction (AAPC: +0.6%, p = 0.1) and for ESWT (AAPC: +1.8%, p = 0.4), but without statistical significance. On the contrary, we observed a slight reduction of search for Vacuum device (AAPC: −1 %, p < 0.01). The interest in PE decreased from 2004 to today (AAPC: −1%, p < 0.01), for surgical treatment (AAPC: −3.1%, p < 0.01), drug treatment (AAPC: −3.1%, p < 0.01), and for psychotherapy (AAPC: −6.7%, p < 0.01). On the contrary, the interest in spray drugs has increased significantly (AAPC: +5.1%, p < 0.01). Patients are searching the web for sexual diseases treatment options. Understanding people inquisitiveness together with degree of knowledge could be supportive to guide counseling in the decision-making-process and put effort in certifying patient information, avoiding them to fall in the pernicious trap of ‘fake-news’.

IntroductionImmunotherapy is changing the way we think about and treat urothelial carcinoma (UC). The PD-1/PD-L1 pathway inhibition has shown robust efficacy, associated with an acceptable toxicity profile, in patients with locally advanced and metastatic unresectable disease, addressing a high decades-old unmet medical need. Material and methodsUsing the Pubmed database, we conducted a literature review for English written published articles up to June 2020. The highest available evidence for the immunotherapy treatment of UC with ICIs were evaluated. The leading phase one, two and three clinical trials were considered for inclusion (n = 12). Patient’s data were extracted from studies depicting the UTUC subpopulation.ResultsTwo monoclonal antibodies targeting PD-1 (pembrolizumab and nivolumab) and three to its ligand PD-L1 (atezolizumab, avelumab, and durvalumab) have obtained US FDA and EMA approval for the second-line treatment of platinum-pretreated patients, between 2016 and 2019. Atezolizumab and Pembrolizumab are even currently approved in the first-line setting for cisplatin ineligible patients, with PD-L1- positive tumor. The neoadjuvant scenario in localized high-risk disease is still evolving, with the first data available to date limited to the muscle-invasive bladder carcinoma. The management of patients with upper tract urothelial carcinoma (UTUC: renal pelvis and ureters) is complicated by the lack of specific high-level evidence, due to the rarity of the disease. No published studies addressing immunotherapy in UTUC patients only are available. The largest clinical trials aimed at UC patients, regardless of the upper or lower location of the primary tumor, have enrolled a minority of patients with UTUC, providing the data on which our current knowledge is based. However, targeted scientific efforts are needed to improve our level of care.ConclusionsThis review summarizes the main currently available evidence on the use of the PD-1/PD-L1 pathway inhibition with reference to patients presenting with UTUC.

The growing demand for glans penis augmentation (GPA) makes it a hot topic in the field of andrological surgery, albeit still widely debated. The lack of high supporting evidence and its technically challenging aspects are the main concerns. The aim of this study was to review the current literature about GPA in order to provide an easy and comprehensive overview of the topic. GPA is suitable for managing both cosmetic and functional issues. Counseling should be the cornerstone of the decision-making process. A thorough understanding of the glans anatomy and treatment strategies remain essential to safely and effectively address the patient’s needs. GPA can be performed using injectable fillers or surgical grafting. Glans-shaft penis asymmetries, small glans size, and loss of glans tumescence can be managed by both injectable fillers and surgery. On the other hand, patients with lifelong premature ejaculation can mainly benefit from using injectable fillers. Currently, available studies show promising results but are limited by small sample’s size and non-randomized design. Furthermore, treatment-related complications are poorly reported. The long-term efficacy and safety profiles of GPA techniques should be further investigated.

Penile prostheses (PPs) are an excellent treatment to be considered for patients suffering from erectile dysfunction (ED), refractory to oral medications, or unwilling to consider intracavernosal injections or other therapeutic strategies. Nowadays the market is dominated by three-piece inflatable penile prosthesis (IPP), which are considered the best option available. However, in some specific cases three-piece IPP may be superseded by semi-rigid penile prosthesis (SRPP) and two-piece IPP. Despite the advantages of these implants, the literature is quite scarce, not robust and rarely takes into consideration the partner’s satisfaction. This clearly affects the strength of our conviction. Most of the studies confirm that SRPPs and two-piece IPPs can be considered a valid alternative in patients with hand dexterity issues, refractory ischaemic priapism, neophallus and in cases of complex anatomies. In addition, the ease of placement and the high confidence level of surgeons make them a powerful tool in the armamentarium of urologists.

Sexual disorders following retroperitoneal pelvic lymph node dissection (RPLND) for testis tumor can affect the quality of life of patients. The aim of the current study was to investigate several different andrological outcomes, which may be influenced by robot-assisted (RA) RPLND. From January 2012 to March 2020, 32 patients underwent RA-RPLND for stage I nonseminomatous testis cancer or postchemotherapy (PC) residual mass. Modified unilateral RPLND nerve-sparing template was always used. Major variables of interest were erectile dysfunction (ED), premature ejaculation (PE), dry ejaculation (DE), or orgasm alteration. Finally, fertility as well as the fecundation process (sexual intercourse or medically assisted procreation [MAP]) was investigated. Ten patients (31.3%) presented an andrological disorder of any type after RA-RPLND. Hypospermia was present in 4 (12.5%) patients, DE (International Index of Erectile Function-5 [IIEF-5] <25) in 3 (9.4%) patients, and ED in 3 (9.4%) patients. No PE or orgasmic alterations were described. Similar median age at surgery, body mass index (BMI), number of nodes removed, scholar status, and preoperative risk factor rates were identified between groups. Of all these 10 patients, 6 (60.0%) were treated at the beginning of our robotic experience (2012-2016). Of all 32 patients, 5 (15.6%) attempted to have a child after RA-RPLND. All of these 5 patients have successfully fathered children, but 2 (40.0%) required a MAP. In conclusion, a nonnegligible number of andrological complications occurred after RA-RPLND, mainly represented by ejaculation disorders, but ED occurrence and overall sexual satisfaction deficit should be definitely considered. No negative impact on fertility was described after RA-RPLND.

Low intensity extracorporal shock wave therapy (Li-ESWT) may induce tissue regeneration, neo-angiogenesis and improve endothelial function. This has shown promise in the treatment of erectile dysfunction (ED). The aim of this narrative review was to describe potential therapeutic areas of Li-ESWT in sexual medicine other than ED. An extensive literature search and review of the most recent guidelines revealed that Li-ESWT has been used in the treatment of Peyronie’s disease (PD) and is being investigated as a method of improving stem cell therapy. In PD, Li-ESWT has been shown to decrease pain but no clinically relevant benefits regarding plaque size or penile curvature have been shown in randomized clinical trials. For stem cell optimization, only two preclinical studies have been conducted within the realm of sexual medicine. These show that application of Li-ESWT to the tissue after stem cell transplantation may increase the erectile response following cavernous nerve or diabetes damage. More research is needed to bring this concept from bench to bedside. In addition to this, Li-ESWT has shown promise in pelvic pain and it’s effects on testicles have been preliminarily investigated in preclinical studies.

Background: Robot-assisted partial nephrectomy (RAPN) is increasingly being employed in the management of renal cell carcinoma (RCC) and it is expanding in the field of complex renal tumors. The aim of this systematic review was to consolidate and assess the results of RAPN when dealing with entirely central hilar masses and to examine the various methods used to address the surgical difficulties associated with them. Methods: A thorough literature search in September 2023 across various databases focused on RAPN for renal hilar masses, adhering to PRISMA guidelines. The primary goal was to evaluate RAPN’s surgical and functional outcomes, with a secondary aim of examining different surgical techniques. Out of 1250 records, 13 full-text manuscripts were reviewed. Results: Evidence is growing in favor of RAPN for renal hilar masses. Despite a predominance of retrospective studies and a lack of long-term data, RAPN shows positive surgical outcomes and preserves renal function without compromising cancer treatment effectiveness. Innovative suturing and clamping methods are emerging in surgical management. Conclusions: RAPN is a promising technique for managing renal hilar masses in RCC, offering effective surgical outcomes and renal function preservation. The study highlights the need for more long-term data and prospective studies to further validate these findings.

Low-intensity extracorporeal shockwave therapy (LiESWT) represents a promising treatment for patients with erectile dysfunction (ED). We investigated the efficacy of LiESWT combined with tadalafil 5 mg once daily in men with type 2 diabetes mellitus (T2DM) and ED and compared LiESWT protocols administering different number of shockwaves. We performed a retrospective matched-pair comparison using data from a prospectively maintained database. Seventy-eight patients who received tadalafil 5 mg once daily for 12 weeks + LiESWT performed with an electrohydraulic source for 3 weeks (Group A) were matched 1:1 to patients who received tadalafil 5 mg once daily alone for 12 weeks (Group B). A subgroup analysis was performed according to the number of shockwaves delivered during each session (1500, 1800, and 2400 in subgroup A1, A2, and A3, respectively). The mean International Index of Erectile Function-5 (IIEF-5) score variations with respect to baseline recorded at 4, 12, and 24 weeks after the end of the treatment were investigated as treatment outcomes. The mean IIEF-5 scores significantly improved in all groups and subgroups at 4-week follow-up without intergroup differences. At 12- and 24-week follow-up, the mean IIEF-5 improvement was significantly higher among patients in the A3 subgroup (+5.0 ± 2.1 [P < 0.001] and +4.7 ± 2.3 [P < 0.001], respectively). The combined approach with tadalafil 5 mg once daily and LiESWT with a protocol involving 2400 shockwaves provides significant advantages in terms of IIEF-5 improvement and durability compared to tadalafil 5 mg once daily alone in patients with T2DM and ED.