Arthur L. Burnett

Sexual and urinary functional outcomes after pelvic surgeries such as radical prostatectomy remain unsatisfactory today despite advances in surgical technique. A call to action exists to explore, develop and apply adjunct technologic modalities that may bring about improvement in these outcomes. This study aimed to investigate the potential application of grid electrodes for periprostatic cavernous nerve mapping during radical prostatectomy. We conducted an engineering design process for evaluation and prototyping an electrode-containing grid, followed by testing its feasibility in a simulated radical prostatectomy cadaveric workshop and its usability in a clinical investigation of men with localized prostate cancer undergoing radical prostatectomy. We demonstrated that electrode-containing grids can be used during radical prostatectomy and would meet requirements for localizing and recording nerve signals in the periprostatic region during radical prostatectomy that are functionally relevant for penile erection and urinary continence functions. These findings suggest the potential utility of adjunct technologies to improve functional outcomes after radical prostatectomy as well as potentially other pelvic surgeries in which iatrogenic nerve injury is known to occur. The primary strength of this study is its methodical approach for developing and testing electrode-containing grids as an electrophysiological nerve testing and recording tool for periprostatic cavernous nerve mapping. Limitations relate to indeterminate real-time functional measures of nerve signaling activity during surgical perturbations. Our study suggests that electrode-containing grids may be applied in an intraoperative neuromonitoring platform for radical prostatectomy, serving as a tool for periprostatic cavernous nerve mapping. Applying this technology during radical prostatectomy may facilitate nerve localization and preservation objectives intraoperatively, thereby translating into improvements in functional outcomes after this surgery.

Demand has increased in recent years to develop and implement strategic approaches for improving functional outcomes following pelvic surgery. Intraoperative neurophysiological monitoring represents one such possible approach for this field. It involves generating neuronal activity within the nerve supply of pelvic organs and structures, conventionally using an external electrical current, and conjunctively recording neuronally mediated functional responses, which then, in real time, guides the surgical dissection in a manner that maximizes nerve preservation. A central aspect of this methodology is the creation of a neuronal stimulus. As such, sacral neurostimulation is proposed, strategically exploiting the neuroregulatory influence of the sacral spinal cord in pelvic physiology. While resembling sacral neuromodulation, a distinct methodology designed for long-term reprogramming of neural circuits, sacral neurostimulation aims to produce more immediate nerve signaling effects. Several technical options in this mode of neurostimulation are described, in which stimulatory electrodes are applied transspinally or peripherally to the neural pathways of the sacral spinal cord. These options can be categorized as surgical, percutaneous, and transcutaneous techniques. Ongoing studies in this field may reveal the most applicable techniques and optimal parameters for inducing erections and other neuronally mediated functional responses in the pelvic region as well. In turn, sacral neurostimulation may contribute toward applying neurophysiological monitoring during pelvic surgeries as a potential advance for improving postoperative functional outcomes. This narrative review serves to present the novelty of sacral neurostimulation for intraoperative induction of penile erection and its possible use in intraoperative neurophysiological monitoring for pelvic surgery.

Background: Erectile dysfunction (ED) is a prevalent sexual dysfunction, and due to the limited efficacy of conventional treatments, stem cell (SC)-based regenerative approaches are being extensively investigated. We aimed to investigate the overall effect of SC therapy (SCT) on ED by consolidating findings from clinical studies and offering a general overview of the intervention content and design of these studies. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We systematically reviewed MEDLINE, PubMed, Web of Science and ClinicalTrials.gov from inception to July 26, 2024. The outcomes were analyzed using the Comprehensive Meta-Analysis software version 3.0. The Q statistic and I² statistics were used to evaluate heterogeneity. Results: In this meta-analysis, a total of 11 studies evaluated International Index of Erectile Function (IIEF) levels, with an overall mean effect estimated at 16.872 [95% confidence interval (CI): 13.311–20.432]. The findings demonstrated statistically significant improvements in IIEF (Z=9.288, P2=92.59%). Furthermore, subgroup analyses revealed significant differences in patient diagnosis (z=3.29, P=0.017), baseline IIEF values (z=−3.64, P=0.003), and the type of SCs applied (z=−2.38, P=0.019). Conclusions: This study suggests that SCT may represent a promising alternative approach for the treatment of ED. However, the current evidence is primarily derived from early-phase studies characterized by small sample sizes, heterogeneous populations, lack of control groups, and short follow-up durations. Therefore, while preliminary findings indicate a potential improvement in erectile function following treatment, the overall level of certainty remains low. Further well-designed, randomized controlled trials with larger sample sizes are required before definitive conclusions can be reached and broader clinical implementation can be recommended.

Intraoperative neurophysiological monitoring (IONM) has been introduced as a potentially useful adjunct technology when performing pelvic surgeries such as radical prostatectomy for improving postoperative functional outcomes. It involves surveying the functional integrity of critical intrapelvic nerve structures in conjunction with registering neuronally mediated functional effects in the pelvic region during surgery, such that intraoperative adjustments can be made with the intent to minimize iatrogenic nerve injury. Such critical nerve structures include the periprostatic cavernous nerves, the source of neurochemical mediators of penile erection and urinary continence. To implement this technology, a neuronal stimulus is needed for activating physiological responses in the pelvic region. As such, we describe an innovative technical procedure for applying neurostimulation at the sacral spinal cord, bearing in mind the significance of this spinal level in neuroregulating pelvic functions, including penile tumescence and urethral sphincteric activity. Our procedure involves percutaneous insertion of 26-gauge, 50-mm monopolar insulated needle electrodes into the low back, guided by external physical landmarks, that contact the laminae at the fourth and fifth lumbar vertebral levels, from which an electrical current is delivered, thereby driving sacral spinal cord neural impulses to pelvic organs and structures. We performed the procedure in a pilot investigation of patients undergoing open radical prostatectomy just prior to surgical dissection of the prostate, assessing tumescence responses using a proprietary Sentinel^® functional near-infrared spectrophotometry sensor cuff placed on the penis. In five patients with mild or no erectile dysfunction preoperatively, we recorded higher than baseline variance in oxygenated and deoxygenated hemoglobin concentrations after neurostimulation (P<0.05), consistent with the onset of penile tumescence. In two patients with moderate to severe erectile dysfunction, neurostimulation did not elicit significant spectrophotometric changes or penile tumescence. There were no adverse events related to this procedure. Our findings suggest that sacral neurostimulation using a percutaneous needle electrode insertion technique is a feasible and safe procedure that may be used intraoperatively during radical prostatectomy to induce penile erection. Its potential role for assessing the functional integrity of neuroregulated erectile function in an IONM platform for radical prostatectomy surgeries is proposed, although further investigation is needed to demonstrate its utility for this purpose.

The artificial urinary sphincter endures as the standard of care treatment for mild to severe male stress urinary incontinence. Prior studies report outcomes from predominantly single-center retrospective series. Herein we present data from a multi-institutional analysis of artificial urinary sphincter outcomes (AUSCO) to assess efficacy, safety, and quality of life to standardize result reporting. AUSCO is a single-arm, prospective, multi-center study designed to evaluate the AMS 800™ in men with primary stress urinary incontinence (NCT04088331). One hundred fifteen participants were implanted at 17 sites. The primary endpoint was > 50% improvement in 24-hour pad weight 12 months post device activation. Secondary endpoints including pad use, urinary incontinence events per day, quality of life and device satisfaction were measured between 3- and 12- months post device activation and compared to baseline. At 12 months, 94% (91/97) participants experienced >50% pad weight reduction (p<0.001) and 60% (61/101) reported zero pad use. Participants also reported substantial improvement in quality of life scores and incontinence events per day post device activation. Seventeen participants (15%) had serious adverse events, 10 (8.7%) in which the events were device related. Nine participants (7.8%) had revisions: mechanical malfunction (3), erosion (2), lack of efficacy (1), other (3), and zero due to infection. In this prospective trial, the artificial urinary sphincter allowed most men to achieve total continence with a serious adverse event rate less than 15%. Participants experienced significant continence recovery with transformational improvement in patient-reported outcomes.

Background: The development of recurrent ischemic priapism (RIP) is associated with mental health disorders, psychiatric medications, and substance use, but the temporal relationship between the onset of RIP and the development of these risk factors is poorly understood. Aim: This study aimed to investigate the chronology of psychosocial and substance use risk factors relative to the initial clinical presentation of RIP. Methods: We conducted a retrospective cohort study of 73 adult patients diagnosed with RIP at a single academic center, identified via manual chart review of the electronic health record. Patients presenting with RIP between 2004 and 2020 were included, with data collection extending to 2025 to ensure a minimum follow-up of nearly 5 years for all participants to minimize censoring bias and capture delayed risk factor onset. Outcomes: The date of the first RIP presentation (index event) was compared to the first documented date of several risk factors, including anxiety, depression, psychiatric medication use, and substance use. Results: In the overall cohort, there was no statistically significant difference in the proportion of any risk factor developing before versus after the onset of RIP. Further, in a sub-analysis of 35 patients with sickle cell disease (SCD), a higher proportion of patients initiated psychiatric medication after the onset of RIP, although this was not statistically significant (P = .0522). No other factors reached statistical significance in the SCD sub-analysis. Clinical implications: The findings suggest that RIP may be a psychologically traumatic event that contributes to the development of the same psychosocial risk factors it is associated with. Strengths and limitations: The primary strength of this study is its novel investigation into the temporal relationship between RIP and psychosocial risk factors, supported by a design that ensured a minimum follow-up period of over 4 years for all participants. Limitations are primarily related to its retrospective, single-center chart-review design. Conclusion: Our findings suggest a complex, potentially bidirectional relationship that highlights the need for integrated mental health screening for all patients with RIP, particularly for the high-risk SCD population.