AUA 2024 Meeting: Key Takeways for Sexual Dysfunction
By Juan José Andino MD, MBA
UCLA Urology Assistant Clinical Professor
MLK Community Healthcare Urology
While attendees to this year’s American Urological Association meeting in San Antonio can stream the Key Takeaway sessions through the conference website, other Urologists or Advance Practice Providers won’t have immediate access to this information. I had the pleasure of highlighting sexual dysfunction with Dr. Tobias Köhler MD, MPH from Mayo Clinic Urology.
Dr. Dave Penson, AUA Secretary, piloted a new way of sharing key takeaways. A more conversational, podcast-style conversation between a more senior Urologist and junior attending was used to highlight high-impact topics.
Testosterone Deficiency
Reassurance about the safety of testosterone therapy (TRT) was a common theme. The TRAVERSE trial published last year highlighted the cardiovascular and prostate safety of testosterone replacement therapy.
In the Sunday plenary moderated by Dr. Morgentaler, Dr Larry Lipshultz and Dr Mike Hsieh highlighted the data supporting the safety of using TRT in men on active surveillance for prostate cancer (PCa), not only those who have undergone definitive treatment. One of the key studies referenced in the active surveillance space, “Oncologic Outcomes of Testosterone Therapy for Men on Active Surveillance for Prostate Cancer” was a podium presented by Dr. Elie Kaplan-Marans with PI Dr. Jim Hu. Using SEER-Medicare data, the authors demonstrate that there was no difference in prostate-cancer specific mortality, overall mortality, and the TRT group actually had lower conversion to definitive PCa therapy. The study is now published in European Urology.
Lastly, a group from John’s Hopkins led by Dr. Taylor Kohn presented “Testosterone Therapy in Women is not associated with Increased Cardiovascular Risk.” In this large claims-based analysis, the authors compared rates of major adverse cardiovascular events, DVT, and PE in women on testosterone therapy vs a control group. Similar to the data in men, systemic testosterone therapy was not associated with increased risk of cardiovascular events.
Erectile Dysfunction
A large portion of the Sunday plenary sessions was dedicated to the surgical management of erectile dysfunction with inflatable penile implants (IPP). One key aspect of these sessions was the low use of “Salvage” techniques for dealing with infected penile implants. The historical teaching has been that if an IPP is infected, it is an emergency and must be removed. As Dr. Charles Welliver highlighted, this is an oversimplification and doesn’t take into account the long-term impact on patient outcomes. For any patient that doesn’t have systemic symptoms of sepsis or significant tissue necrosis, IV antibiotics for 24-48 hours, coordination with surgeon(s) who perform implant surgeries, and replacement with a malleable penile implant can significantly improve outcomes for men who wish to remain sexually active. Despite data going back as far as 1998 showing that 81-93% effectiveness of salvage protocols, in the real world only about 17% of infected implants are managed this way. This presents a huge opportunity for improving the management of this rare but feared complication of penile prosthetic surgery.
In addition, we highlighted a podium presented by Dr. Navid Leelani from an ongoing Sexual Medicine Society of North America (SMSNA) collaboration: “Surgeon Volume in Penile Prosthesis Implantation Impacts Re-Operation Rates.” Our group was able to access Medicare patient data and compare outcomes based on the surgical volume of prosthetic surgeons thanks to data obtained by Boston Scientific. This is the first national study to show that highest quartile surgeons (performing > 31 implants per year) had lower re-operation rates for penile implant cases, both inflatable and malleable. This data highlights that for patients with severe ED, Urologists and APPs should identify local or regional prosthetic surgeons to whom they can refer patients when they fail medical therapy.
For folks in southern California, I am happy to serve as a resource for these cases – both for infected cases who may be candidates for salvage or patients with severe ED who are interested in learning more about surgical treatment (feel free to message me through Doximity, email, or contact the UCLA Men’s Health clinic).
We completed this portion by highlighting the podium presentation from Dr. Wayne Hellstrom and group of thought leaders in sexual medicine including Drs. Gerard Brock, Arthur Burnett, Tim Holland, and Ken James “Efficacy and Safety of MED3000, a novel topical therapy for the treatment of erectile dysfunction.” MED3000 (Eroxon) is the new, over-the-counter ED treatment recently approved by the FDA.
The gel is thought to work by stimulating nerve endings in the glans through subtle and quick temperature changes that lead to nitrous oxide released and required vasodilation needed for erections. 60% of patients had a clinical response to topical gel, defined as a 4 point or greater increase in International Index of Erectile Function (IIEF) score. 32 to 55% of patients were able to engage in penetrative activity after 10 min. Finally, it had a good safety profile with only mild side effects noted – 3% headache, 1% penile burning, and 0.7% nausea. Time will tell where this new agent fits in the current paradigm of ED management.
Peyronie’s Disease (Acquired Penile Curvature)
We concluded our session talking about Peyronie’s disease. The poster “Comparison of Collagenase Clostridium Histolyticum (CCH) to Surgery for the Management of Peyronie’s Disease: A Randomized Trial – 1 Year Outcomes” summarized study led by Dr. Landon Trost. The initial study was published in the Journal of Urology and highlighted similarity in patient satisfaction when randomized to CCH (or Xiaflex) vs surgery, despite differences in objective measures such as curvature, length, and adverse effects. However, in this interim update – there seemed to be a shift towards higher satisfaction in the CCH group at 1 year of follow-up possibly driven by restoration of penile length with CCH. However, as a co-author Dr. Köhler highlighted that given the small sample size, the loss of follow-up of a few patients could be skewing the results. Stay tuned for peer-reviewed publication to come.
It was a pleasure to be a part of my first Key Takeaways session at the annual AUA meeting with Dr. Toby Köhler. I really enjoyed the new format and look forward to seeing what is new at AUA 2025 in Las Vegas (April 26-29).
