Rising vasectomy volume following reversal of federal protections for abortion rights in the United States

In June 2022 the United States Supreme Court issued a ruling in the case Dobbs v. Jackson that overturned Roe v. Wade, the 1973 ruling establishing a federally protected right to abortion in the United States. Anecdotal reports suggested increased vasectomy volume following this event; however, no published data exist. We sought to describe trends in vasectomy consultation before and after the Dobbs v. Jackson ruling (referred to as pre- and post-Dobbs herein). Following IRB approval, we reviewed charts of all adults seeking vasectomy consultation in July-August 2021 and July-August 2022 at a large healthcare organization. We then aggregated vasectomy procedural billing data from 2018 to present. The primary outcome was volume of vasectomy consultation appointments and the secondary outcome was number of vasectomies performed. In July-August 2021 (Pre-Dobbs), 116 men attended vasectomy consultation versus 142 men in July-August 2022 (Post-Dobbs). Median age Post-Dobbs was significantly younger than Pre-Dobbs (35 vs 38 years, respectively, p = 0.01) with a significant increase in Post-Dobbs men under 30 seeking vasectomy (p = 0.005). A total of 16.9% (24/142) of Post-Dobbs men were childless, compared to 8.6% (10/116) of Pre-Dobbs men (p = 0.05). Of those with children, median number of offspring was unchanged at 2. Billing data showed a significant increase in vasectomy procedural volumes Post-Dobbs. While overturning Roe v Wade directly impacted female reproductive rights, number of vasectomy consultations and procedures increased significantly following this decision. Younger men, especially those under 30, as well as childless men were significantly more likely to seek consultation Post-Dobbs compared to the prior reproductive legal climate. While longer-term data are needed, findings indicate that men are invested in maintaining reproductive autonomy for themselves and their partners.

Metabolic syndrome and the urinary microbiome of patients undergoing percutaneous nephrolithotomy

Objective

To identify possible stone-promoting microbes, we compared the profiles of microbes grown from stones of patients with and without metabolic syndrome (MetS). The association between MetS and urinary stone disease is well established, but the exact pathophysiologic relationship remains unknown. Recent evidence suggests urinary tract dysbiosis may lead to increased nephrolithiasis risk.

Methods

At the time of percutaneous nephrolithotomy, bladder urine and stone fragments were collected from patients with and without MetS. Both sample types were subjected to expanded quantitative urine culture (EQUC) and 16 S ribosomal RNA gene sequencing.

Results

Fifty-seven patients included 12 controls (21.1%) and 45 MetS patients (78.9%). Both cohorts were similar with respect to demographics and non-MetS comorbidities. No controls had uric acid stone composition. By EQUC, bacteria were detected more frequently in MetS stones (42.2%) compared to controls (8.3%) (p=0.041). Bacteria also were more abundant in stones of MetS patients compared to controls. To validate our EQUC results, we performed 16 S ribosomal RNA gene sequencing. In 12/16 (75.0%) sequence-positive stones, EQUC reliably isolated at least one species of the sequenced genera. Bacteria were detected in both "infectious" and "non-infectious" stone compositions.

Conclusion

Bacteria are more common and more abundant in MetS stones than control stones. Our findings support a role for bacteria in urinary stone disease for patients with MetS regardless of stone composition.

Long-term outcomes after plaque excision grafting for Peyronie's disease and subanalysis of patients who undergo the procedure despite preoperative counseling against it

BACKGROUND

Plaque excision and grafting (PEG) has been recommended for patients with Peyronie's disease (PD) with >60° curvature and/or hinge effect and strong preoperative erections, while placement of an inflatable penile prosthesis (IPP) is recommended when rigidity is suboptimal. Nevertheless, many patients counseled to undergo an IPP decline and insist on proceeding with PEG due to personal preference or desire to avoid an implant.

AIM

We aim to review long-term outcomes in patients who underwent PEG for PD at our institution and investigate whether there is any difference in long-term outcomes in patients who undergo PEG despite a recommendation to undergo IPP.

METHODS

We conducted a retrospective chart review from 2007 to 2021 on PEG surgery performed at a single tertiary care institution in patients ≥18 years old who had >3 months of follow-up.

OUTCOMES

Postoperative information was gathered from the electronic medical record, including postoperative erectile function, patient satisfaction, and the ability to engage in penetrative sexual intercourse.

RESULTS

An overall 251 patients underwent PEG with a median follow-up of 12 months (IQR, 6-54). Among these, 54 (22%) were initially advised to undergo IPP but elected for PEG. Patients who underwent PEG despite counseling to undergo IPP reported lower postoperative ability to engage in intercourse (51% vs 76%). Seven (13%) patients initially advised to undergo IPP eventually received an IPP, relative to 7 (4%) initially advised to undergo PEG.

CLINICAL IMPLICATIONS

Thorough preoperative assessment of erectile function and penile deformity can guide clinician counseling and manage patient expectations during decision making between PEG surgery and IPP implantation for PD.

STRENGTHS AND LIMITATIONS

Limitations of this study include its retrospective nature, high attrition to follow-up, and risk of recall and selection bias. This is a large study with a median follow-up of 12 months, with a high-volume single surgeon who treats patients in a specialized population of complex cases.

CONCLUSION

Patients who were initially counseled to undergo IPP due to suboptimal erectile rigidity but elected for PEG had worse postoperative ability to engage in penetrative intercourse, and a higher proportion of these patients eventually received an IPP.

The natural history of benign prostatic hyperplasia-related voiding symptoms following penile prosthesis implantation

Background

There is a rising prevalence of benign prostatic hyperplasia (BPH)-related urinary symptoms along with erectile dysfunction in the aging male population. Therefore, assessment of lower urinary tract symptoms (LUTS) is advised before penile prosthesis surgery with some men requiring preoperative transurethral surgical management to reduce the risk of post-procedure complications. However, less is known about the natural history of men with uncomplicated LUTS who do not require surgical management for BPH before penile prosthesis.

Objective

We sought to assess the natural history of BPH-related uncomplicated LUTS in men following penile prosthesis surgery.

Design

Single institution retrospective review.

Methods

Following institutional review board approval, we performed a retrospective review of all adult males with a preoperative diagnosis of LUTS undergoing penile prosthesis surgery at our institution from January 2017 to November 2022. The primary outcome was progression to transurethral surgery.

Results

From 2017 to 2022, 211 patients with preexisting LUTS underwent penile prosthesis surgery and met all criteria for inclusion including no history of transurethral surgery. The median (interquartile range, IQR) AUA symptom score (AUA-SS) was 12 (12). Post-void residual was below 200 cc in 96.2% of patients preoperatively and 99.1% of patients after surgery. At a median (IQR) follow-up duration of 9 (23) months after surgery, 5.7% (12/211) of patients had progressed to bladder outlet surgery and 35.5% of patients endorsed LUTS bother with a median (IQR) AUA-SS of 14.5 (11.8).

Conclusion

The majority of patients with uncomplicated LUTS did not require bladder outlet surgery following penile prosthesis implantation and could be managed with conservative or pharmacologic measures alone. Prostate gland size was significantly larger in patients who progressed to bladder outlet surgery. While the results are overall reassuring, further study is needed to identify specific factors associated with pursuing bladder outlet surgery in this small subset of patients.

Penile prostheses harbor biofilms driven by individual variability and manufacturer even in the absence of clinical infection

BACKGROUND

Culture-based studies have shown that penile prostheses harbor biofilms in the presence and absence of infection, but these findings have not been adequately validated using contemporary microbiome analytic techniques.

AIM

The study sought to characterize microbial biofilms of indwelling penile prosthesis devices according to patient factors, device components, manufacturer, and infection status.

METHODS

Upon penile prostheses surgical explantation, device biofilms were extracted, sonicated, and characterized using shotgun metagenomics and culture-based approaches. Device components were also analyzed using scanning electron microscopy.

OUTCOMES

Outcomes included the presence or absence of biofilms, alpha and beta diversity, specific microbes identified and the presence of biofilm, and antibiotic resistance genes on each prosthesis component.

RESULTS

The average age of participants from whom devices were explanted was 61 ± 11 years, and 9 (45%) of 20 had a diagnosis of diabetes mellitus. Seventeen devices were noninfected, and 3 were associated with clinical infection. Mean device indwelling time prior to explant was 5.1 ± 5.1 years. All analyzed components from 20 devices had detectable microbial biofilms, both in the presence and absence of infection. Scanning electron microscopy corroborated the presence of biofilms across device components. Significant differences between viruses, prokaryotes, and metabolic pathways were identified between individual patients, device manufacturers, and infection status. Mobiluncus curtisii was enriched in manufacturer A device biofilms relative to manufacturer B device biofilms. Bordetella bronchialis, Methylomicrobium alcaliphilum, Pseudoxanthomonas suwonensis, and Porphyrobacter sp. were enriched in manufacturer B devices relative to manufacturer A devices. The most abundant bacterial phyla were the Proteobacteria, Actinobacteria, and Firmicutes. Glycogenesis, the process of glycogen synthesis, was among the predominant metabolic pathways detected across device components. Beta diversity of bacteria, viruses, protozoa, and pathways did not differ among device components.

CLINICAL IMPLICATIONS

All components of all penile prostheses removed from infected and noninfected patients have biofilms. The significance of biofilms on noninfected devices remains unknown and merits further investigation.

STRENGTHS AND LIMITATIONS

Strengths include the multipronged approach to characterize biofilms and being the first study to include all components of penile prostheses in tandem. Limitations include the relatively few number of infected devices in the series, a relatively small subset of devices included in shotgun metagenomics analysis, and the lack of anaerobic and other expanded conditions for culture.

CONCLUSION

Penile prosthesis biofilms are apparent in the presence and absence of infection, and the composition of biofilms was driven primarily by device manufacturer, individual variability, and infection, while being less impacted by device component.

A scoping review of ejaculatory dysfunction due to surgical treatments for benign prostatic hyperplasia: limitations of available tools for assessment and reporting

INTRODUCTION

Clinicians primarily focus on the presence or absence of anterograde ejaculation following surgery for benign prostatic hyperplasia (BPH). Failing to assess dysfunctional ejaculation and associated bother in a granular fashion can underestimate the prevalence and significance of ejaculatory dysfunction in this population.

OBJECTIVES

This scoping review provides critical appraisal of existing tools assessing ejaculatory function and associated bother, emphasizing the importance of adequate history-taking, preoperative counseling, and supplemental questions that should be used prior to and after treatment.

METHODS

A literature review was conducted using pertinent keywords from 1946 to June 2022. Eligibility criteria included men developing ejaculatory dysfunction following BPH surgery. Measured outcomes included the assessment of patient bother related to ejaculatory function, pre- and postoperative scores from the Male Sexual Health Questionnaire (MSHQ). and Danish Prostate Symptom sexual function domain (DAN-PSSsex).

RESULTS

Results of this study included only 10 documented patients' bother due to ejaculatory dysfunction following treatment. Pre- and postoperative MSHQ were used as the diagnostic tool in 43/49 studies, one study documented "preservation of anterograde ejaculation", and one used DAN-PSSsex. Q1-4 of the MSHQ were used in 33/43 studies, 3/43 used Q1, 3, 5-7, 1/43 used solely Q4, 1/43 used Q1-3 + Q6 and Q7, and 5/43 used the entire MSHQ. No studies used post-ejaculation urinalysis to diagnose retrograde ejaculation. Only four studies explicitly documented bother and found 25-35% of patients were bothered with a "lack of ejaculate" or "other ejaculation difficulties" during sexual activity after BPH surgery.

CONCLUSIONS

There are currently no studies stratifying patient bother by various components of ejaculation (force, volume, consistency, sensation of seminal expulsion, painful ejaculation, etc.) after BPH surgery. Opportunities for improvement exist in reporting ejaculatory dysfunction related to BPH treatment. A comprehensive sexual health history is needed. Further investigation into effects of BPH surgical treatments on specific characteristics of the patient's experience of ejaculation is required.

Comparison of patient-reported outcomes after penile prosthesis placement in men with and without Peyronie's disease

We evaluated outcomes in patients undergoing penile prothesis (PP) implantation for erectile dysfunction (ED) and concurrent Peyronie's Disease (PD). A clinician-developed survey to assess satisfaction was sent to 354 patients who underwent PP placement from 2012-2018 by a single-surgeon. Results were compared based on the presence or absence of concurrent PD. 79 patients completed the survey (response rate 22%), including 38 patients (48%) with concurrent ED and PD (ED/PD). Mean follow-up was 31 months (standard deviation 19). 87% felt their condition was "very much" or "much" improved. There was no significant difference in patient-reported overall satisfaction with their PP or satisfaction with current penile length/girth based on the presence or absence of PD. 87% of patients with PD were satisfied with their degree of penile straightening after PP plus or minus concurrent straightening maneuvers such as modeling, plication, or incision/grafting. Sub-group analyses were performed to evaluate outcomes in those with concurrent PD/ED who required plaque incision/grafting at the time of PP placement for more severe deformity (n = 19). 47% of these patients were dissatisfied with their current penile length, compared with only 16% of those patients with PD/ED who did not require grafting (p = 0.05). In conclusion, the presence of PD alone may not impact PP satisfaction, but patients with more severe baseline deformity who require incision/grafting may be less satisfied with outcomes including penile length.

Single-port transvesical versus open simple prostatectomy: a perioperative comparative study

OBJECTIVE

To compare the initial perioperative outcomes of single-port transvesical simple prostatectomy (SP RASP) patients to those of open simple prostatectomy (OSP).

PATIENTS AND METHODS

Perioperative data from 42 consecutive patients with BPH who underwent SP RASP were prospectively reviewed. Similarly, data from forty-three consecutive patients who underwent the standard OSP, were retrospectively collected. Through direct suprapubic bladder access, prostatic enucleation was performed using the prostatic capsule as a landmark. Then a complete vesicourethral mucosal advancement flap was accomplished. OSP was performed according to the standard approach. Demographics, Intra- and perioperative data were analyzed and assessed with a descriptive analysis.

RESULTS AND LIMITATIONS

Baseline characteristics were comparable between the two groups, except for the preoperative median post-void residual volume, which was higher in the OSP group (p = 0.004). The SP RASP group had less intraoperative estimated blood loss (p < 0.001), no need for continuous bladder irrigation (p < 0.001), and less in-hospital opioid use (p < 0.001). Patients in the SP RASP group were discharged on postoperative day zero, compared to a median of 2 days for OSP (p < 0.001). The median Foley catheter duration was 7 days for SP RASP, compared to a median of 10 days for OSP (p < 0.001). SP RASP group had fewer postoperative complications, however, this did not reach statistical significance.

CONCLUSION

SP RASP is an alternative approach in treating surgical BPH. It may offer patients less morbidity in comparison to OSP.

Microbe-metabolite interaction networks, antibiotic resistance, and in vitro reconstitution of the penile prosthesis biofilm support a paradigm shift from infection to colonization

To understand differences between asymptomatic colonized and infected states of indwelling medical devices, we sought to determine penile prosthesis biofilm composition, microbe-metabolite interaction networks, and association with clinical factors. Patients scheduled for penile prosthesis removal/revision were included. Samples from swabbed devices and controls underwent next-generation sequencing, metabolomics, and culture-based assessments. Biofilm formation from device isolates was reconstituted in a continuous-flow stir tank bioreactor. 93% of 27 analyzed devices harbored demonstrable biofilm. Seven genera including Faecalibaculum and Jeotgalicoccus were more abundant in infected than uninfected device biofilms (p < 0.001). Smokers and those with diabetes mellitus or cardiac disease had lower total normalized microbial counts than those without the conditions (p < 0.001). We identified microbe-metabolite interaction networks enriched in devices explanted for infection and pain. Biofilm formation was recapitulated on medical device materials including silicone, PTFE, polyurethane, and titanium in vitro to facilitate further mechanistic studies. Nearly all penile prosthesis devices harbor biofilms. Staphylococcus and Escherichia, the most common causative organisms of prosthesis infection, had similar abundance irrespective of infection status. A series of other uncommon genera and metabolites were differentially abundant, suggesting a complex microbe-metabolite pattern-rather than a single organism-is responsible for the transition from asymptomatic to infected or painful states.

Expanded Utilization of Intralesional Therapies for Treatment of Peyronie's Disease

Purpose

In this narrative review we explore additional indications for which intralesional collagenase Clostridium histolyticum (CCH) injection therapy may be used, in addition to those utilized in the IMPRESS trials. The goal is to provide updated assessment of available intralesional therapies and justify whether to expand clinical indications based on advancements over the last decade.

Results

Patients receiving CCH in the acute phase of PD have shown significant improvement in penile curvature - which may be even more significant than reported due to progressive curvature over the longitudinal course of injection therapy. Across studies, patients with ventral plaques achieved the greatest curvature improvement (~30°) compared to PD patients with dorsal or lateral plaques. Patients with curvature > 90° have been minimally documented. However, the concept of patients with higher degree of curvature achieving more significant degrees of improvement prevails across studies. Studies including PD patients with volume loss deformities or indentation(s) focus on curvature improvement and do not gauge improvement in these girth loss or indentation features specifically. PD patients with calcification may benefit from CCH, however, critical analysis of included study designs and results compared to placebo do not lend for strong support of CCH in PD at this time.

Conclusion

Based on the most recent research, the use of CCH in the acute phase of PD and patients with ventral penile plaques may be effective and safe. The limited available research on the efficacy of CCH on calcified plaque(s) and curvature greater than 90° is promising, however, more research is needed to ensure safety and success in this patient cohort. Finally, the current literature continues to show the use of CCH is not effective in PD patients with volume loss, indentation, or hourglass deformity. When expanding the use of CCH to patients not originally included in the IMPRESS trials, providers must prioritize minimizing chances of potential injury to urethral tissue. Finally, further investigation is required to determine whether CCH has utility for curvature greater than 90° or calcified plaques, although the limited available literature is promising.

A Review of Combined Phosphodiesterase-5-Inhibitors and α-Blockers versus Phosphodiesterase-5-Inhibitors Alone for Lower Urinary Tract Symptoms due to Benign Prostatic Hyperplasia

Guidelines from the American Urological Association (AUA) and the European Association of Urology (EAU) present conflicting recommendations regarding combination therapy of phosphodiesterase 5 inhibitors (PDE5is) with α-blockers to treat benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). Use of PDE5is is widespread in the population of patients with LUTS/BPH. In this scoping review, we examine the evidence regarding the safety and efficacy of combined PDE5is and α-blockers compared to PDE5i medications alone. A search was conducted using PubMed, Cochrane, and Web of Science to identify manuscripts discussing the safety of PDE5i and α-blockers in combination or comparing this combination to PDE5is alone in the treatment of LUTS/BPH. Study designs, data, and conclusions were qualitatively analyzed. Combination therapy was found to be safe across all studies; importantly, no evidence documents increased risk of hypotension. Most studies reported added improvement in symptom and quality of life scores compared to PDE5i alone, with additional International Prostate Symptom Score (IPSS) change ranging from -1.30 to -8.50 and IPSS quality of life score change ranging from -0.15 to -1.50. Objective metrics such as postvoid residual volumes and maximum flow rate were inconsistently reported. Taken together, the current body of data suggests that combining PDE5i α-blocker therapy is safe and that there are opportunities for additional symptomatic improvement, though it should be utilized for select patients. Situations with particular utility could include patients with comorbid erectile dysfunction or without sufficient improvement on monotherapy.

Using IsoPSA With Prostate Imaging Reporting and Data System Score May Help Refine Biopsy Decision Making in Patients With Elevated PSA

OBJECTIVE

To assess how IsoPSA, a structure-based serum assay which has been prospectively validated in detecting clinically significant prostate cancer (csPCa), can help the biopsy decision process when combined with the prostate imaging reporting and data systems (PI-RADS).

MATERIALS AND METHODS

This was a single-center retrospective review of prospectively collected data on patients receiving IsoPSA testing for elevated PSA (>4.0ng/mL). Patients were included if they had received an IsoPSA test and prostate MRI within 1 year of IsoPSA testing, and subsequently underwent prostate biopsy. Multivariable logistic regression was used to identify predictors of (csPCa, ie, GG ≥ 2) on biopsy. Predictive probabilities for csPCa at biopsy were generated using IsoPSA and various PI-RADS scores.

RESULTS

Two hundred and 7 patients were included. Twenty-two percent had csPCa. Elevated IsoPSA ratio (defined as ≥6.0) (OR: 5.06, P = .015) and a PI-RADS 4-5 (OR: 6.37, P <.001) were significant predictors of csPCa. The combination of elevated IsoPSA ratio and PI-RADS 4-5 lesion had the highest area under the curve (AUC) (AUC: 0.83, P <.001). The predicted probability of csPCa when a patient had a negative or equivocal MRI (PI-RADS 1-3) and a low IsoPSA ratio (≤6) was <5%.

CONCLUSION

The combination of PI-RADS with IsoPSA ratios may help refine the biopsy decision-making process. In our cohort, a negative or equivocal MRI with a low IsoPSA may provide a low enough predicted probability to omit biopsy in such patients.

Subcoronal inflatable penile prosthesis implantation: indications and outcomes

BACKGROUND

While implantation of an inflatable penile prosthesis (IPP) is commonly performed via infrapubic or penoscrotal approaches, the subcoronal (SC) approach for IPP implantation may safely and reliably allow for additional reconstructive procedures through a single incision.

AIM

The aim of this study is to report outcomes, including complications, of the SC approach and to determine common characteristics of patients undergoing the SC approach.

METHODS

A retrospective chart review from May 11, 2012, to January 31, 2022, was performed at a single, tertiary care institution to identify patients with IPP implantation via the SC approach.

OUTCOMES

Postoperative information was reviewed and extracted from all clinic notes available following the date of IPP implantation in the electronic medical record, detailing any complications including wound complications, need for revision or removal, device malfunction, and infections.

RESULTS

Sixty-six patients had IPP implantation via the SC approach. Median follow-up duration was 29.4 (interquartile range 14.9-50.1) months. One (1.8%) patient had a simple wound complication. Two (3.6%) experienced postoperative infection of the prosthesis, which resulted in explantation of the device. One of these infected prostheses later experienced partial glans necrosis. Revision for mechanical failure or unsatisfactory cosmetic result was performed in 3 (7.3%) IPPs placed via a SC incision.

CLINICAL IMPLICATIONS

The SC approach for implantation of IPP is safe and feasible with low complication and revision rates. It offers urologists an alternative to the classic infrapubic and penoscrotal approaches, both of which would require a second incision for additional reconstructive procedures required to adequately address deformities associated with severe Peyronie's disease. Therefore, urologists who treat these specialized populations of men may benefit from having the SC approach in their array of techniques for IPP implantation.

STRENGTHS AND LIMITATIONS

The limitations of this study include its retrospective nature, risk of selection bias, lack of comparison groups, and sample size. This study reports on early experience with the SC approach performed by a single high-volume reconstructive surgeon, who treats a specialized population of patients requiring complex repair during implantation of an IPP, particularly those with Peyronie's disease.

CONCLUSION

The SC incision for IPP implantation has low rates of complications and remains our approach of choice for IPP implantation in patients with severe Peyronie's disease, including curvatures >60°, severe indentation with hinge, and grade 3 calcification, which are unlikely to respond adequately to manual modeling alone.

Impact of intravesical Bacillus Calmette-Guérin and chemotherapy on the bladder microbiome in patients with non-muscle invasive bladder cancer

Introduction

Intravesical therapy (IVT), including Bacillus Calmette-Guérin (BCG), is the standard of care for high grade (HG) non-muscle invasive bladder cancer (NMIBC). Despite the use of IVT, many patients recur after treatment. The bladder microbiome and its role in disease processes has recently risen to prominence. We aim to characterize changes that occur in the bladder microbiome over the course of intravesical therapy and assess whether these changes correlate with outcomes in patients with NMIBC.

Methods

Patients with NMIBC undergoing induction BCG or intravesical therapy were prospectively enrolled from January 2019 to March 2020. Patients with clinical T2 or greater pathology or active urinary tract infection at enrollment were excluded. Twenty-nine patients had catheterized (bladder) urine samples collected prior to induction intravesical therapy and prior to each IVT instillation. Twenty-seven received BCG while 2 received intravesical gemcitabine. Bacteria were identified using 16S ribosomal RNA gene sequencing. Bladder microbiome changes were evaluated and differences between patients who recurred and patients who did not recur after IVT were investigated.

Results

Across the 29 patients analyzed, bacterial richness decreased significantly following intravesical therapy (Richness, P=0.01). Evenness and overall diversity did not change significantly (Pielou, P=0.62; Shannon, P=0.13). Patients who experienced recurrence had a higher relative abundance of Aerococcus in their urine (P&lt;0.01), while those who did not recur had significantly more Ureaplasma (P=0.01) and Escherichia/Shigella species (P=0.05). Patients with decreased levels of alpha diversity were more likely to fall within the non-recurrence cohort.

Conclusion

IVT for NMIBC appears to change the urinary microbiome by decreasing richness while not altering evenness or overall diversity. The presence of Aerococcus species may be predictive of a poor cancer response to IVT, while the presence of Ureaplasma and Escherichia/Shigella may predict a favorable response to IVT. Further studies are warranted to elucidate and confirm the significance of changes in the bladder microbiome.

Bilateral Cavernosal Artery Ligation to Treat Ischemic Priapism Following Inflatable Penile Prosthesis Implantation

OBJECTIVE

To describe the first known case of recurrent acute priapism after penile prosthesis implantation.

MATERIALS AND METHODS

A 60-year-old gentleman with a history of recurrent ischemic priapism without hemoglobinopathy presented with refractory erectile dysfunction and underwent uncomplicated penile prosthesis placement. His course was complicated by early acute ischemic priapism confirmed via ultrasound. Due to his pain, attempts to relieve the priapism using ultrasound-guided phenylephrine injections were attempted but were unsuccessful.

RESULTS

He subsequently underwent exploration with confirmation of distal ischemic priapism followed by brisk bright red blood from the proximal corpora upon device externalization. A perineal exploration was performed and the bilateral cavernosal arteries were suture ligated with immediate relief. The device was reimplanted and the patient recovered uneventfully.

CONCLUSION

We report the first known case of ischemic priapism following inflatable penile prosthesis implantation. The details of this case challenge the dogma that priapism is a binary event and instead supports an imbalance between unopposed cavernosal artery inflow possibly due to vascular calcifications and compromised venous outflow due to the presence of the device. Prosthetic urologists should be aware of this rare phenomenon and consider all available approaches on an individualized case-by-case basis.

An Online Investigation Into Direct-to-Consumer Men's Health Clinics: The Who, What, and Where

OBJECTIVE

To characterize direct-to-consumer (DTC) men's health clinics by reviewing their online content. Increasing numbers of patients are seeking treatment for erectile dysfunction (ED) and hypogonadism from DTC "men's health" clinics. Treatments are often used off-label, with lack of transparency of provider credentials and qualifications.

METHODS

We identified DTC Men's Health Clinics in the United States by internet search by state using the terms, "Men's Health Clinic," and "Low T Center." All stand-alone clinics were reviewed.

RESULTS

Two hundred and twenty-three clinics were reviewed, with 147 (65.9%) offered ED treatments and 196 (87.9%) offering testosterone replacement, and 120 (53.8%) offering both ED treatment and testosterone replacement. Of those clinics offering ED treatments, 93 (63.3%) advertised shockwave therapy and 84 (57.1%) PRP therapy. There were 56 (38%) who offered shockwave therapy and PRP. ICI was significantly more likely to be offered if there was a urologist on staff (p <.001). Clinic providers represented 20 different medical and alternative medicine specialties. Internal medicine was most common (17.4%), followed by family medicine (11.1%). A nonphysician (nurse practitioner or physician assistant) was listed as the primary provider in 10 clinics (4.5%) and 45 clinics (20.1%) did not list their providers. Urologists were listed as the primary provider in 10.3% of clinics. A naturopathic provider was listed as a staff member in 22 (11.6%) of clinics.

CONCLUSION

There is significant heterogeneity and misinformation available to the public regarding men's health. Familiarity with and insight into practice patterns of "men's health" clinics will help provide informed patient care and counseling.

Post-Vasectomy Semen Analysis: Optimizing Laboratory Procedures and Test Interpretation through a Clinical Audit and Global Survey of Practices

PURPOSE

The success of vasectomy is determined by the outcome of a post-vasectomy semen analysis (PVSA). This article describes a step-by-step procedure to perform PVSA accurately, report data from patients who underwent post vasectomy semen analysis between 2015 and 2021 experience, along with results from an international online survey on clinical practice.

MATERIALS AND METHODS

We present a detailed step-by-step protocol for performing and interpretating PVSA testing, along with recommendations for proficiency testing, competency assessment for performing PVSA, and clinical and laboratory scenarios. Moreover, we conducted an analysis of 1,114 PVSA performed at the Cleveland Clinic's Andrology Laboratory and an online survey to understand clinician responses to the PVSA results in various countries.

RESULTS

Results from our clinical experience showed that 92.1% of patients passed PVSA, with 7.9% being further tested. A total of 78 experts from 19 countries participated in the survey, and the majority reported to use time from vasectomy rather than the number of ejaculations as criterion to request PVSA. A high percentage of responders reported permitting unprotected intercourse only if PVSA samples show azoospermia while, in the presence of few non-motile sperm, the majority of responders suggested using alternative contraception, followed by another PVSA. In the presence of motile sperm, the majority of participants asked for further PVSA testing. Repeat vasectomy was mainly recommended if motile sperm were observed after multiple PVSA's. A large percentage reported to recommend a second PVSA due to the possibility of legal actions.

CONCLUSIONS

Our results highlighted varying clinical practices around the globe, with controversy over the significance of non-motile sperm in the PVSA sample. Our data suggest that less stringent AUA guidelines would help improve test compliance. A large longitudinal multi-center study would clarify various doubts related to timing and interpretation of PVSA and would also help us to understand, and perhaps predict, recanalization and the potential for future failure of a vasectomy.

Aspiration and Sclerotherapy: A Minimally Invasive Treatment for Hydroceles and Spermatoceles

OBJECTIVE

To describe our contemporary experience with aspiration and sclerotherapy (AS) as a non-surgical alternative for patients with symptomatic hydrocele and spermatocele who prefer non-surgical treatment.

MATERIALS AND METHODS

Patients were identified by billing diagnosis code for hydrocele or spermatocele from 2015-2019. Patients underwent AS with doxycycline (200-400mg). Physical exam, ultrasound and aspirate microscopy were used to differentiate hydrocele from spermatocele. Baseline and follow-up data were recorded.

RESULTS

In total, 65 patients underwent AS, 54/65 (83%) for hydrocele and 11/65 (17%) for spermatocele with mean aspirate volumes 307mL (SD 238mL) and 138mL (SD 112mL), respectively. Follow-up data was available for 38/54 (70%) hydroceles and 8/11 (73%) spermatoceles with median follow-up 28 (IQR 23-41) and 22 (IQR 18.5-30.5) months respectively. Relief of patient reported bother associated with scrotal size occurred in 29/38 (77%) hydroceles and 8/9 (89%) spermatoceles. 2/54 (4%) hydrocele patients developed hematoma managed with in-office aspiration. Immediate post-procedural pain occurred in 2/56 (4%) hydroceles and 2/10 (20%) spermatocele. Post-procedural pain requiring more than 5 tablets of hydrocodone/acetaminophen 5mg/325mg occurred in 2/57 (3%) hydroceles and 2/10 (20%) spermatoceles. Surgical repair was ultimately pursued in 3/38 (8%) and 1/9 (11%) patients with persistent hydrocele and spermatocele respectively.

CONCLUSION

AS is a safe and effective treatment alternative for hydrocele and spermatocele for patients wishing to avoid surgery.

Socioeconomic Disparities and Risk Factors in Patients Presenting With Ischemic Priapism: A Multi-Institutional Study

OBJECTIVES

To evaluate contemporary clinical presentations of priapism, their association with socioeconomic characteristics, and the role of prescribing providers in priapism episodes in a large cohort of patients managed at 3 major academic health systems.

METHODS

We identified all consecutive patients presenting with ischemic priapism to the emergency departments of three major academic health systems (2014 -2019). Demographic characteristics, priapism etiologies, and clinical management were evaluated. Univariable and multivariable analyses were used to assess the contribution of socioeconomic characteristics and the role of prescribing providers in priapism episodes.

RESULTS

We identified 102 individuals with a total of 181 priapism encounters. Hispanic race, lower income quartile, sickle-cell disease, and illicit drug use were associated with increased risk of recurrent episodes. Of ICI users, 57% received their prescriptions from non-urological medical professionals (NUMPs); the proportion with recurrent episodes was higher for NUMPs compared to urologists (24% vs 0%, P = 0.06) with no demographic differences identified between patients treated by either group.

CONCLUSION

Socioeconomic disparities exist among patients presenting with recurrent episodes of priapism, potentially highlighting systemic issues with access to care and patient education. With most patients who developed ischemic priapism from ICI being prescribed these medications by NUMPs, further investigation is required to elucidate the prescribing and counseling patterns of these providers. Increased awareness of disparities and complications may improve patient safety.

Standardization of microbiome studies for urolithiasis: an international consensus agreement

Numerous metagenome-wide association studies (MWAS) for urolithiasis have been published, leading to the discovery of potential interactions between the microbiome and urolithiasis. However, questions remain about the reproducibility, applicability and physiological relevance of these data owing to discrepancies in experimental technique and a lack of standardization in the field. One barrier to interpreting MWAS is that experimental biases can be introduced at every step of the experimental pipeline, including sample collection, preservation, storage, processing, sequencing, data analysis and validation. Thus, the introduction of standardized protocols that maintain the flexibility to achieve study-specific objectives is urgently required. To address this need, the first international consortium for microbiome in urinary stone disease - MICROCOSM - was created and consensus panel members were asked to participate in a consensus meeting to develop standardized protocols for microbiome studies if they had published an MWAS on urolithiasis. Study-specific protocols were revised until a consensus was reached. This consensus group generated standardized protocols, which are publicly available via a secure online server, for each step in the typical clinical microbiome-urolithiasis study pipeline. This standardization creates the benchmark for future studies to facilitate consistent interpretation of results and, collectively, to lead to effective interventions to prevent the onset of urolithiasis, and will also be useful for investigators interested in microbiome research in other urological diseases.

Peyronie's disease: pharmacological treatments and limitations

Introduction: Peyronie's disease (PD) is a disorder of the tunica albuginea from disordered and excessive deposition of collagen resulting in a palpable scar, pain, erect penile deformity and erectile dysfunction that significantly impacts patients both physically and emotionally.Areas Covered: Several treatment options have been described for PD, including shockwave therapy, traction therapy, both oral and intralesional pharmacological options, and surgery. This review seeks to examine the data for different types of non-surgical treatments for PD. We review how various treatment modalities impact several relevant clinical endpoints for Peyronie's disease, including effects on pain, penile curvature, plaque formation, and erectile function. We performed a literature search using PubMed and SCOPUS while referencing AUA, EAU, and CUA guidelines for management of Peyronie's Disease for studies published 1980-2020.Expert opinion: Intralesional collagenase injections have the strongest evidence and are the only FDA approved intralesional treatment for PD. Penile traction therapy (PTT) is low risk and may be beneficial in patients willing to invest significant time using the devices. Furthermore, oral combination therapy with other modalities may provide some benefit. Further investigation is required to better understand pathophysiology of PD and clarify the therapeutic utility of existing treatments, potentially with a multimodal strategy.

Surgical ergonomics for urologists: a practical guide

Poor ergonomics in the operating room can have detrimental effects on a surgeon's physical, psychological and economic well-being. This problem is of particular importance to urologists who are trained in nearly all operative approaches (open, laparoscopic, robotic-assisted, microscopic and endoscopic surgery), each with their own ergonomic considerations. The vast majority of urologists have experienced work-related musculoskeletal pain or injury at some point in their career, which can result in leaves of absence, medical and/or surgical treatment, burnout, changes of specialty and even early retirement. Surgical ergonomics in urology has been understudied and underemphasized. In this Review, we characterize the burden of musculoskeletal injury in urologists and focus on various ergonomic considerations relevant to the urology surgeon. Although the strength of evidence remains limited in this space, we highlight several practical recommendations stratified by operative approach that can be incorporated into practice without interrupting workflow whilst minimizing injury to the surgeon. These recommendations might also serve as the foundation for ergonomics training curricula in residency and continuing medical education programmes. With improved awareness of ergonomic principles and the sequelae of injury related to urological surgery, urologists can be more mindful of their operating room environment and identify ways of reducing their own symptoms and risk of injury.

Implications of Calcification in Peyronie's Disease, A Review of the Literature

A common characteristic of Peyronie's Disease (PD) is plaque calcification, which is associated with decreased response to treatments and higher rates of surgical intervention. Despite its prevalence in the PD population, the literature on plaque calcification is limited. While the diagnosis of PD is mostly clinical, imaging modalities such as ultrasound can be used to identify plaque calcification. The proper identification of plaque calcification is crucial for guiding management and setting therapeutic expectations for patients with PD. Herein we discuss what is known about PD plaque calcification, including epidemiology, etiology, diagnosis, and management.

Chronic Scrotal Content Pain: a Review of the Literature and Management Schemes

PURPOSE OF REVIEW

Chronic scrotal content pain (CSCP) is a complex condition with multiple etiologies that requires a thorough understanding of its pathophysiology, workup, and treatment options. We performed a comprehensive and contemporary review to augment our current understanding of CSCP.

RECENT FINDINGS

We discuss new advances in CSCP-specific pain questionnaires, modern studies of microscopic spermatic cord denervation and its variations, and novel techniques including electric nerve stimulation and cryoablation in addition to randomized control trials with significant negative findings. We also present literature focusing on the prevention of CSCP secondary to surgical iatrogenic causes. The constantly evolving literature of CSCP has led to the significant evolution in its diagnosis and treatment, from oral medications to salvage options after microscopic spermatic cord denervation. With each advance, we come closer to developing a more thorough, evidence-based algorithm to guide urologists in treatment of CSCP.

Human Penile Ossification: A Rare Cause of Sexual Dysfunction - A Case Report and Review of the Literature

Human penile ossification is a rare urologic condition with approximately 40 cases reported in the literature so far. While bone is essential for penetrative intercourse in many non-human mammals, human penile ossification appears to be part of a metaplastic process occurring after injury or trauma. Conditions such as Peyronie’s disease, diabetes mellitus, local trauma, and end-stage renal disease have been associated with this entity. We report the case of a 65-year-old male with penile curvature and a history of painful intercourse who underwent partial excision and grafting with bovine pericardial graft and was found on pathologic examination to have penile ossification.

Amphetamine/Dextroamphetamine Salts for Delayed Orgasm and Anorgasmia in Men: A Pilot Study

OBJECTIVE

To describe our experience with amphetamine/dextroamphetamine salts (AMP) as a treatment for delayed orgasm/anorgasmia (DO/AO).

METHODS

We identified patients with DO/AO from September 2017 to September 2019. Baseline characteristics and patient-reported orgasmic latency time (OLT) were recorded. After extensive screening, patients were treated with AMP. Validated questionnaires were administered including International Index of Erectile Function, quantitative Androgen Deficiency in the Aging Male and Adult ADHD Self-Report Scale. OLT change, adverse effects, and patient satisfaction were assessed. Baseline characteristics were compared using chi-squared test. OLT changes were compared with one-way ANOVA. Multivariable logistic regression was performed to identify predictors of treatment success. P < 0.05 was statistically significant.

RESULTS

Seventeen men received AMP - 6 of 17 (35.3%) for AO and 11 of 17 (64.7%) for DO, with median follow-up 1.0 year (interquartile range [IQR] 1.0 year). Amongst responders, AMP improved subjective experience of sex in 8 of 17 (47.1%) patients (2/6 with AO). Of those, 6 of 17 (35.3%; 1/6 with AO) experienced reduced OLT or increased frequency of orgasm. Non-responders were older than responders, with median age 69.5 (IQR 4.3) vs 61.0 years (IQR 12.3; P = 0.024). There were no other significant differences in baseline characteristics among responders. Of note, 6 of 8 (75%) responders and 8 of 9 (88.9%) non-responders failed other treatment modalities prior to AMP. Among responders with DO and improved OLT, mean OLT decreased by 72.3% (40.7 to 11.1 minutes, P = 0.049) during intercourse. Minimal side effects were noted including insomnia and jitters, each in one patient respectively.

CONCLUSION

AMP as a treatment for AO/DO merits further investigation. Measurable improvements in OLT or frequency of orgasm occurred in more than a third of patients. Larger prospective multicenter studies with strict inclusion and exclusion criteria are warranted.