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Penile prosthesis implantation is a safe and effective treatment option in the management of erectile dysfunction, associated with high satisfaction and low complication rates. Infection is a rare complication (0.5-3%), but devastating for the patient and surgeon when it occurs. Adapting from other surgical disciplines, we have utilized vancomycin paste to provide prolonged focal antibiotic exposure around the penile prosthesis pump, a site prone to infection. The aim of this study is to determine the safety and efficacy of intraoperative vancomycin paste with regards to infection prevention during penile prosthesis placement. This is a multi-institutional nonrandomized retrospective IRB-approved study comparing patients who underwent placement of a primary inflatable penile prosthesis with intraoperative vancomycin paste to those without. Primary outcomes included pump fibrosis, infection, erosion, hematoma, and complete device malfunction. From April 2019 to October 2019, two surgeons utilized vancomycin paste intraoperatively during virginal penile prosthesis surgery on 90 patients, whose mean age was 60 years. These patients were compared to an historical control group that included 166 patients, also with a mean age of 60 years, who underwent the same penile prosthesis surgery between 2014 and 2017 without the paste. Among the intervention group, the overall complication rate was 1.1%, due to a scrotal hematoma. Ultimately, there was no statistically significant difference in infection rate (0% in both groups) or overall complication rate (1.1% in the intervention group compared to 1.2% in the control group). The use of vancomycin paste appears to be safe, however future prospective studies are needed to determine its efficacy in infection prevention.

Background There is a significant need for a non-biohazardous, educational platform to equip and maintain the surgical skills required by urology trainees and low-volume implanters for inflatable penile prosthetic (IPP) placement. Aim To design and develop an anatomic, hydrogel-based simulation platform for training and evaluate IPP placement using modern education theory. Methods The backward design concept was used as a framework in the design and development of an IPP simulation platform. Steps included delineating requirements from a physicians’ perspective, translating requirements into engineering tasks (deliverables), developing a prototype, and pilot validation. Using a combination of 3-dimensional printing and hydrogel casting, a genitourinary tract model was constructed to replicate the appropriate steps of IPP placement guided by expert feedback. Full-immersion IPP simulations were performed through both infrapubic and penoscrotal approaches by 4 expert surgeons under operative conditions. Questionnaires evaluating the simulation’s realism, value as a training tool, and further recommendations were completed. Outcomes Using backward design educational pedagogy, a high-fidelity, full-procedural IPP simulation was fabricated and verified as an adequate educational tool for training and assessment. Results An expert consensus on the anatomic landmarks, steps and substeps, instruments, and errors to be included in the model was reached using a hierarchical task analysis and was successfully translated into a prototype hydrogel model. Experts performed all appropriate steps of IPP surgery and rated the simulation highly in terms of its realism and value as a training tool. On average, experts agreed that the model could function as a training tool, assessment tool, prerequisite for IPP accreditation, and requirement before live surgery. Experts stated they would have their trainees ideally complete an average of 1.75 models before live surgical training. All experts believed an operative checklist would be an ideal assessment tool.

To assess whether a focused, simulation training course can improve trainee surgical knowledge and confidence in the treatment of male stress urinary incontinence.Urology residents participated in a prosthetic education course as part of the 2018 SUPS and SMSNA annual meeting. The course included didactic lectures and a hands-on cadaveric laboratory. Participants completed questionnaires before and after the lab (2 weeks and 6 months) to assess procedural knowledge and confidence. Analysis of lab responses was performed using the Wilcoxon signed rank test for matched pairs.Thirty-two residents (median age 29, range 27-34) participated in the course. The majority were postgraduate year 4 (63%) or postgraduate year 5 (20%). Most participants reported minimal AUS or sling experience with 50% and 94% reporting less than 5 cases, respectively. Overall score from the knowledge assessment improved significantly between the pre-lab versus 2-week post-lab (P = .02) and pre-lab versus 6-month post-lab (P = .01). Similarly, procedural confidence improved between pre-lab vs 2-week post-lab (P.001) and pre-lab versus 6-month post-lab (P.001). Knowledge and confidence assessments were not different between year of residency training or pre-lab experience.Simulation training improves knowledge and confidence in prosthetic surgery for male stress incontinence. In the current climate of reduced exposure and limited availability of prosthetic educators, simulation courses can provide much needed educational value.

Background Modern-day penile prostheses use infection retardant coating to decrease rates of postoperative infection, subsequently reducing explantation and revision rates as well. The Coloplast Titan models are dipped into antimicrobial solutions right before implantation, and the components used for dipping can be tailored toward the patient. Aim To compare infection, explantation, and revision rates among different dipping solutions used before implantation for patients with diabetes receiving a Coloplast Titan implant. Methods We systematically reviewed 932 patients with diabetes receiving a primary penile implant across 18 different centers from the period April 2003 to August 2018. Of those patients, 473 received a Coloplast device, whereas 459 received an AMS device. Data regarding the type of antimicrobial solution used before implantation were recorded for 468 patients receiving a Coloplast Titan, including whether or not they suffered a postoperative infection and if they underwent explantation and/or revision. Outcome rates were compared using Fisher’s exact and Pearson’s chi-square tests, and logistic regression modeling was performed to account for covariates. Outcomes The main outcome measures of this study were postoperative infection, explantation, and revision rates. Results Of the total 932 patients reviewed, 33 suffered a postoperative infection. Of 468 patients receiving Coloplast implants, there was a 3.4% infection rate. The most commonly used antibiotic combination before dipping was vancomycin + gentamicin (59.0%). There was a significantly lower rate of postoperative infection, explantation, and revision when vancomycin + gentamicin was used than those associated with the use of all other dipping solutions ([1.4% vs 6.4%; P = .004], [1.1% vs 8.3%; P < .001], and [2.5% vs 12.5; P < .001], respectively). After adjusting for age, body mass index, preoperative blood glucose level, and hemoglobin A1c, the use of other dips was an independent predictor of postoperative infection (odds ratio: 0.191; P = .049). The inclusion of rifampin in the dipping solution trended toward being a significant risk factor for infection (P = .057). Including antifungals in the dipping solution did not affect infection (P = .414), explantation (P = .421), or revision (P = .328) rates. Clinical Implications Vancomycin + gentamicin was the most efficacious combination of antibiotics used for dipping in terms of preventing postoperative infection and subsequent explantation and revision. Strengths and Limitations Data were sampled across multiple institutions providing a large sample that may be more representative of the population of interest. A key limitation of the study was its retrospective nature, which prevented us from controlling certain variables. Conclusion The use of rifampin did not provide the same type of protection, possibly representing a shift in resistance patterns of common bacteria responsible for device infection.

Testicular torsion is a known cause of morbidity in pediatric patients, but the burden in the adult population is poorly understood. We sought to determine the incidence of testicular torsion and risk factors for orchiectomy in a population encompassing all ages. A cohort analysis of 1625 males undergoing surgery for torsion was performed using the 2011 and 2012 Healthcare Cost and Utilization Project Nationwide Emergency Departments Sample. Patient and hospital factors were examined for association with orchiectomy vs. testicular salvage. The estimated yearly incidence of testicular torsion was 5.9 per 100,000 males ages 1-17 years and 1.3 per 100,000 males ≥18 years. Among those undergoing surgical intervention, orchiectomy was performed in 33.6%. The risk of orchiectomy was highest in patients 1-11 years of age and patients over 50 years of age (46.0% and 69.7% of patients, respectively). Orchiectomy was also associated with public insurance (Medicaid/Medicare) or self-pay as primary payer. While testicular torsion is less common in the adult population, the rate of orchiectomy is high. Those with disadvantaged payer status are also at increased risk for testicular loss.

Defining the risks associated with diabetes mellitus in patients undergoing penile prosthesis implantation remains controversial. Our study aims to assess whether preoperative hemoglobin a1c and preoperative blood glucose levels are associated with an increased risk for postoperative infection in diabetic men. We performed a retrospective review of 932 diabetic patients undergoing primary penile prosthesis implantation from 18 high-volume penile prosthesis implantation surgeons throughout the United States, Germany, Belgium, and South Korea. Preoperative hemoglobin a1c and blood glucose levels within 6 h of surgery were collected and assessed in univariate and multivariate models for correlation with postoperative infection, revision, and explantation rates. The primary outcome is postoperative infection and the secondary outcomes are postoperative revision and explantation. In all, 875 patients were included in the final analysis. There were no associations between preoperative blood glucose levels or hemoglobin a1c levels and postoperative infection rates; p = 0.220 and p = 0.598, respectively. On multivariate analysis, a history of diabetes-related complications was a significant predictor of higher revision rates (p = 0.034), but was nonsignificant for infection or explantation rates. We conclude preoperative blood glucose levels and hemoglobin a1c levels are not associated with an increased risk for postoperative infection, revision, or explantation in diabetic men undergoing penile prosthesis implantation.

A lack of uniformity exists for insurance payer coverage for all categories of penile prostheses (PP). We sought to determine common insurance coverage criteria and barriers to implantation across common insurance plans from healthcare referral regions (HRR) nationwide. Coverage criteria and stipulations were reviewed regarding erectile dysfunction (ED) etiology, ED duration, contributing comorbid conditions, medications, drug use, diagnostic tests, use of procedures and prior interventions. Seventy of 100 plans included coverage criteria. 36.1% provided coverage only in cases of gender dysphoria. 27.7% required documentation of trial, contraindication or intolerance to pharmacologic therapy, with varying descriptors of what this entailed. 13.8% required at least consideration of prior pharmacologic therapy. 4.2% required trial or contraindication to classic second-line therapies. 25.0% stated that ED must be organic. Psychogenic ED was covered by 12.5% of plans. Eleven plans required at least 6 or 12 months of symptoms. Laboratory evaluation to rule out hypogonadism or hyperprolactinemia was required by five plans. Insurance coverage criteria for PP placement were highly variable by state and plan. Coverage is provided for PP implantation in most cases for ED of organic etiology following failure of pharmacologic therapy when contributing comorbidities are optimally managed.

To describe recent advances in infection prevention strategies for penile prosthesis surgery. Improvements in surgical technique, antibiotic prophylaxis, prosthetic device design, and patient selection have globally reduced penile prosthesis infection rates. However, current societal antibiotic prophylaxis guidelines may fail to cover all organisms implicated in penile prosthesis infections, particularly fungal and anaerobic pathogens. Although significant strides have been made in reducing penile prosthesis infections, further education and research efforts are needed to continue to prevent this infrequent, but devastating complication. This review discusses recent advances in penile infection understanding and prevention.

Erectile dysfunction management is intended to restore capacity for penile erection. Although effective, none of the currently available treatments approved by the US Food and Drug Administration reverse erectile dysfunction pathophysiology. Penile arterial bypass surgery is intended to restore erectile function without the need for the chronic use of vasoactive medications or penile prosthesis placement. In select cases, venous ligation surgery may be beneficial, but this approach is not supported by the most recent guidelines on erectile dysfunction management. The lack of high-quality research surrounding penile vascular surgery has limited its use.

INTRODUCTION AND OBJECTIVE: COVID-19 has changed the educational landscape precluding in-person surgical training opportunities. We examine the utility and feasibility of remote proctoring for IPP surgical skills training using a full-procedural hydrogel simulation model. METHODS: 9 urology residents at the University of Rochester (PGY 1-4) were paired and remotely proctored by an expert at Boston University using the Zoom web conferencing tool. During IPP training sessions, both participants and proctor were given a model with a full surgical setup. Pre-learning included a narrated full-procedural demonstration by the proctor followed by a full procedure IPP simulation guided by proctor feedback. Pre- and post-training surveys assessed confidence (0-100) and procedural knowledge (15 questions). Opinions on virtual learning and its application to this training session were collected. RESULTS: 66.7% of residents never performed a live IPP placement, while the remaining completed a median (IQR) of 6 cases (4.5-8). All confidence and knowledge measures significantly increased after the remote session (Table 1). Knowledge assessment scores increased by 13% following the remote session, which was reflected in a 48%, 22% and 18% increase in participants' confidence in the ability to perform a simulated IPP procedure, knowledge of IPP procedural steps and applied anatomy respectively. Despite, 77.8% of residents with no prior experience with hands-on virtual training, 100% found remote training valuable and beneficial for learning basic IPP skills and steps of the procedure. The residents highly rated the ability to practice complex skills with zero-patient harm (88.9%), the non-biohazardous nature of the model (66.7%), and having their own hydrogel training model (88.9%). The limitations include single session, lower quality communication and lack of an interface for physical guidance within the virtual environment. CONCLUSIONS: Remote proctoring using a web conferencing tool and non-biohazardous IPP simulation model is feasible with improvement in both confidence and procedural knowledge. Despite its limitations, this approach provides opportunities for hands-on training with remote experts in a safe environment during the cessation of in-person training events.

Background Fungal infections of inflatable penile prostheses (IPPs) are inadequately understood in the literature. Aim To review a multi-institution database of IPP infections to examine for common patient and surgical factors related to IPP fungal infections. Methods This is a retrospective Institutional Review Board–approved analysis of 217 patients at 26 institutions who underwent salvage or device explant between 2001 and 2018. Patient data were compiled after an extensive record review. Outcomes 26 patients (12%) with fungal infections were identified. Results 23 of 26 patients (83%) with a fungal IPP infection were either diabetic or overweight. 15 patients had undergone primary IPP implantation, and the other 11 had previously undergone an average of 1.7 IPP-related surgeries (range 1–3; median 2). The average age at implantation was 63 years (range 31–92; median 63). 18 of the 26 patients with fungal infection had diabetes (69%), with a mean hemoglobin A1c (HbA1c) value of 8.4 (range 5.8–13.3; median 7.5). Twenty-two patients (85%) were overweight or obese. The mean body mass index for all patients was 30.1 kg/m2 (range 23.7–45 kg/m2; median 28.4 kg/m2), and that for diabetic patients was 30.8 kg/m2 (range 24.1–45 kg/m2, median 29.7 kg/m2). Ninety-one percent of implants were placed with intravenous antibiotics, consistent with current American Urological Association guidelines: an aminoglycoside plus first- or second-generation cephalosporin or vancomycin or ampicillin/sulbactam or piperacillin/tazobactam. 65% (17 of 26) of infected IPPs had only fungal growth in culture. No patient had concomitant immunosuppressive disease or recent antibiotic exposure before IPP implantation. Clinical Implications More than two-thirds of the fungal infections occurred in diabetic patients and 85% occurred in overweight or obese patients, suggesting that antifungal prophylaxis may be appropriate in these patients. Strengths & Limitations This is the largest series of fungal infections reported to date in the penile prosthesis literature. The overall number of such cases, however, remains small. Conclusion Fungal infections represent 12% of all penile prosthesis infections in our series and were seen mostly in diabetic or overweight patients, who may benefit from antifungal prophylaxis.

The purpose of this study is to investigate the relationship between inflatable penile prosthesis (IPP) infection, time of year, climate, temperature and humidity. This is a retrospective IRB-approved analysis of 211 patients at 25 institutions who underwent salvage procedure or device explant between 2001 and 2016. Patient data were compiled after an extensive review of all aspects of their electronic medical records. Climate data were compiled from monthly norms based on location, as well as specific data regarding temperature, dew point, and humidity from dates of surgery. Rigorous statistical analysis was performed. We found that penile prosthesis infections occurred more commonly in June (n = 24) and less frequently during the winter months (n = 39), with the lowest number occurring in March (n = 11). One-hundred thirty-nine infections occurred at average daily temperatures greater than 55 °F, compared to 72 infections at less than 55 °F. The incidence rate ratio for this trend was 1.93, with a p-value of

Penile shunting is the standard of care in management of ischemic priapism refractory (IPR) to non-surgical interventions. Due to high rates of impotence, corporal fibrosis, and loss of penile length, recent literature suggests these patients benefit from immediate penile prosthesis (PP) placement. An IRB-exempt anonymous electronic survey of the 2,168 members of the International Society for Sexual Medicine (ISSM) was conducted. The survey included demographic information, confidence and experience related management of IPR. The aim was to evaluate current practice patterns in management of IPR and to investigate the role of immediate PP implantation in the management of prolonged (>36-hours) IPR. The survey response rate was 11.6% (n=251). Most respondents were urologists (173), from the USA (49.1%), and had completed a fellowship in male sexual medicine, men’s health, reconstruction, or andrology (71.1%). The majority (91.3%) see at least one case of prolonged priapism (>36 hours) that requires surgical management yearly. When looking at volume in training and after, our respondents had a significantly higher experience with penile prostheses (over 70%, >=10) as compared to shunts (less than 40%, >=10). Overall, 70.9% of respondents felt more comfortable with a malleable PP than a shunt. However, penile shunts are still preferred as the first line of surgical management by nearly 80% of respondents as compared to 12.7% who instead prefer a PP. We also found that under 40% of respondents currently use penile MRI or corporal biopsies in their management of prolonged assessment. This is the first study to assess current clinical practices in management of IPR globally. As in any anonymous self-reported survey-based research, recall bias, sampling bias are an inherent limitation. Penile shunting for IPR continues to be the preferred treatment despite emerging data. Respondents performed PP surgery routinely and feel more confident placing PP than performing penile shunting procedures.

Introduction The epidemiology of penile fractures in the emergency setting is not well described. Aim Examine the incidence, evaluation, management, risk factors predicting surgical repair or hospital transfer, and use of financial resources in patients presenting with penile fractures to the emergency departments (ED) nationwide in the Unites States. Methods ED visits with a primary diagnosis of penile fractures (International Classification of Diseases, Ninth Edition codes) between 2010-2014 were abstracted from the Nationwide Emergency Department Sample. Main Outcome Measure Penile fracture incidence, disposition, hospital, and clinical factors which were associated with immediate surgical repair or transfer to another institution, and cost were investigated. Results 8,029 ED visits for penile fracture in the United States were observed, which represents a national incidence of 1.02 per 100,000 male subjects per year. No meaningful trends in incidence were observed over the 5-year period. 63.9% were treated non-surgically or discharged from the ED, 25.7% underwent surgical repair, and 10.3% were transferred to other institutions. Hospital factors which predicted surgical repair included Northeast region, teaching hospital status, trauma hospital status, high volume ED, and urban location. Clinical risk factors which predicted surgical repair included hypertension, smoking, alcohol dependence, drug abuse, erectile dysfunction, hematuria, urethral injury, and urinary retention. Factors leading to patient transfers included non-academic, rural and non-trauma hospitals, low economic income and low emergency department volume. In addition, weekend and spring presentation were associated with higher transfer rates, while summer presentation was associated with surgical repair. Clinical Implications A large proportion of penile fractures are discharged from the ED, indicating possible health care access disparity. Strengths & Limitations This is one of the first population-based study of penile fracture incidence, disposition, risk factors which predict surgery or transfer, and cost in the US ED setting. The unexpected high number of discharges may be a result of misdiagnosis; alternatively these data may reveal previously under-reported management patterns in the community. Conclusion This large retrospective study of penile fractures in the US ED setting demonstrates a stable incidence of penile fractures presenting to the US emergency departments. A quarter of patients undergo immediate surgical repair, 10% are transferred to other institutions and 63.9% of patients are discharged home. The high proportion of ED discharges may be due to access to health care disparities.

Introduction Although diabetes mellitus (DM) is often discussed as a risk factor for inflatable penile prosthesis (IPP) infection, the link between DM diagnosis and IPP infection remains controversial. High-quality population-based data linking DM to an increased risk of IPP infection have not been published. Aim To evaluate the association of DM with IPP infection in a large public New York state database. Methods The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for men who underwent initial IPP insertion from 1995–2014. Diabetic patients were identified using ICD-9-CM codes. Patients presenting for first operation with diagnosis or Current Procedural Terminology codes suggestive of prior IPP surgery were excluded. Chi-squared analyses were performed to compare infection rates in diabetics and non-diabetics within the pre- and postantibiotic impregnated eras. Multivariate Cox proportional hazards models were constructed to evaluate whether or not DM was independently associated with IPP infection in the time periods before (1995–2003) and after (2004–2014) the widespread availability of antibiotic impregnated penile prostheses. Main Outcome Measure Time to prosthesis infection was measured. Results 14,969 patients underwent initial IPP insertion during the study period. The overall infection rate was 343/14,969 (2.3%). Infections occurred at a median 3.9 months after implant (interquartile ratio: 1.0–25.0 months). Infectious complications were experienced by 3% (133/4,478) of diabetic patients and 2% (210/10,491) of non-diabetic patients (P < .001). Diabetes was associated with a significantly increased IPP infection risk on multivariable analysis controlling for age, race, comorbidities, insurance status, annual surgeon volume, and era of implantation (Hazard Ratio: 1.32, 95% CI: 1.05–1.66, P = .016). Conclusion Our analysis supports the notion that DM is a risk factor for IPP infection. This has important implications for patient selection and counseling, and raises the question of whether this increased risk can be mitigated by optimization of glycemic control before surgery.

Penile prosthesis (PP) insertion in the setting of corporal fibrosis can be challenging and a variety of techniques have been described to accomplish this, however the necessity of these maneuvers is debatable. Our objective was to investigate techniques and outcomes of PP placement in patients with corporal fibrosis at tertiary referral centers. Multicenter outcomes of 42 patients (mean age 53.4 ± 1.9 years) with corporal fibrosis who underwent placement of PP over a 10-year period were reviewed. The most common etiology of corporal fibrosis was prior PP explant due to either infection (40.5%) and/or erosion (16.7%). Fourteen patients (33.3%) had a history of priapism, 5 (11.9%) of which had one or more distal surgical penile shunts. Techniques used for PP placement included: sequential dilation (8-12 mm) with standard dilators in 15 (35.7%), dilation with cavernotomes in 25 (59.5%) and limited sharp corporal excision and dilation with cavernotomes in 1 (2.4%). Narrow cylinders were employed in ten patients (23.8%). Major complications occurred in one patient (2.4%) who underwent explant for infection and distal erosion. Most patients with corporal fibrosis can undergo successful placement of a PP using standard dilators or cavernotomes. Sharp corporal excision and other measures are rarely required.

American Urological Association (AUA) antibiotic prophylaxis recommendations may be insufficient for covering organisms commonly found in penile prosthesis infections. In this study we assess the difference between AUA recommended antibiotic prophylaxis and nonstandard prophylaxis in preventing device infections in penile prosthesis surgery performed in diabetic patients.A multicenter, retrospective cohort study of diabetic patients undergoing primary penile prosthesis surgery was performed between April 2003 and August 2018. Eighteen institutions from the United States, Europe and Korea contributed. The association between antibiotic prophylaxis type and postoperative penile prosthesis infections, device explantations and revision surgeries was assessed.Standard AUA antibiotic prophylaxis was followed in 48.6% (391) of cases while nonstandard prophylaxis was used in 51.4% (413). Common nonstandard antibiotic prophylaxis included vancomycin-gentamycin-fluoroquinolone, clindamycin-fluoroquinolone, and vancomycin-fluoroquinolone among other combinations. Patients who received AUA prophylaxis had significantly more postoperative device infections (5.6% vs 1.9%, p0.01) and explantations (8.3% vs 2.0%, p0.001) compared to those who received nonstandard prophylaxis. Patients who received AUA prophylaxis had significantly higher odds of a postoperative device infection (OR 2.8, 95% CI 1.1-7.3) and explantation (OR 3.6, 95% CI 1.4-9.1) compared to those who received nonstandard prophylaxis.Diabetic men with erectile dysfunction who received standard AUA prophylaxis for penile prosthesis surgery had significantly greater odds of experiencing a postoperative device infection and device explantation compared to patients who received nonstandard prophylaxis. Our study provides a strong rationale for a prospective investigation to establish the most appropriate prophylaxis strategy in penile prosthesis surgery.

INTRODUCTION AND OBJECTIVE:Erectile dysfunction (ED) is a common and costly urologic condition with increasing prevalence as men age. Penile prosthesis implantation is an effective surgical treatme...

INTRODUCTION AND OBJECTIVE:This video demonstrates a high-fidelity, anatomical, full procedural simulation for placement of a 3-piece IPP.METHODS:Anatomical penile models consisting of a male pelvi...

INTRODUCTION AND OBJECTIVE:Simulation training is particularly relevant in prosthetic urology because of limited training during residency, low prosthetic surgical experience and decreased availabi...

Introduction Scientific literature has experienced a significant growth in the number of authors per publication each year. Erectile dysfunction (ED) is one of the most common urologic conditions, accounting for over 2.9 million outpatient visits per year. Given the prevalence of ED and the large literature base available on this condition, bibliometric analysis of the ED literature could provide urologists and sexual medicine specialists with a better understanding of publication trends in this topic area. Aim The purpose of this study was to investigate trends in authorship, citations, and impact score for ED original and review articles published in urology and sexual medicine journals. Methods We analyzed ED original research and review articles indexed in MEDLINE between January 1, 2006, and December 31, 2016. Descriptive statistics were used to evaluate the mean number of authors for articles by journal type and time period (2006 vs 2016). Linear regression was used to examine the relationship between number of authors, number of citations, and relative citation ratio (RCR). Main Outcome Measure The primary outcomes of interest included mean number of authors, citations, and RCR per manuscript by journal type and time period. Results A total of 3,516 articles were analyzed, 2,938 (83.6%) original and 578 (16.4%) review articles. The mean number of authors among ED publications increased from 4.8 in 2006 to 6.4 in 2016, a 34.4% increase. Original articles had a greater mean number of authors compared to review articles (6.0 vs 4.3, P < .001). The mean number of authors for original articles significantly increased from 5.0 in 2006 to 7.0 in 2016 (P < .001), an increase of 38.9%. A positive linear relationship was observed between mean number of authors and number of citations per manuscript (r = 0.015, P < .01) as well as RCR (r = 0.37, P < .0001). The largest authorship increases were observed in European Urology (78.8%), BJU International (78.6%), and Journal of Sexual Medicine (58.1%). Clinical Implications Authorship trends should be taken into consideration when urologists and sexual medicine experts review ED articles for the purpose of informing patient care. Strength and Limitations Primary strengths include a large literature base spanning multiple years for analysis and a systematic literature search to identify relevant ED literature. Findings are limited to ED literature published in the urology and sexual medicine journals analyzed. Conclusion The number of authors per ED manuscript has significantly increased over time, most notably among original research articles. Increasing authorship was associated with more citations and higher RCR in the ED literature.

Objective To characterize penile prosthesis surgery utilization and assess for regional differences in the use of this procedure across the United States. Materials & Methods We examined penile prosthesis surgeries (inflatable and semirigid implants) in Medicare beneficiaries with erectile dysfunction (ED) for the years 2006 through 2014. Adjusted utilization rates were calculated per 1000 beneficiaries accounting for age and race. Utilization rates were examined nationally and by hospital referral region (HRR). Results The national adjusted rate of penile prosthesis surgery declined from 5.41 per 1000 beneficiaries in 2006 to 3.74 per 1000 beneficiaries in 2014. The number of beneficiaries diagnosed with ED outpaced the number of patients undergoing surgery. Regional variation was observed; a 12-fold difference in 2014 (1.9/1000 in Norfolk, VA to 24.2/1000 in Miami, FL). Adjustment of 2014 data by urology provider density reduced variation between HRRs, and as a result a 3.5-fold difference was observed. Over 60% of HRRs performed 0 to Conclusion The rate of penile prosthesis surgery is declining amongst Medicare beneficiaries with ED. Significant regional variation exists in the utilization of penile prosthesis surgery. This variation may be explained by a series of urologist and patient-specific factors, including provider density. Penile prosthesis surgery in Medicare beneficiaries is likely highly dependent on where these patients seek care.

Introduction: Infections in urologic prosthetic surgery are complex complications for patients and surgeons.

Introduction Penile prosthesis infections remain challenging despite advancements in surgical technique, device improvements, and adoption of antibiotic prophylaxis guidelines. Aim To investigate penile prosthesis infection microbiology to consider which changes in practice could decrease infection rates, to evaluate current antibiotic prophylaxis guidelines, and to develop a proposed algorithm for penile prosthesis infections. Methods This retrospective institutional review board–exempt multi-institutional study from 25 centers reviewed intraoperative cultures obtained at explantation or Mulcahy salvage of infected three-piece inflatable penile prostheses (IPPs). Antibiotic usage was recorded at implantation, admission for infection, and explantation or salvage surgery. Cultures were obtained from purulent material in the implant space and from the biofilm on the device. Main Outcome Measures Intraoperative culture data from infected IPPs. Results Two hundred twenty-seven intraoperative cultures (2002–2016) were obtained at salvage or explantation. No culture growth occurred in 33% of cases and gram-positive and gram-negative organisms were found in 73% and 39% of positive cultures, respectively. Candida species (11.1%), anaerobes (10.5%) and methicillin-resistant Staphylococcus aureus (9.2%) constituted nearly one third of 153 positive cultures. Multi-organism infections occurred in 25% of positive cultures. Antibiotic regimens at initial implantation were generally consistent with American Urological Association (AUA) and European Association of Urology (EAU) guidelines. However, the micro-organisms identified in this study were covered by these guidelines in only 62% to 86% of cases. Antibiotic selection at admissions for infection and salvage or explantation varied widely compared with those at IPP implantation. Conclusion This study documents a high incidence of anaerobic, Candida, and methicillin-resistant S aureus infections. In addition, approximately one third of infected penile prosthesis cases had negative cultures. Micro-organisms identified in this study were not covered by the AUA and EAU antibiotic guidelines in at least 14% to 38% of cases. These findings suggest broadening antibiotic prophylaxis guidelines and creating a management algorithm for IPP infections might lower infection rates and improve salvage success.

Inflatable penile prosthesis (IPP) surgery is an effective, safe and satisfactory treatment option for medication-refractory erectile dysfunction. Postoperative complications include infection, mechanical failure, erosion, and pain. Current literature suggests the need for a better approach to postoperative pain management after IPP surgery. Clinical studies have demonstrated that postoperative pain is different in diabetic patients. We sought to determine if there is a difference in pain after IPP placement in diabetics. This is a single-institution retrospective review. The main outcome measure was the number of 30-day postoperative visits for pain. The secondary outcome included differences in how pain was managed. The top HbA1c quartile was compared with the other HbA1c quartiles. Diabetes was present in 92 (54.4%) patients and 96% of these had HbA1c 8. Significant postoperative pain was more common in patients with HbA1c 8 (41% vs 13%, p = 0.047) and resulted in more unplanned visits (27% vs 11%, p = 0.042). Patients with HbA1c 8 with significant postoperative pain were more likely to be managed with opioids and gabapentin (30% vs 14%, p = 0.05). There were no statistical differences in age between diabetics and non-diabetics (mean 59 vs 61, p = 0.193). Hispanic and African-American patients represented 87% of the poorly controlled diabetics compared with only 13% of white patients (p 0.001). Poorly controlled diabetics had more medical comorbidities (p 0.001). On logistic regression, a HbA1c 8 was predictive of an unplanned visit for pain with an OR of 2.83 (p = 0.04). Significant pain after IPP surgery was higher in diabetics with HbA1c 8, which resulted in more unplanned 30-day postoperative visits. Patients with significant postoperative pain were managed with a combination of opioids and gabapentin. Future studies are required to optimize pain management in diabetics following IPP placement.

Inflatable penile prostheses are an important tool in the treatment of medically refractory erectile dysfunction. One of the major complications associated with these prostheses is infections, which ultimately require device explanation and placement of a new device. Over the past several decades, significant work has been done to reduce infection rates and optimize treatment strategies to reduce patient morbidity. This article reviews the current state of knowledge surrounding penile prosthesis infections, with attention to the evidence for methods to prevent infection and best practices for device reimplantation.

Intracavernosal self-injection (ICI) is an effective treatment for erectile dysfunction. A rare but serious complication is needle breakage. We report an unusual case of a 51-year-old transgender female patient who did not desire gender-affirming surgery, and used ICI to treat her longstanding erectile dysfunction. She presented to the emergency department 2 months after needle breakage during ICI, and was subsequently successfully treated with intraoperative fluoroscopy and needle fragment extraction. It is important to recognize transgender patients may desire to preserve sexual function, and for providers to engage in discussion surrounding sexual health throughout treatment for gender dysphoria.

The epidemiology of genitourinary foreign bodies (GUFB) has been mainly described through case reports and small series. The aim of this study is to investigate the epidemiologic, medical, and socioeconomic factors associated with GUFB, along with the resultant costs of care in emergency departments (EDs) nationwide. ED visits with the primary diagnosis of a GUFB between 2010 and 2014 were abstracted from the Nationwide Emergency Department Sample database. Between 2010 and 2014, a weighted estimate of 102,333 visits to the ED with GUFB were recorded in the US, representing a national incidence of 7.6 ED visits per 100,000 persons. Of these visits, 4.7% resulted in admission and males were more likely to be admitted (24.8% vs. 2.1%, p

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Intracavernosal injection therapy (ICI) was the first pharmacologic treatment in the management of erectile dysfunction. ICI allows for customization of medication composition and concentrations, making it a highly effective treatment with an acceptable side effect profile. The objective was to investigate the long-term results of ICI using validated and non-validated instruments. This is a retrospective, single-institution study of 105 patients (mean age 61.6 ± 11.1) patients using ICI. Mean duration of ICI was 8.4 ± 6.25 years. Pre- and post-treatment patient-reported penile rigidity were 41.1% ± 29.3 and 89.6% ± 13.6, respectively (p

INTRODUCTION AND OBJECTIVES:The epidemiology of penile fractures in the emergency setting is not well described. Aim of this study is to examine the incidence, evaluation, management and use of fin...

INTRODUCTION AND OBJECTIVES:Recent reports have suggested that pre-operative diabetic control may be predictive of infection rates following penile prosthesis (PP) implantation. In this study, we s...

INTRODUCTION AND OBJECTIVES:The most devastating complication following penile prosthesis (PP) implantation is an infection requiring device explantation. Current AUA guidelines recommend antibioti...

INTRODUCTION AND OBJECTIVES:Constraints on surgical resident training and inequalities in the availability of expert surgical educators may limit the acquisition of prosthetic surgical skills. As a...