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Mohammad Alkhamees,1 Meshari A Al-Zahrani,1 Sulaiman Almutairi,1 Hammam Alkanhal,1 Mana Almuhaideb,2 Saad M Abumelha3– 5 1Department of Urology, College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia; 2College of Medicine, King Saud University, Riyadh, Saudi Arabia; 3Division of Urology, Department of Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia; 4King Abdullah International Medical Research Center (KAIMRC), Riyadh 11426, Saudi Arabia; 5College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 11426, Saudi ArabiaCorrespondence: Mohammad AlkhameesDepartment of Urology, College of Medicine, Majmaah University, Al-Majmaah 11952, Saudi ArabiaTel +966-554463808Fax +966-164042500Email m.alkhamees@mu.edu.saPurpose: This study evaluated the study habits of Saudi urology residents throughout their residency training. It examines the study time and quality of study materials used by Saudi urology residents and identifies ways to maximize study benefits.Patients and Methods: An online questionnaire was distributed to 152 registered residents in regions throughout Saudi Arabia (response rate: 93.4%). The questionnaire addressed study habits throughout training, motivations for studying, preferred study resources, impressions on teaching quality, study preparation methods, and exam preparedness among junior and senior residents.Results: Among all residents, 37.3% read for 2– 5 hours weekly. Juniors read significantly more than seniors (P = 0.034). Marital status affects seniors’ study habits (P = 0.029). For most seniors, preparation for the final board exam is the greatest motivation for studying (P = 0.006). The AUA/EAU guidelines were useful information source for seniors (P = 0.001). Fifty-four percent (54.4%) of residents felt that their residency program did not provide protected study time prior to the board exams. Moreover, the majority (64.8%) felt that the training program did not adequately prepare them for the board exams.Conclusion: We recommend that local program directors implement more effective teaching methods. Structured reading habits and specific study materials were found to be positive predictors of successful performance. Residents should also be educated in balancing working hours, social life, and study.Keywords: resident, study habits, Saudi Arabia, urology

Purpose: Non-obstructive azoospermia (NOA) is a common, but complex problem, with multiple therapeutic options and a lack of clear guidelines. Hence, there is considerable controversy and marked variation in the management of NOA. This survey evaluates contemporary global practices related to medical and surgical management for patients with NOA., Materials and Methods: A 56-question online survey covering various aspects of the evaluation and management of NOA was sent to specialists around the globe. This paper analyzes the results of the second half of the survey dealing with the management of NOA. Results have been compared to current guidelines, and expert recommendations have been provided using a Delphi process., Results: Participants from 49 countries submitted 336 valid responses. Hormonal therapy for 3 to 6 months was suggested before surgical sperm retrieval (SSR) by 29.6% and 23.6% of participants for normogonadotropic hypogonadism and hypergonadotropic hypogonadism respectively. The SSR rate was reported as 50.0% by 26.0% to 50.0% of participants. Interestingly, 46.0% reported successful SSR in <10% of men with Klinefelter syndrome and 41.3% routinely recommended preimplantation genetic testing. Varicocele repair prior to SSR is recommended by 57.7%. Half of the respondents (57.4%) reported using ultrasound to identify the most vascularized areas in the testis for SSR. One-third proceed directly to microdissection testicular sperm extraction (mTESE) in every case of NOA while others use a staged approach. After a failed conventional TESE, 23.8% wait for 3 months, while 33.1% wait for 6 months before proceeding to mTESE. The cut-off of follicle-stimulating hormone for positive SSR was reported to be 12-19 IU/mL by 22.5% of participants and 20-40 IU/mL by 27.8%, while 31.8% reported no upper limit., Conclusions: This is the largest survey to date on the real-world medical and surgical management of NOA by reproductive experts. It demonstrates a diverse practice pattern and highlights the need for evidence-based international consensus guidelines., Competing Interests: The authors have nothing to disclose., (Copyright © 2024 Korean Society for Sexual Medicine and Andrology.)

Purpose: Sperm DNA fragmentation (SDF) is a functional sperm abnormality that can impact reproductive potential, for which four assays have been described in the recently published sixth edition of the WHO laboratory manual for the examination and processing of human semen. The purpose of this study was to examine the global practices related to the use of SDF assays and investigate the barriers and limitations that clinicians face in incorporating these tests into their practice., Materials and Methods: Clinicians managing male infertility were invited to complete an online survey on practices related to SDF diagnostic and treatment approaches. Their responses related to the technical aspects of SDF testing, current professional society guidelines, and the literature were used to generate expert recommendations via the Delphi method. Finally, challenges related to SDF that the clinicians encounter in their daily practice were captured., Results: The survey was completed by 436 reproductive clinicians. Overall, terminal deoxynucleotidyl transferase deoxyuridine triphosphate Nick-End Labeling (TUNEL) is the most commonly used assay chosen by 28.6%, followed by the sperm chromatin structure assay (24.1%), and the sperm chromatin dispersion (19.1%). The choice of the assay was largely influenced by availability (70% of respondents). A threshold of 30% was the most selected cut-off value for elevated SDF by 33.7% of clinicians. Of respondents, 53.6% recommend SDF testing after 3 to 5 days of abstinence. Although 75.3% believe SDF testing can provide an explanation for many unknown causes of infertility, the main limiting factors selected by respondents are a lack of professional society guideline recommendations (62.7%) and an absence of globally accepted references for SDF interpretation (50.3%)., Conclusions: This study represents the largest global survey on the technical aspects of SDF testing as well as the barriers encountered by clinicians. Unified global recommendations regarding clinician implementation and standard laboratory interpretation of SDF testing are crucial., Competing Interests: The authors have nothing to disclose., (Copyright © 2024 Korean Society for Sexual Medicine and Andrology.)

Purpose: Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition., Materials and Methods: An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method., Results: A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4-6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated., Conclusions: This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians., Competing Interests: The authors have nothing to disclose., (Copyright © 2023 Korean Society for Sexual Medicine and Andrology.)

Purpose: Sperm DNA fragmentation (SDF) testing was recently added to the sixth edition of the World Health Organization laboratory manual for the examination and processing of human semen. Many conditions and risk factors have been associated with elevated SDF; therefore, it is important to identify the population of infertile men who might benefit from this test. The purpose of this study was to investigate global practices related to indications for SDF testing, compare the relevant professional society guideline recommendations, and provide expert recommendations., Materials and Methods: Clinicians managing male infertility were invited to take part in a global online survey on SDF clinical practices. This was conducted following the CHERRIES checklist criteria. The responses were compared to professional society guideline recommendations related to SDF and the appropriate available evidence. Expert recommendations on indications for SDF testing were then formulated, and the Delphi method was used to reach consensus., Results: The survey was completed by 436 experts from 55 countries. Almost 75% of respondents test for SDF in all or some men with unexplained or idiopathic infertility, 39% order it routinely in the work-up of recurrent pregnancy loss (RPL), and 62.2% investigate SDF in smokers. While 47% of reproductive urologists test SDF to support the decision for varicocele repair surgery when conventional semen parameters are normal, significantly fewer general urologists (23%; p=0.008) do the same. Nearly 70% would assess SDF before assisted reproductive technologies (ART), either always or for certain conditions. Recurrent ART failure is a common indication for SDF testing. Very few society recommendations were found regarding SDF testing., Conclusions: This article presents the largest global survey on the indications for SDF testing in infertile men, and demonstrates diverse practices. Furthermore, it highlights the paucity of professional society guideline recommendations. Expert recommendations are proposed to help guide clinicians., Competing Interests: The authors have nothing to disclose., (Copyright © 2023 Korean Society for Sexual Medicine and Andrology.)

Introduction: Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, there have been some reports regarding the impact of COVID-19 on male psychosexual health. Aims and Objectives: To assess the severity of stress during COVID-19 and to determine the association of stress levels with partner relationships and sexual activity. Methodology: A cross-sectional study was conducted in Saudi Arabia through social media platforms via an online questionnaire between 1 December 2020 and 31 January 2021 among 871 participants after a pilot study among 20 participants, of which 497 were included in the study. Stress levels were assessed using the Arabic version of the Depression, Anxiety, and Stress Scale (DASS-21). Statistical analysis was conducted using SPSS version 20.0. Responses were presented as frequencies and percentages, and associations were studied using the Chi-squared test/Fisher’s exact test. A value of p ≤ 0.05 was considered significant. Results: A total of 497 participants who had been infected with COVID-19 completed the survey. In total, it was found that 203 (40.8%) had severe stress scores (severe and extremely severe scores merged), while 131 (26.4%) had moderate stress scores. About 84 (16.9%) participants agreed that their sexual desire decreased, 91 (18.1%) confirmed their sexual intercourse frequency decreased, and sexual satisfaction decreased in 76 (15.3%). A significant positive correlation was found in that those who disagreed with having a good sexual relationship tended to have severe stress (p < 0.001). Conclusion: There were increased levels of stress during the lockdown period, which impacted psychosexual health.

Objective: Our aim was to assess sexual activity, partner relationships among males who had been infected with COVID-19, to study the impact of COVID-19 infection on partner relationship and to find out the association between partner and sexual relationship during lockdown., Materials and Methods: A cross sectional study was conducted in Saudi Arabia through social media platforms via online questionnaire between December 1, 2020 and January 31, 2021 among 871 participants after a pilot study among 20 participants of which 497 were included in the study. Statistical analysis was conducted using SPSS version 20.0 (IBM Inc., Armonk, NY, USA). Responses were presented as frequencies and percentages and the association was studied using Chi squared test/Fisher's exact test. The value of p ≤ .05 was considered significant., Results: Out of the total study participants, nearly 85% of them belonged to the age range of 18 to 39 years, more than half of the participants were married. In the six months prior to the study being conducted, 268 respondents (53.9%) did not have sexual relationships. Respondents with positive COVID-19 infection reported that their partner lived with them in the same house during home isolation and was also found to be significantly associated with having intact sexual relationships in the last six months of the lockdown period (p-value < .001). Moreover, respondents who reported having good relationships with their partners during the pandemic were found to be significantly associated with having intact sexual relationships during the pandemic lockdown (p-value < .001)., Conclusions: Among the COVID-19-positive respondents, sexual activity and partner relationships were largely found to be intact during the pandemic lockdown period.

Background: Empirical therapy is sometimes used by urologists who desire to improve the outcomes for infertility patients. However, the literature on empirical therapies is scarce. Therefore, we aimed to assess the clinical practice of urologists regarding the use of empirical therapy in the treatment of infertility patients., Methodology: An online survey using Google Forms was used to collect data during the Saudi Urological Association Annual Meeting, February 2019. Additional data were gathered electronically in March and April 2019 and sent to respondents. The study was closed in May 2019. No incentives were provided to the respondents., Results: A total of 96 (80%) urologists participated in the survey, of whom 69.8% were consultants, and 20.8% were andrology-trained urologists. Empirical therapy was used by 86.5% of urologists for patients with idiopathic oligoasthenoteratozoospermia. The most commonly used empirical therapies were zinc, L-canitine, clomiphene citrate, and L-arginine. The main factors that influenced the selection of empirical therapy were follicle-stimulating hormone, total testosterone, and luteinizing hormone levels., Conclusion: Empirical therapy was used by more than three-quarters of the participants for idiopathic male infertility. There were no clear guidelines for the ideal therapy to be considered for individual patients while treating empirically. Our concern is that urologists use a wide variety of medications without significant data to support these medications., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Urology Annals.)

Background: Surgery is considered the most effective treatment for Benign prostatic hyperplasia (BPH) and Transurethral resection of prostat (TURP) is considered the gold standard. The goal of this study is to assess the surgical interventions used in Saudi Arabia, the difference in surgical procedures done depending on age and years of experience and the participant's impression on the new modalities in the management of BPH., Methodology: An online survey using Google Forms was sent to the participants. The data were collected during Saudi Urological Association Annual Meeting February 2019. Additional data were gathered 2 months later. The study was closed in May 2019. No incentives were provided to participants., Results: A total of 65 (54.1% response rate) urologist participated in the survey, of whom 41.5% of respondents were aged <40 years, while 40% of them aged between 40 and 60 years. Forty-seven (72.3%) out of 65 were consultants. The essential investigations used by most participants prior to surgical interventions are prostate specific antigen, urine culture, urinalysis, and abdominal ultrasound. The most used surgical interventions are unipolar transurethral resection (TURP), Bipolar TURP, and open prostatectomy. About 50% of respondents preferred open prostatectomy for prostate size above 100 g. In general, 40%-50% of participants believe that urethral lift, Rezum, Aquablation, prostate artery embolization, and robotic simple prostatectomy are useful options., Conclusion: TURP continues to be the main intervention for prostate sizes <100 g. Open prostatectomy is widely used intervention for prostate sizes more than 100 g. New modalities gained little acceptance among urologist practicing in Saudi Arabia. Hands on workshops may help in educating urologists and introduce these new modalities for the future use., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Urology Annals.)

Objective: The aim of this study is to determine the methods used to evaluate and manage urethral strictures by urologists practicing in Saudi Arabia., Materials and Methods: This is a cross-sectional study based on a validated questionnaire directed to all urologists and senior residents practicing in Saudi Arabia. Categorical data reported as frequencies and percentages. A Chi-square test was used for inferential analysis. P < 0.05 was considered statistically significant., Results: We received 112 responses, of which 78% were from board-certified urologists. The majority were working in government hospitals. The rate of endoscopic procedures performed exceeded open urethroplasty. Direct Vision Internal Urethrotomy was the most common procedure performed as stated by 85% of the responses. Uroflowmetry with postvoid residual was the most common investigation requested to assess strictures before and after the operation usually in adjunction with retrograde urethrogram and or cystoscopy. Most of the urologists believed in a step-wise approach in the management of strictures and that urethroplasty is indicated only after repeated trials of endoscopic management., Conclusion: Our results revealed a preference, and perhaps misuse, of endoscopy which might raise a concern regarding patients' prognosis with repeated endoscopic management. Most of the urologists seem to be reluctant to proceed to a definitive treatment on the time of diagnosis either due to a lack of experience or knowledge. The results showed no difference between practice in government and private hospitals., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Urology Annals.)