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Prolonged ischemic priapism presents a treatment challenge given the difficulty in achieving detumescence and effects on sexual function. To evaluate current practice patterns, an open, web-based multi-institutional survey querying surgeons' experience with and perceived efficacy of tunneling maneuvers (corporoglanular tunneling and penoscrotal decompression), as well as impressions of erectile recovery, was administered to members of societies specializing in male genital surgery. Following distribution, 141 responses were received. Tunneling procedures were the favored first-line surgical intervention in the prolonged setting (99/139, 71.2% tunneling vs. 14/139, 10.1% implant, p < .001). Although respondents were more likely to have performed corporoglanular tunneling than penoscrotal decompression (124/138, 89.9% vs. 86/137, 62.8%, p < .001), penoscrotal decompression was perceived as more effective among those who had performed both (47.3% Very or Extremely Effective for penoscrotal decompression vs. 18.7% for corporoglanular tunneling; p < .001). Many respondents who had performed both tunneling procedures felt that most regained meaningful sexual function after either corporoglanular tunneling or penoscrotal decompression (33/75, 44.0% vs. 33/74, 44.6%, p = .942). While further patient-centered investigation is warranted, this study suggests that penoscrotal decompression may outperform corporoglanular tunneling for prolonged priapism, and that recovery of sexual function may be higher than previously thought after tunneling procedures., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Objective: To evaluate influencing factors of preference signaling (PS) among urology residency applicants during the 2022 American Urological Association (AUA) Match., Methods: We emailed an anonymous, deidentified questionnaire survey to applicants to our institution for the 2022 AUA Match. The main question asked to applicants was "What factor(s) went into your decision to send 'Program X' a preference signal?" Certain questions allowed the selection of multiple options, and applicants were further asked to specify these by selecting a single most important option. Descriptive statistical analyses were conducted using IBM SPSS software., Results: Out of 601 registrants to the AUA match, 324 individuals applied to our institution and therefore received a survey; 77 responded for a 24% response rate. A total of 383 PS were sent by the 77 applicants. Overall, 73% and 49% of the total 383 PS had program location and reputation, respectively, selected as an influencing factor. More than 1 influencing factor was considered in 73% of PS selections, with program location (45%) considered the most important factor. In relation to applicant competitiveness, 35% of PS were sent to perceived "target" programs, 31% to "reach" programs, and 8% to "safety" programs. Among respondents who matched, 75% matched at a home, away, or signaled program., Conclusion: Program location appears to be the most influential factor in sending a program a PS. Programs were also signaled based on applicant's perception of their own competitiveness. PS appears to have a possible beneficial impact on obtaining interviews and successfully matching., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To characterize the most common presentation and clinical risk factors for artificial urinary sphincter (AUS) cuff erosion to distinguish the relative frequency of symptoms that should trigger further evaluation in these patients., Materials and Methods: We retrospectively reviewed our tertiary center database to identify men who presented with AUS cuff erosion between 2007 - 2020. A similar cohort of men who underwent AUS placement without erosion were randomly selected from the same database for symptom comparison. Risk factors for cuff erosion - pelvic radiation, androgen deprivation therapy (ADT), high-grade prostate cancer (Gleason score ≥ 8) - were recorded for each patient. Presenting signs and symptoms of cuff erosion were grouped into three categories: obstructive symptoms, worsening incontinence, and localized scrotal inflammation (SI)., Results: Of 893 men who underwent AUS placement during the study interval, 61 (6.8%) sustained cuff erosion. Most erosion patients (40/61, 66%) presented with scrotal inflammatory changes including tenderness, erythema, and swelling. Fewer men reported obstructive symptoms (26/61, 43%) and worsening incontinence (21/61, 34%). Men with SI or obstructive symptoms presented significantly earlier than those with worsening incontinence (SI 14 ± 18 vs. obstructive symptoms 15 ± 16 vs. incontinence 37 ± 48 months after AUS insertion, p<0.01). Relative to the non-erosion control group (n=61), men who suffered erosion had a higher prevalence of pelvic radiation (71 vs. 49%, p=0.02)., Conclusion: AUS cuff erosion most commonly presents as SI symptoms. Obstructive voiding symptoms and worsening incontinence are also common. Any of these symptoms should prompt further investigation of cuff erosion., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Objective: To determine whether a patient's health literacy impacts patient satisfaction following inflatable penile prosthesis (IPP) or artificial urinary sphincter (AUS) placement., Materials and Methods: A retrospective study of patients who underwent IPP or AUS between January 1, 2016 and July 31, 2020 was performed. A telephone questionnaire assessed overall satisfaction and if patients would undergo surgery again. Health literacy was measured using the Brief Health Literacy Screen (BHLS). Multivariate ordinal logistic regression was used to assess the association between health literacy and patient satisfaction., Results: At a median follow up of 2.4 years, 113 (70%) of the 162 IPP patients were either satisfied or very satisfied with their procedure and 120 (74%) patients would undergo surgery again. Of the 76 AUS patients, 65 (86%) were either satisfied or very satisfied with their procedure and 65 (86%) patients would undergo surgery again. After adjustment for potential confounders, increasing BHLS score was significantly associated with satisfaction for both IPP (OR 1.31, 95% CI 1.11-1.54; P = .001) and AUS surgery (OR 1.25, 95% CI 1.02-1.56; P = .034), as well as with likelihood of undergoing IPP surgery again (OR 1.53, 95% CI 1.25-1.87; P <.001). BHLS was not associated, however, with likelihood of undergoing AUS surgery again (P = .403)., Conclusion: Men with lower health literacy are less likely to be satisfied following prosthetic surgery. The BHLS is an important tool that can be used to identify patients who may benefit from increased preoperative counseling to improve patient expectations and quality of life following prosthetic surgery., Competing Interests: Declaration of conflicts of interest National Principal Investigator for Boston Scientific (MRK); Consultant Boston Scientific (DFM), (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To evaluate the clinical and prognostic details of periurethral abscess (PUA) formation following urethroplasty (UP)., Methods: A retrospective review was performed to identify men who developed PUA after UP between 2007 and 2019 at a single tertiary care referral center. Patient demographics, stricture characteristics, and UP technique were recorded. Outcomes included time to PUA, presenting symptoms, wound cultures, imaging, and ultimate management. Comparative analysis between PUA and non-PUA patients was performed using Fisher's Exact test and Student's t-test., Results: Among 1499 UP cases, 9 (0.6%) developed PUA. Mean stricture length was 4.6 cm with most located in the bulbar urethra (5/9, 56%), while 4/9 (44%) had undergone prior UP. PUA rates were 7/288 (2.4%) and 2/815 (0.3%) for substitution and anastomotic UP respectively. Voiding cystourethrogram (VCUG) demonstrated extravasation in 67% (4/6) of available UP cases imaged. Subsequent VCUG confirmed leak improvement or resolution in all cases. Wound cultures were frequently polymicrobial (4/6, 67%). Management included antibiotics with (6/9) and without (3/9) incision and drainage (I/D). Urinary drainage was performed in 5 patients using suprapubic tube (3/5) and foley placement (2/5). PUA resolution was observed in all patients while stricture symptom recurrence was observed in 2/9 (22%) patients with mean time to recurrence of 15 months. Overall mean follow-up time was 22 months., Conclusion: PUA is a rare complication of UP that may be more common in setting of postoperative urine leak. PUA is safely managed with I/D, urethral rest, and antibiotics, with low risk of recurrent stricture formation thereafter., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To evaluate the distance from critical pelvic structures (CPS, defined as bladder and iliac vessels) among inflatable penile prosthesis (IPP) reservoirs placed into the space of Retzius (SOR) and high submuscular (HSM) locations using cross-sectional imaging. IPP reservoir placement into the HSM location has been proposed as a strategy to prevent injury due to greater distance from CPS., Methods: Our institutional database was retrospectively reviewed to identify men who underwent IPP insertion between 2007 and 2020 and had available cross-sectional abdominopelvic imaging after the time of surgery. Patients were grouped based on reservoir placement technique (SOR vs. HSM). Staff radiologists blinded to placement technique evaluated reservoir position to determine the shortest distance between CPS and the reservoir and if a mass effect was present on CPS. Variables were analyzed using chi-squared, Fisher's exact, and student's T-tests as indicated., Results: Among 1,010 IPP cases performed during the study interval, 139 (13%) were imaged. Compared with SOR reservoirs (n = 32), HSM reservoirs (n =107) were significantly less likely to induce a mass effect on the bladder (72 vs. 9%, P = <.01) or iliac vessels (34 vs. 4%, P = <.01) and were located roughly 5 times further from the bladder (10 ± 22 vs. 49 ± 36 mm, P = <.01) and iliac vessels (5 ± 9 vs. 23 ± 26 mm, P = <.01)., Conclusion: This study radiographically confirms that IPP reservoirs are located significantly further away from CPS following HSM placement compared to SOR placement., Competing Interests: Conflict of Interest Please copy this Conflict of Interest form and paste into your word processing software, type in each author and either indicate “no conflict” or specify any conflicts; it will be required that you submit the completed form (with all authors indicated) with the revised manuscript. Please list only conflicts of interest specific to this manuscript.Mehraban Kavoussi: No ConflictGrayden S. Cook: No ConflictShaun M. Nordeck: No ConflictBenjamin M. Dropkin: No ConflictGregory A. Joice: No ConflictSarah C. Sanders: No ConflictSteven J. Hudak: Dr. Steven Hudak is a paid speaker and consultant for Boston Scientific CorporationJeffrey H. Pruitt: No ConflictAllen F. Morey: Dr. Allen Morey receives honoraria for being a guest lecturer/meeting participant for Boston Scientific and Coloplast Corp., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aims: To examine the rate of lower urinary tract complications (LUTC) and urinary diversion (UD) after artificial urinary sphincter (AUS) explantation with the acute reconstruction of AUS cuff erosion defects., Methods: We performed a retrospective study of patients who underwent in-situ urethroplasty (ISU) for AUS cuff erosion from June 2007 to December 2020. Outcomes included LUTC (urethral stricture, diverticulum, fistula), AUS reimplantation, and UD. Defect size was prospectively estimated acutely and a subanalysis was performed to determine the impact of erosion severity (small erosions [<33% circumferential defect] and large erosions [≥33%]) on these outcomes. Kaplan-Meier curves were created to compare survival between the two groups., Results: A total of 40 patients underwent ISU for urethral cuff erosion. The median patient age was 76 years old with a median erosion circumference of 46%. The overall LUTC rate was 30% (12/40) with 35% (14/40) of patients requiring permanent UD. Secondary AUS placement occurred in 24/40 (60%) patients with 11/24 (46%) leading to repeat erosion. On subanalysis, small erosion was associated with improved LUTC-free and UD-free survival but not associated with AUS reimplantation., Conclusions: Lower urinary tract complications are common after AUS cuff erosion and can lead to the need for permanent UD. Patients with larger erosions are more likely to undergo UD and reach this end-stage condition earlier compared to patients with small erosions., (© 2021 Wiley Periodicals LLC.)

Objectives: To report our initial experience with the extra-tunical grafting (ETG) procedure. This procedure was recently introduced by UCSF investigators as a tunica-sparing technique for management of penile concavity deformities., Methods: We retrospectively reviewed records of patients who underwent ETG at our tertiary-care referral center between 2017 - 2020.  A collagen graft made from bovine pericardium (Lyoplant) was placed overlying the defect without violating the tunica albuginea or mobilizing the neurovascular bundle. The stretched penile length (SPL) and circumference at the location of deformity were measured intra-operatively. Patient reported outcomes were evaluated by an anonymous 10-question online survey., Results: 19 men underwent ETG with a median follow-up of 59 (IQR: 24 - 708) days. ETG was performed via either a window (15/19, 78%) or a de-gloving (4/19, 21%) incision with concomitant penile plication performed in 16/19 (84%) patients. Penile circumference increased by an average of 1.4 cm + 0.5 (P = 0.03) at the location of deformity, while pre- and post-operative SPL were similar (14.0 + 1.4 vs 14.0 + 1.3 cm, P = 0.95). Overall patient satisfaction was reported by 13/15 (86%) patients. Twelve out of 15 (80%) patients reported concavity deformity to be "improved", with 73% reporting "much better". Among 8 patients with follow up greater than six months, graft palpability was reported in 4/8 (50%) patients but was not bothersome., Conclusion: The ETG procedure appears to be safe and effective for the treatment of penile concavity deformities.  Patient outcomes and satisfaction are favorable at intermediate follow up., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Previously, incisionless plication (IP) for correction of congenital penile curvature (CPC) has been performed after penile degloving via a circumscribing incision., Aim: To describe our experience with non-degloving incisionless penile plication (NDIP) for correction of CPC and compare these outcomes with those of men who underwent degloving incisionless penile plication (DIP)., Methods: We conducted a retrospective review of men ≤ 45 years of age who underwent incisionless penile plication for correction of CPC between 2008 and 2020 at two adult tertiary hospitals. Patients underwent either NDIP, performed through a 2-3 cm longitudinal incision along the proximal-to-mid shaft opposite the point of maximum penile curvature, or DIP via a sub-coronal circumscribing incision., Main Outcome Measures: Surgical and patient-reported outcomes were compared between the non-degloving and degloving groups., Results: Among the 38 men (mean age, 26 years) who met the inclusion criteria, 25 underwent NDIP, including 6 patients with biplanar curvature (2 Ventral, 4 Dorsal, 6 Lateral). Thirteen patients underwent DIP, including 1 patient with biplanar curvature (1 ventral, 1 lateral). Curvature reduction was 50 ± 23 degrees for the NDIP group and 36 ± 10 degrees for the DIP group (P = .04). Five (20%) patients in the NDIP group and nine (69%) patients in the DIP group experienced a reduction in stretched penile length following plication (SPL) (P = .01). One patient in the NDIP group underwent an additional plication for recurrent curvature., Conclusion: Both NDIP and DIP are safe and highly efficacious techniques for the correction of CPC. Kusin SB, Khouri RK, Dropkin BM, et al., Plication for Correction of Congenital Penile Curvature: With or Without Degloving?. Sex Med 2021;9:100462., (Copyright © 2021 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Inflatable penile prosthesis (IPP) reservoirs are typically placed into the Space of Retzius (SOR) or alternative locations including the High Submuscular (HSM) space via transinguinal (TI) or counter incision (CI) techniques. A cadaver study showed variability in reservoir location after TI-HSM placement., Aim: To evaluate reservoir location using cross-sectional imaging following IPP insertion., Methods: We retrospectively reviewed our institutional database and identified men who underwent virgin penoscrotal IPP insertion between 2007 and 2019. We then identified those men who subsequently underwent cross-sectional imaging prior to October 2019. Radiologists evaluated cross-sectional imaging in a blinded manner and categorized reservoir locations as follows: 1) submuscular; 2) posterior to the external oblique fascia and lateral to the rectus abdominis musculature; 3) preperitoneal; 4) retroperitoneal; 5) intraperitoneal; 6) inguinal canal; 7) subcutaneous. Patients were stratified by reservoir placement technique, transinguinal space of Retzius (TI-SOR), transinguinal high submuscular (TI-HSM), or counterincision high submuscular (CI-HSM). Clinical characteristics and outcomes were reviewed and compared. Statistical analysis was performed using Chi-squared and Fisher's exact tests., Outcomes: Variability exists in the TI placement of SOR and HSM reservoirs, CI-HSM reservoirs were associated with a low level of variability., Results: Among 561 men who underwent virgin IPP insertion during the 12-year study period, 114 had postoperative cross-sectional imaging (29 TI-SOR, 80 TI-HSM, and 5 CI-HSM). Among the 114 patients imaged, TI-HSM reservoirs were more likely than TI-SOR to be located anterior to the transversalis fascia (48 vs 14%, P < .01) and were less likely to be located in the preperitoneal space (18 vs 62%, P < .01). Rates of intraperitoneal reservoir location were similar between the TI-HSM and TI-SOR groups (5 vs 7%, P = .66). Among imaged CI-HSM reservoirs, 4 (80%) were anterior to the transversalis fascia and 1 (20%) was within the inguinal canal. Among all 536 transinguinal cases (131 TI-SOR and 405 TI-HSM), rates of reservoir-related complications requiring operative intervention were similar between groups (5 vs 2%, P = .24). No complications were noted among the 25 patients in the CI-HSM cohort., Clinical Implications: The level of variability seen in this study did not seem to impact patient safety, complications were rare in all cohorts., Strengths and Limitations: This study is the first and largest of its kind in evaluating reservoir positioning in live patients with long-term follow-up. This study is limited in its retrospective and nonrandomized nature., Conclusions: Despite variability with both TI-HSM and TI-SOR techniques, reservoir related complications remain rare. Kavoussi M, Cook G, Nordeck S, et al. Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice. J Sex Med 2021;18:2039-2044., (Copyright © 2021 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine association between post-prostatectomy incontinence (PPI) severity and weight changes before and after restoration of continence via artificial urinary sphincter (AUS)., Methods: Single surgeon, retrospective review of urologic prosthetic surgery (UPS) after radical prostatectomy (RP). A cohort of post-RP inflatable penile prosthesis (IPP) patients served as a surgical control. Body Mass Index (BMI) and total body weight were assessed pre and post-UPS. Multivariable linear regression was utilized to assess BMI changes post-UPS., Results: 187 AUS and 63 IPP patients met selection criteria. Greater PPI severity was associated with faster BMI gain after RP (coeff. 0.14 kg/m2, P = 0.03, per pad used) and magnitude of incontinence improvement (mean reduction in daily pad use) after AUS insertion was associated with greater BMI reduction at 12 months post-UPS (coeff. - 0.13 kg/m2, P = 0.04). On multivariable regression, AUS insertion was associated with a decrease in BMI by - 2.83 kg/m2 12 months post-UPS (P = 0.02). Twelve months post-UPS, men with AUS exhibited a mean BMI reduction of -1.0 kg/m 2 compared to a mean BMI increase in the IPP cohort of 0.4 kg/m 2 (P < 0.01). Compared to IPP, AUS patients experienced absolute body weight reduction by 6 kg [Median(IQR): 90.4 (80.3-100.1) vs 96.4 (87.1-108.8) kg, P = 0.03], with nearly one-third having clinically significant weight loss (>5% body weight) at 12 months post-UPS (31.8% vs 8.3%, P < 0.01)., Conclusion: Severe PPI appears to be associated with weight gain and correction of PPI via AUS insertion with weight loss., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To analyze our institutional experience transitioning from overnight observation (OBS) to same day surgery (SDS) for artificial urinary sphincter (AUS) procedures. Prior research has questioned the need for OBS following AUS surgery., Methods: We retrospectively reviewed AUS surgeries performed by a single surgeon at our tertiary academic medical center between 08/2013 and 01/2020. Patients were grouped based on discharge status: OBS vs SDS. Cost savings associated with SDS were estimated using room and bed charges from a contemporary group of AUS patients., Results: We identified 525 AUS cases that met inclusion criteria. Men in the SDS group (n = 318) were more likely to have undergone a virgin AUS insertion and were slightly younger and healthier. Men in the OBS group (n = 207) were more likely to suffer an immediate postoperative complication (1% vs 0%, P < .01) and to be readmitted within 90 days of surgery (15% vs 5%, P < .01). The groups did not vary with respect to multiple other perioperative outcomes measures. Among patients who underwent AUS surgery between 09/2017 and 08/2020, those with OBS status (n = 39) had mean additional room and bed charges of $ 745 ± 302 vs none for SDS patients (n = 183)., Conclusion: SDS for AUS insertion is safe, effective, and associated with significant cost savings. Routine overnight observation after AUS insertion appears to be unnecessary., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aims: To evaluate the relationship between serum testosterone (T) levels and artificial urinary sphincter (AUS) cuff erosion in a population of incontinent men who underwent AUS placement., Methods: A retrospective analysis of our single-surgeon AUS database was performed to identify men with T levels within 24 months of AUS placement. Men were stratified into two groups based on serum testosterone: low serum testosterone (LT) (<280 ng/dl) and normal serum testosterone (NT) (>280 ng/dl). Multivariable analysis was performed to control for risk factors. The outcome of interest was the incidence of and time to spontaneous urethral cuff erosion; other risk factors for cuff erosion were also evaluated., Results: Among 161 AUS patients with serum testosterone levels, 84 (52.2%) had LT (mean: 136.8 ng/dl, SD: 150.4 ng/dl) and 77 (47.8%) had NT (mean: 455.8 ng/dl, SD: 197.3 ng/dl). Cuff erosion was identified in 42 men (26.1%) at a median of 7.1 months postoperatively (interquartile range: 3.6-13.4 months), most of whom (30/42, 71.4%) were testosterone deficient. LT levels were less common (54/119, 45.4%) in the non-erosion cohort (p = 0.004). Men with low T were nearly three times as likely to suffer AUS erosion than men with normal T (odds ratio = 2.519, p = 0.021). LT level was the only factor associated with AUS erosion on multivariable analysis., Conclusions: LT is an independent risk factor for AUS cuff erosion. Men with LT are more likely to present with cuff erosion, but there is no difference in time to erosion., (© 2021 Wiley Periodicals LLC.)

INTRODUCTION Patient-reported pads per day use is a widely used metric in grading the severity of stress urinary incontinence and guiding surgical decision-making, particularly in mild-to-moderate cases. We sought to compare patient-reported stress urinary incontinence severity by pads per day with objective findings on standing cough test. We hypothesize that patient-reported pads per day often underestimates stress urinary incontinence severity., Materials and Methods: We retrospectively reviewed our male stress urinary incontinence surgical database and identified 299 patients with self-reported mild-to-moderate stress urinary incontinence who were evaluated with standing cough test prior to surgical intervention between 2007 and 2019. Patients were evaluated with the Male Stress Incontinence Grading Scale for urinary leakage during a standing cough test. This test has been shown to reliably and accurately predict surgical success. Binary logistic regression analysis was used to identify parameters associated with stress urinary incontinence upgrading in a multivariable model., Results: Among 299 patients with reported mild-to-moderate stress urinary incontinence, 101 (34%) were upgraded to severe stress urinary incontinence by standing cough test. Prior stress urinary incontinence surgery (OR 4.1, 95% CI 2.0-8.0, p < 0.0001) and radiation (OR 3.2, 95% CI 1.7-5.7, p < 0.0001) were significantly associated with Male Stress Incontinence Grading Scale upgrading in multivariable analysis., Conclusions: Roughly one-third of men who report mild-to-moderate stress urinary incontinence actually have severe incontinence observed on physical examination. All men being evaluated for stress urinary incontinence should undergo standing cough test to accurately grade incontinence severity and guide surgical management.

Purpose of Review: To review risk factors for AUS complications and present a systematic approach to their diagnosis and management., Recent Findings: Established risk factors for AUS complications include catheterization, channel TURP, pelvic radiation, urethroplasty, anticoagulation, cardiovascular disease, diabetes mellitus, frailty index, hypertension, low albumin, and low testosterone. We present our algorithm for diagnosis and management of AUS complications. Despite being the gold standard of treatment for men with SUI, major and minor complications can occur at any point after AUS insertion. Careful consideration of the urologic, medical, and operative risk factors for each patient can help prevent complications. A systematic approach to early and late complications facilitates their identification and effective management. The evaluating urologist must have a thorough understanding of potential AUS complications in order to restore quality of life in men with bothersome SUI.

Objective: At present, excision and primary anastomosis (EPA) urethroplasty is a highly reliable method of reconstruction for short bulbar urethral strictures. Longer strictures are often managed with grafting techniques to ensure a tension-free repair. Here we report our initial experience with a new, extended anastomotic technique for long bulbar strictures that incorporates plication of the ventral corporal bodies to reduce the distance between the urethral ends and obviates the need for grafting., Methods: We reviewed records for all urethroplasties performed by a single surgeon at our institution between January 2018 and February 2020. We identified a cohort of older patients with complex strictures who underwent Extended Primary Anastomosis with Penile Plication (EPAPP). Patient demographics, stricture characteristics, perioperative 75 parameters, and postoperative outcomes were evaluated., Results: Of 346 urethroplasty records reviewed, 10 patients (2.9%) underwent EPAPP. Mean stricture length was 3.75 ± 1.4 cm. EPAPP patients were older than those repaired by other techniques (mean age 66.6 vs 55.6, P = .024), and most were not sexually active preoperatively. Postoperative voiding cystourethrogram confirmed urethral patency without extravasation in all patients. At a median follow up of 9.7 months (IQR 8.5-11.5) 8 patients remained asymptomatic after EPAPP alone and 2 patients required a single balloon dilation for stricture recurrence., Conclusion: EPAPP is a promising alternative option for the management of long bulbar strictures among appropriately selected patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Antibiotic stewardship is now a priority for the urologic community. Perioperative antibiotic use at the time of inflatable penile prosthesis (IPP) insertion has become a topic of interest., Objectives: To review the literature available to inform the practice of antibiotic administration before, during, and after IPP insertion., Methods: We performed a literature review based on a search for the terms "Antibiotics" and "Penile Prosthesis" in the PubMed database. Manuscripts were individually reviewed for relevance to the administration of antibiotics in conjunction with IPP insertion. Best practice statements and guidelines from stakeholder organizations were also reviewed., Results: The benefits of preoperative antibiotic prophylaxis have been well studied in the orthopedic and general surgery literature, but a dearth of studies are available in the specific context of IPP insertion. High-quality retrospective studies have demonstrated reduced infection rates with the use of antibiotic-impregnated or antibiotic-coated IPPs. Limited research on the use of postoperative antibiotics after IPP insertion has actually not demonstrated a benefit from this very common practice. Indeed, the broader surgical literature suggests a net harm from continued postoperative antibiosis. A 2017 guideline recommendation from the Center for Disease Control and Prevention states that additional prophylactic antibiotics should not be administered after procedures deemed clean or clean-contaminated., Conclusion: The benefits of single-dose preoperative antibiotics and the use of antibiotic-impregnated or antibiotic-coated IPPs are well established. Postoperatively, the available IPP and broader surgical literature does not reflect a benefit from the administration of additional antibiotics and demonstrates higher rates of antibiotic-associated adverse events and the emergence of drug resistance. In average-risk patients undergoing IPP insertion, contemporary data suggest that it is safe for postoperative antibiotics to be withheld. Dropkin BM, Kaufman MR. Antibiotics and Inflatable Penile Prosthesis Insertion: A Literature Review. Sex Med 2021;9:174-180., (Copyright © 2020 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

INTRODUCTION We sought to explore whether patients discharged without antibiotics after artificial urinary sphincter (AUS) insertion were more likely to require device explantation for infection or erosion compared to patients discharged with antibiotics at our institution and compared to patients in other large, contemporary series., Materials and Methods: AUS insertions performed at our institution between 2013 and 2017 were retrospectively reviewed to determine demographics, comorbidities, and perioperative and medium-term outcomes. Patients were grouped based on 1) known risk factors for infectious complications or erosion and 2) postoperative antibiotic prescription status. Patients were placed in Group 1 if they did not demonstrate risk factors and did not receive postoperative antibiotics, Group 2 if they did possess risk factors but did not receive postoperative antibiotics, and Group 3 if they had risk factors and received postoperative antibiotics., Results: Of the 155 men who met inclusion criteria, 44, 47, and 64 were categorized in Groups 1, 2, and 3, respectively. Median (IQR) follow up was similar across Groups 1, 2, and 3 (12.7 [4.6-25.1] versus 10.7 [4.5-31.3] versus 8.3 [4.4-26.4] months, p = 0.808). Rates of explantation due to device infection (0 versus 2 versus 6%, p = 0.172) or cuff erosion (2 versus 2 versus 8%, p = 0.253) did not vary significantly between Groups 1-3., Conclusions: Patients undergoing AUS insertion may be unlikely to benefit from the routine administration of postoperative antibiotics. In light of the known consequences of antibiotic overuse, a randomized controlled trial is warranted.

Introduction: With more than 3,500 artificial urinary sphincters placed annually in the United States a significant cost burden is associated with overnight observation following surgery. We sought to determine whether inpatient management after artificial urinary sphincter insertion, our current local standard of care, is necessary with regards to inpatient narcotic requirements and immediate postoperative complications., Methods: This was an institutional review board approved, retrospective review of artificial urinary sphincter insertions identified by CPT code 53445 between June 2013 and September 2017. Medical records were reviewed for patient demographics, postoperative narcotic use and immediate postoperative complications., Results: We identified 163 men who underwent artificial urinary sphincter insertion for analysis. The cohort had a mean age of 69.8 ± 8.5 years, body mass index of 28.9 ± 5.1 kg/m 2 and preoperative pad per day use of 5.8 ± 3.5. Of all patients identified 25 (15%) were using chronic narcotic pain medication preoperatively and 51 (31%) had a diagnosis of diabetes (mean A1c 7.0 ± 1.5%). All but 1 (99%) patients were discharged on the first postoperative day and 1 left on the second postoperative day. Two (1.2%) patients experienced immediate postoperative complication, and 8 (6%) patients failed a voiding trial on postoperative day 1. The 154 (94%) patients who required orally administrated narcotic pain medication after leaving the postanesthesia care unit used a median of 31.0 ± 22.9 morphine milligram equivalents., Conclusions: Immediate postoperative and peridischarge complication rates are around 1% after artificial urinary sphincter insertion, and narcotic requirements following postanesthesia care unit stay are minimal. Outpatient artificial urinary sphincter insertion is likely to be safe, effective and beneficial with regards to patient experience and total costs.

Purpose: We sought to determine whether patients discharged from the hospital without antibiotics after inflatable penile prosthesis insertion were at increased risk for infectious complications compared to patients at our institution discharged with oral antibiotics and patients in other contemporary series., Materials and Methods: We reviewed the medical records of patients who underwent inflatable penile prosthesis insertion from 2013 through 2017. Group 1 patients had no risk factors for infectious complications and did not receive postoperative antibiotics. Group 2 patients had risk factors for infectious complications but did not receive postoperative antibiotics. Group 3 patients had risk factors for infectious complications and received postoperative antibiotics., Results: Of the 222 men who met study inclusion criteria 88 (40%) were in group 1, 48 (21%) were in group 2 and 86 (39%) were in group 3. The mean ± SD number of risk factors for infection was lower in group 2 than in group 3 (1.08 ± 0.28 vs 1.24 ± 0.46, p = 0.013). Median followup did not vary among groups 1, 2 and 3 (4.6 months, IQR 1.8-7.2; 3.5, IQR 1.4-6.9; and 4.5, IQR 1.4-7.4; p = 0.146, respectively). Rates of explantation due to device infection (0% vs 4% vs 5%, p = 0.130) and nonoperative infectious complications (1% vs 2% vs 2%, p = 0.829) did not vary among groups 1 to 3, respectively., Conclusions: Patients who undergo inflatable penile prosthesis insertion appeared unlikely to benefit from routine administration of postoperative antibiotics. In the current era of antibiotic stewardship these findings have the potential for substantial individual and population health benefits.

Aim: To examine the location of midurethral slings (MUS) at the time of excision to determine associations between presenting symptoms and sling location at explant., Methods: We performed an IRB approved, retrospective review of MUS explants between January 2011 and March 2016. Symptoms and physical examination findings were compared between women with slings explanted from the mid-urethra (MU) and women with slings explanted from the proximal urethra/bladder neck (PU/BN)., Results: We included 95 consecutive women who underwent MUS explant in the analysis. Presenting symptoms included pain in 69 women (72.6%), urinary urgency in 66 (66.5%), voiding dysfunction in 55 (57.9%), urge urinary incontinence (UUI) in 41 (43.2%), stress urinary incontinence in 34 (35.8%), and recurrent urinary tract infections in 22 (23.2%). At sling explant, 2 (2.1%) slings were found at the distal urethra, 33 (34.7%) at the MU and 60 (63.2%) at the PU/BN. Women with slings explanted from the PU/BN were more likely to present with urgency (78.3% vs 54.5%; P = 0.017) and UUI (53.3% vs 27.3%; P = 0.015) and less likely to present with pain on examination (48.3% vs 75.8%; P = 0.01)., Conclusions: The majority of MUS requiring explant in this cohort were found at the PU/BN. The most common presenting symptom before MUS explant was pain, followed by urgency and voiding dysfunction. PU/BN location of MUS is likely a factor in the development of urgency and UUI in women who ultimately undergo explant., (© 2019 Wiley Periodicals, Inc.)

Background: Total hip arthroplasty (THA) relieves pain and improves physical function in patients with hip osteoarthritis, but requires a year or more for full postoperative recovery. Proponents of intermuscular surgical approaches believe that the direct-anterior approach may restore physical function more quickly than transgluteal approaches, perhaps because of diminished muscle trauma. To evaluate this, we compared patient-reported physical function and other outcome metrics during the first year after surgery between groups of patients who underwent primary THA either through the direct-anterior approach or posterior approach., Questions/purposes: We asked: (1) Is a primary THA using a direct-anterior approach associated with better patient-reported physical function at early postoperative times (1 and 3 months) compared with a THA performed through the posterior approach? (2) Is the direct-anterior approach THA associated with shorter operative times and higher rates of noninstitutional discharge than a posterior approach THA?, Methods: Between October 2008 and February 2010, an arthroplasty fellowship-trained surgeon performed 135 THAs. All 135 were performed using the posterior approach. During that period, we used this approach when patients had any moderate to severe degenerative joint disease of the hip attributable to any type of arthritis refractory to nonoperative treatment measures. Of the patients who were treated with this approach, 21 (17%; 23 hips) were lost to followup, whereas 109 (83%; 112 hips) were available for followup at 1 year. Between February and September 2011, the same surgeon performed 86 THAs. All 86 were performed using the direct-anterior approach. During that period, we used this approach when patients with all types of moderate to severe degenerative joint disease had nonoperative treatment measures fail. Of the patients who were treated with this approach, 35 (41%; 35 hips) were lost to followup, whereas 51 (59%; 51 hips) were available for followup at 1 year. THAs during the surgeon's direct-anterior approach learning period (February 2010 through January 2011) were excluded because both approaches were being used selectively depending on patient characteristics. Clinical outcomes included operative blood loss; allogeneic transfusion; adverse events; patient-reported Veterans RAND-12 Physical (PCS) and Mental Component Summary (MCS) scores, and University of California Los Angeles (UCLA) activity scores at 1 month, 3 months, and 1 year after surgery. Resource utilization outcomes included operative time, length of stay, and discharge disposition (home versus institution). Outcomes were compared using logistic and linear regression techniques., Results: After controlling for relevant confounding variables including age, sex, and BMI, the direct-anterior approach was associated with worse adjusted MCS changes 1 and 3 months after surgery (1-month score change, -9; 95% CI, -13 to -5; standard error, 2), compared with the posterior approach (3-month score change, -9; 95% CI, -14 to -3; standard error, 3) (both p < 0.001), while the direct-anterior approach was associated with greater PCS improvement at 3 months compared with the posterior approach (score change, 6; 95% CI, 2-10; standard error, 2; p = 0.008). There were no differences in adjusted PCS at either 1 month or 12 months, and no clinically important differences in UCLA scores. Although the PCS score differences are greater than the minimum clinically important difference of 5 points for this endpoint, the clinical importance of such a small effect is questionable. At 1 year after THA, there were no intergroup differences in self-reported physical function, although both groups had significant loss-to-followup at that time. Operative time (skin incision to skin closure) between the two groups did not differ (81 versus 79 minutes; p = 0.411). Mean surgical blood loss (403 versus 293 mL; p < 0.001; adjusted, 119 more mL; 95% CI, 79-160; p < 0.001) and in-hospital transfusion rates (direct-anterior approach, 20% [17/86] versus posterior approach, 10% [14/135], p = 0.050; adjusted odds ratio, 3.6; 95% CI, 1.3-10.1; p = 0.016) were higher in the direct-anterior approach group. With the numbers available, there was no difference in the frequency of adverse events between groups when comparing intraoperative complications, perioperative Technical Expert Panel complications, and other non-Technical Expert Panel complications within 1 year of surgery, although this study was not adequately powered to detect differences in rare adverse events., Conclusions: With suitable experience, the direct-anterior approach can be performed with expected results similar to those of the posterior approach. There may be transient and small benefits to the direct-anterior approach, including improved physical function at 3 months after surgery. However, the greater operative blood loss and greater likelihood of blood transfusions, even when the surgeon is experienced, may be a disadvantage. Given some of the kinds of bias present that we found, including loss to followup, the conclusions we present should be considered preliminary, but it appears that any benefits that accrue to the patients who had the direct-anterior approach would be transient and modest. Prospective randomized studies on the topic are needed to address the differences between surgical approaches more definitively., Level of Evidence: Level III, therapeutic study.

Immunoglobulin G4-related disease is a fibroinflammatory condition of unclear etiology that can present with inflammatory changes and enlargement of a wide variety of organs, most commonly in the gastrointestinal tract. A diagnosis requires an elevated serum immunoglobulin G4 concentration and a tissue biopsy showing a dense plasma cell infiltrate with an increased percentage of immunoglobulin G4+ plasma cells. This disease infrequently presents in the genitourinary tract, and as such might be unfamiliar to and potentially overlooked by urologists. Here we present the third reported case of immunoglobulin G4-related disease manifesting as a mass in the urinary bladder., (© 2015 The Japanese Urological Association.)

Purpose: We documented the natural history of asymptomatic nonobstructing renal calculi managed with active surveillance and explored factors predicting stone related events to better inform shared decision making., Materials and Methods: Patients with asymptomatic nonobstructing renal calculi electing active surveillance of their stone(s) were retrospectively reviewed. Stone characteristics, patient characteristics, and stone related events were collected. We evaluated the effects of stone size and location on development of symptoms, spontaneous passage, requirement for surgical intervention, and stone growth., Results: We identified 160 stones with an average size of 7.0 ± 4.2 mm among 110 patients with average followup of 41 ± 19 months. Forty-five (28% of total) stones caused symptoms during followup. Notably 3 stones (3% of asymptomatic subgroup, 2% of total stones) caused painless silent obstruction necessitating intervention after an average of 37 ± 17 months. The only significant predictor of spontaneous passage or symptom development was location. Upper pole/mid renal stones were more likely than lower pole stones to become symptomatic (40.6% vs 24.3%, p = 0.047) and to pass spontaneously (14.5% vs 2.9%, p = 0.016)., Conclusions: Among asymptomatic nonobstructing renal calculi managed with active surveillance, most remained asymptomatic through an average followup of more than 3 years. Less than 30% caused renal colic, less than 20% were operated on for pain and 7% spontaneously passed. Lower poles stones were significantly less likely to cause symptoms or pass spontaneously. Despite 3 stones causing silent hydronephrosis suggestive of obstruction, regular followup imaging facilitated interventions that prevented renal loss., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Indwelling epidural catheter placement for prolonged drug delivery or is commonplace. Epidural catheter placement leading to a subsequent epidural mass is infrequently symptomatic and thus not often sought after or uncovered. Such masses can mimic lesions causing tumor, infection, and inflammation, and when found, the etiology of granuloma formation is unclear. This article describes a case of a benign epidural granuloma masquerading as an epidural tumor thought to be caused by epidural catheter placement for postoperative total hip replacement pain control. After symptoms of mechanical and radiculopathic pain arose, the patient underwent an open biopsy, spinal decompression, and intradural exploration as an MRI evaluation identified a mass in the spinal canal. Pathologic examination identified a benign fibrous granuloma. At 36-month follow-up, there was no evidence of symptom or tumor recurrence.