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Introduction: Electronic patient messaging utilization has increased in recent years and has been associated with physician burnout. ChatGPT is a language model that has shown the ability to generate near-human level text responses. This study evaluated the quality of ChatGPT responses to real-world urology patient messages., Methods: One hundred electronic patient messages were collected from a practicing urologist's inbox and categorized based on the question content. Individual responses were generated by entering each message into ChatGPT. The questions and responses were independently evaluated by 5 urologists and graded on a 5-point Likert scale. Questions were graded based on difficulty, and responses were graded based on accuracy, completeness, harmfulness, helpfulness, and intelligibleness. Whether or not the response could be sent to a patient was also assessed., Results: Overall, 47% of responses were deemed acceptable to send to patients. ChatGPT performed better on easy questions with 56% of responses to easy questions being acceptable to send as compared to 34% of difficult questions ( P = .03). Responses to easy questions were more accurate, complete, helpful, and intelligible than responses to difficult questions. There was no difference in response quality based on question content., Conclusions: ChatGPT generated acceptable responses to nearly 50% of patient messages with better performance for easy questions compared to difficult questions. Use of ChatGPT to help respond to patient messages can help to decrease the time burden for the care team and improve wellness. Artificial intelligence performance will likely continue to improve with advances in generative artificial intelligence technology.

Aesthetic penile augmentation is considered investigational and not shown to be safe or efficacious. This study sought to characterize the quality and reliability of YouTube videos on the topic of penile augmentation. A systematic search identifying the 100 most viewed YouTube videos on penile augmentation was conducted. The videos were then evaluated by two independent urologists for reliability and quality using a modified DISCERN scoring system and Global Quality Scale (GQS). The median total views were 530,612 (range 123,478-32,914,713). The median DISCERN and GQS scores for all 100 videos were generally poor at 1.75 (IQR 1-2.63) and 2.5 (IQR 1.5-3.5), respectively. A little under half of the videos had a physician present (44.7%). DISCERN and GQS scores were significantly higher in videos with physicians compared to those without one (p < 0.001 for both). The majority of videos discussed nonsurgical methods of penile augmentation (65.1%) with penile traction devices being the most frequently discussed (19.2%). Urologists and medical organizations should strive to have more of a presence in this space to ensure patients are appropriately educated and counseled before pursuing potentially ineffective or harmful treatments., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

In this comprehensive review, the intricate relationship between paternal factors and pregnancy loss is examined. While pregnancy loss has historically been predominantly attributed to maternal factors, recent research underscores the significant contribution of the male partner. The review delves into various aspects of paternal influence, including paternal age, health, chromosome abnormalities, Y chromosome deletions, and sperm DNA fragmentation. Notably, advanced paternal age is found to be associated with an increased risk of recurrent pregnancy loss, shedding light on the importance of understanding the impact of aging on male fertility. Additionally, paternal health, particularly metabolic syndrome, emerges as a noteworthy factor contributing to pregnancy loss. Chromosome abnormalities in male partners, such as balanced translocations, and Y chromosome microdeletions are explored in the context of pregnancy loss risk. Moreover, the review highlights the growing body of evidence linking sperm DNA fragmentation and sperm protein abnormalities to spontaneous pregnancy loss, emphasizing the significance of sperm health in reproductive outcomes. Overall, this review provides a comprehensive overview of the multifaceted role of the male partner in pregnancy loss, calling for a more inclusive approach to pregnancy loss investigations that encompasses both maternal and paternal factors., (© 2024 American Society of Andrology and European Academy of Andrology.)

Background: Sleep quality and duration have been investigated for their association with health. Insomnia affects up to one-third of adults and may impact male erectile function. In addition, medical treatments for insomnia (many of which are sedatives) may also affect erectile quality., Objective: To investigate the association of erectile dysfunction (ED) in patients diagnosed with and treated for insomnia., Design, Setting, and Participants: We utilized the IBM MarketScan (2007-2016) Commercial and Medicare Supplemental Databases (v 2.0). Age- and enrollment-matched controls were selected among patients without insomnia diagnosis or treatment., Outcome Measurements and Statistical Analysis: Cox proportional hazard models were used to estimate the risk of incident ED (ie, diagnosis alone, or diagnosis and treatment with phosphodiesterase-5 inhibitors [PDE5i], intracavernous injection (ICI)/urethral suppositories, and penile prosthesis) after the diagnosis or treatment of insomnia while adjusting for relevant comorbidities., Results and Limitations: In total, 539 109 men with an insomnia diagnosis were identified. Of these men, 356 575 were also medically treated for insomnia. The mean (±standard deviation) follow-up times for patients diagnosed with insomnia and those diagnosed with and treated for insomnia were 2.8 ± 1.6 and 3.1 ± 1.8 yr, respectively. Men with insomnia were more commonly smokers and had a higher number of office visits and comorbidities than controls (p < 0.001). On an adjusted analysis, both untreated and treated insomnia were associated with increased risks of ED diagnosis (hazard ratio or HR [95% confidence interval {CI}]: 1.58 [1.54-1.62] and 1.66 [1.64-1.69], respectively; p < 0.001). Similarly, men with treated insomnia had a higher risk of having ED treated with PDE5i (HR [95% CI]: 1.52 [1.49-1.55]; p < 0.001) and ICI (HR [95% CI]: 1.32 [1.14-1.54]; p < 0.001) when compared with controls. A limitation of this study was that a lack of granularity regarding patient clinical characteristics (eg, severity of disease, laboratory data, etc.) is inherent to insurance claims data. In addition, the follow-up was limited and may affect associations at longer time points., Conclusions: In the current report, a consistent association between insomnia and ED diagnosis was identified. Men diagnosed with insomnia only were found to have a higher risk of developing ED. Moreover, men with pharmacological insomnia treatments were more often prescribed treatments for ED. Given the prevalence of insomnia, future studies are warranted to delineate the association of insomnia and its treatment with erectile function., Patient Summary: Insomnia affects up to one-third of adults and impact male erectile function. Men only diagnosed with insomnia were found to have a higher risk of developing erectile dysfunction (ED). Moreover, men with pharmacological insomnia treatments were more often prescribed treatments for ED., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Phosphodiesterase 5 inhibitor (PDE5i) use has been linked to a number of ocular side effects, such as serous retinal detachment (SRD), retinal vascular occlusion (RVO), and ischemic optic neuropathy (ION)., Aim: We investigated the risk for SRD, RVO, and ION in patients using PDE5is., Methods: We utilized the IBM MarketScan (2007-2021) Commercial and Medicare Supplemental Databases (version 2.0) for this analysis. To estimate overall events risk, Cox proportional hazard models were applied to calculate the hazard ratios (HRs) for erectile dysfunction (ED) diagnosis and the different treatments, adjusting for region, median age, obesity, diabetes mellitus, hyperlipidemia, smoking, hypertension, coronary artery disease, and sleep apnea. Additionally, the same analyses were performed to calculate the HRs for benign prostatic hyperplasia (BPH) diagnosis and the different treatments., Outcomes: HRs for SRD, RVO, and ION., Results: In total, 1 938 262 men with an ED diagnosis were observed during the study period. Among them, 615 838 (31.8%) were treated with PDE5is. In total, 2 175 439 men with a BPH diagnosis were observed during the study period. Among them, 175 725 (8.1%) were treated with PDE5is. On adjusted Cox regression analysis, PDE5i use was not associated with SRD, RVO, ION, and any ocular event when compared with ED diagnosis and other ED treatments. Importantly, as the intensity of ED treatment increased, so did the risk of ocular events. In addition, PDE5i use was not associated with SRD and ION when compared with BPH diagnosis and other BPH treatments. In contrast, in patients with BPH, PDE5i use was associated with RVO (HR, 1.14; 95% CI, 1.06-1.23). Importantly, patients with BPH receiving other medical treatment (ie, 5a reductase/alpha blocker; HR, 1.11; 95% CI, 1.06-1.16) or surgical treatment (HR, 1.10; 95% CI, 1.02-1.19) had a higher risk of RVO., Clinical Implications: We did not observe any consistent association between PDE5i use and any ocular adverse events (SRD, RVO, and ION)., Strengths and Limitations: Because we did not have access to the patients' medical records, we recorded outcome definitions using ICD-9 and ICD-10 coding., Conclusions: Patients using PDE5is for ED or BPH indications did not have an increased risk of ocular events, even when compared with other treatments for ED or BPH., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Normative male genital measurements are clinically useful and temporal changes would have important implications. The aim of the present study is to characterize the trend of worldwide penile length over time., Materials and Methods: A systematic review and meta-analysis using papers from PubMed, Embase, and Cochrane Library from inception to April 2022 was performed. PRISMA guidelines were used for abstracting data and assessing data quality and validity. Pooled means and standard deviations for flaccid, stretched, and erect length were obtained. Subgroup analyses were performed by looking at differences in the region of origin, population type, and the decade of publication. Metaregression analyses were to adjusted for potential confounders., Results: Seventy-five studies published between 1942 and 2021 were evaluated including data from 55,761 men. The pooled mean length estimates were flaccid length: 8.70 cm (95% CI, 8.16-9.23), stretched length: 12.93 cm (95% CI, 12.48-13.39), and erect length: 13.93 cm (95% CI, 13.20-14.65). All measurements showed variation by geographic region. Erect length increased significantly over time (QM=4.49, df=2, p=0.04) in several regions of the world and across all age groups, while no trends were identified in other penile size measurements. After adjusting for geographic region, subject age, and subject population; erect penile length increased 24% over the past 29 years., Conclusions: The average erect penis length has increased over the past three decades across the world. Given the significant implications, attention to potential causes should be investigated., Competing Interests: The authors have nothing to disclose., (Copyright © 2023 Korean Society for Sexual Medicine and Andrology.)

Background: Chemoprotective effect of 5-alpha reductase inhibitors (5-ARi) on bladder cancer (BCa) risk in men with Benign Prostatic Hyperplasia (BPH) has been explored with conflicting results. We sought to examine the effect of 5-ARi on new BCa diagnoses in a large US database., Methods: Men ≥ 50 y/o with a prescription for 5-ARi after BPH diagnosis were identified in the IBM® Marketscan® Research de-identified Databases between 2007 and 2016 and matched with paired controls. Incident BCa diagnoses were identified after BPH diagnosis and/or pharmacologic treatment. Multivariable regression modeling adjusting for relevant factors was implemented. Sub-group analyses by exposure risk were performed to explore the association between 5-ARi and BCa over time. Administration of alpha-blockers (α-B) w/o 5-ARi was also examined., Results: In total, n = 24,036 men on 5-ARi, n = 107,086 on 5-ARi plus alpha-blockers, and n = 894,275 without medical therapy for BPH were identified. The percentage of men diagnosed with BCa was 0.8% for the 5-ARi, 1.4% for the 5-ARi + α-B, and 0.6% for the untreated BPH group of incident BCa (adjusted hazard ratio [aHR], 0.90, 95% confidence interval [CI] 0.56 - 1.47), and 1.08, 95%CI 0.89 - 1.30, respectively). This was also true at both shorter (≤ 2 yr) and longer-term (> 2 yr) follow up. In addition, α-B alone had no change in BCa risk (HR 1.06, 0.86-1.30)., Conclusions: We did not find any diminished risk of new BCa in men treated with 5-ARi (i.e., chemoprotective effect). The current report suggests that 5-ARi do not change a man's bladder cancer risk., (© 2023. The Author(s).)

Male factor infertility is widely considered a harbinger for a man's general health. Failure of reproduction often accompanies other underlying processes, with growing evidence suggesting that a diagnosis of infertility increases the likelihood of developing future cardiac, metabolic, and oncologic diseases. The goal of this review is to provide a comprehensive overview of the research on male fertility as a marker for current and future health. A multidisciplinary approach is essential, and there is growing consensus that the male fertility evaluation offers an opportunity to better men's wellness beyond their immediate reproductive ambitions., (Copyright © 2023 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Patients may turn to social media websites, such as Reddit, for information on erectile dysfunction prior to seeking care from a physician. We sought to identify, characterize, and assess the quality of the erectile dysfunction treatments discussed on the highly influential Reddit website. We assessed 2634 comments from two subreddits, r/AskMen and r/ErectileDysfunction, for positive and negative statements regarding treatments for erectile dysfunction. A total of 45 unique treatments were discussed and consisted of changes in sexual behavior (30%), lifestyle changes (29%), medical interventions (23%), talking with a partner about ED (10%), and use of supplements (8%). Only 24.4% of all treatments discussed are in line with current American Urological Association guidelines. Only 43.8% of all positive statements made endorsed a guidelines-based treatment, indicating a high rate of self-proclaimed success with alternative therapies. Our results indicate that there is active discussion of erectile dysfunction treatment on Reddit with a wide range of therapies recommended, however, the majority of the recommendations are not supported by strong clinical evidence., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Introduction: We sought to better understand the amounts and distribution of political contributions made by urologists in the United States., Methods: The Federal Election Commission was analyzed for political contributions from 2003 to 2022 using the search terms "urology," "urologist," or "urologic surgeon." Contributions were classified by political party (Democratic, Republican, or Independent) and were analyzed for temporal, geographic, and demographic trends., Results: There were a total of 26,441 unique contributions that resulted in $9,943,205 after adjusting for inflation. The total amount of political contributions increased significantly over time, with higher numbers during presidential election years. The Republican party received the highest proportion of donations (69.1%). Importantly, women urologists and urologists working in academic centers were significantly more likely to contribute to Democratic committees ( P < .001 for both). Texas had the highest total amount of contributions ($395,152). Overall contributions to urology political action committees have steadily decreased since 2011, while contributions to individual campaigns and nonurology political action committees have increased., Conclusions: Urologists have been increasingly contributing to political campaigns over the past 19 years, with most of their individual and political action committee contributions going to Republican committees and candidates. Future research evaluating how growing political engagement by urologists affects the development of new health care policy will be important as a new generation of urologists begins to enter practice.

Testosterone Therapy (TTh) trends have changed as a result of clinical research and market forces over the past several years. Understanding the trends or preferences regarding testosterone prescriptions remains unknown. Our objective was to assess both regional and national trends in TTh prescriptions amongst medical specialties within the United States between 2013 and 2017. Publicly available data from the Center for Medicare and Medicaid Services (CMS) Part D Prescriber database with regards to TTh prescriptions across a 5-year span (January 1, 2013-December 31, 2017) were analyzed. TTh therapies were consolidated into four categories: Topical, Oral, Injection and Pellet. Statistical analysis utilizing R 4.0.2 was performed on the resulting data. Trends in prescription modality claim count and cost were plotted over the study period while statistical analysis evaluated associations between TTh modality and medical specialist. We found that Endocrinologists and Urologists prescribed topical testosterone more than all other specialties (60.4% and 53.5%, respectively), while Family and Internal medicine physicians were more likely to prescribe injections (59.82% and 50.69%, respectively). Oral and pellet testosterone were rarely prescribed across all specialties. In conclusion, the wide variation in modalities of testosterone prescriptions illustrates an opportunity for treatment guidelines to be streamlined across all specialists to improve patient outcomes., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Purpose of Review: This review summarize the proper counseling for men with severe male factor infertility., Recent Findings: Men who are experiencing infertility should have a semen analysis, the results of which may imply additional investigations, including genetic and hormonal. Moreover, possible modifiable factors that may harm men's reproductive health should be carefully evaluated. Finally, different treatment options are available., Summary: Approximately 15% of couples struggle with infertility. Complete evaluations of both men and women are required to determine the etiology of infertility and determine appropriate treatment., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Testosterone deficiency is known to affect men with increasing incidence throughout their lifespan. The clinical manifestations of testosterone deficiency, in turn, negatively impact men's quality of life and perception of overall health. The interaction of chronic systemic disease and androgen deficiency represent an area for potential intervention. Here, we explore the topic of testosterone deficiency amongst men with end-stage organ failure requiring transplantation in order to elucidate the underlying pathophysiology of androgen deficiency of chronic disease and discuss whether intervention, including testosterone replacement and organ transplantation, improve patients' outcomes and quality of life., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Direct-to-consumer telemedicine platforms have expanded their reach to include services for the evaluation and treatment of testosterone deficiency., Aim: We aim to (i) evaluate the treatment practices and costs associated with receiving testosterone therapy through direct-to-consumer telemedicine platforms; (ii) compare these practices to the American Urological Association guidelines; and (iii) compare the cost of receiving similar care at a tertiary center., Methods: Google was queried to identify telemedicine platforms offing testosterone therapy. Websites were analyzed for information regarding the initial consultation, initial laboratory evaluation, follow up, treatment monitoring regimen, and associated costs of receiving testosterone therapy. The costs for similar services at a tertiary care center were estimated using a single institution's online cost estimator for a patient with no insurance, private insurance, or Medicare., Outcomes: Evaluation and treatment practices of each platform were compared to the American Urological Association guidelines, and a cost analysis was completed for the cost of (i) undergoing an initial evaluation, and (ii) receiving 12 months of treatment through each platform and at a tertiary center., Results: Three online platforms met inclusion criteria: Hone, Regenex Health, and TRT Nation. The initial evaluation and follow up of patients on TTh were similar between the online platforms and practice guidelines. The costs of the initial consultation were lowest for the patient with Medicare at a tertiary center and via the telemedicine platforms. Conversely, the cost of 12 months of intramuscular testosterone treatment was highest via the telemedicine platforms, ranging from $1,586 to $4,200, as compared to the tertiary center, which ranged from $134.01 to $1,333.04 with varying insurance models. Costs of ongoing treatment with transdermal testosterone are similarly higher via DTC platforms., Clinical Implications: Patients with private insurance or Medicare should be counseled that ongoing treatment through telemedicine platforms will likely incur a greater cost than receiving such care at a tertiary center that can utilize insurance coverage., Strengths & Limitations: Practice and cost comparisons include accurate, up-to-date information based on each platform's website. Limitations include the analysis of only three telemedicine platforms, and the ability to describe only the information provided on each website. In addition, cost estimates for the tertiary center only include a single type of private and public insurance, limiting generalizability., Conclusion: This observational study indicates that direct-to-consumer telemedicine platforms are largely following practice guidelines in the evaluation and treatment of testosterone, however, there is a high cost associated with ongoing treatment. Jesse E, Sellke N, Rivero M-J, et al. Practice Comparison and Cost Analysis of Direct-to-Consumer Telemedicine Platforms Offering Testosterone Therapy. J Sex Med 2022;19:1608-1615., (Copyright © 2022 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: The management of chronic scrotal pain is long and varied, with historical treatment algorithms typically ending with orchiectomy. Microsurgical denervation of the spermatic cord (MDSC) is a testicle-sparing option for patients who have failed conservative treatment options and over its forty-year history has seen many technical refinements., Objectives: To review the history and development of MDSC and discuss the outcomes of different surgical techniques., Methods: A literature review using PubMed and Google Scholar was conducted to identify studies pertaining to surgical treatment of CSP, MDSC, and outcomes. Search terms included "chronic," "scrotal pain," "orchialgia," "spermatic cord," "denervation," and "microsurgery.", Results: We included 21 case reports and series since the first seminal paper describing MDSC technique in 1978. Additional studies that challenged existing conventions or described novel techniques are also discussed. The current standard procedure utilizes a subinguinal incision and a surgical microscope. Open, robotic, and laparoscopic approaches to MDSC have been described, but access to minimally invasive instruments may be limited outside of developed nations. Pain reduction following preoperative spermatic cord predicts success of MDSC. Methods for identifying and preserving the testicular and deferential arteries vary depending on surgeon preference but appear to have comparable outcomes. Future developments in MDSC involve targeted denervation, minimizing collateral thermal injury, and alternative techniques to visualize arterial supply., Conclusion: For patients suffering from CSP, MDSC is a well-studied technique that may offer appropriately selected patients' relief. Future investigation comparing targeted vs full MDSC as well as in vivo study of new techniques are needed to continue to improve outcomes. Sun HH, Tay KS, Jesse E, et al. Microsurgical Denervation of the Spermatic Cord: A Historical Perspective and Recent Developments. Sex Med Rev 2022;10:791-799., (Copyright © 2021 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Male circumcision is a polarizing and prevalent procedure. Little understanding exists regarding patient preferences for circumcision appearance. Our objective was to elicit how mucosal collar length may be perceived in terms of overall cosmesis and desirability among adults., Methods: A questionnaire using REDCap was created and distributed through Amazon Mechanical Turk. Respondents provided demographic information and circumcision status before being challenged with artistic representations of circumcised penises with increasing lengths of mucosal collar. Participants were asked to select the most and least esthetically pleasing image, as well as rate the "importance of appearance" from 0-100. Responses were analyzed with ordinal regression models., Results: Preference for shorter mucosal collars were seen in respondents with a postgraduate education (p=0.013) and no religious affiliation (p=0.034). In contrast, participants reporting a religious affiliation preferred longer mucosal collars (p=0.034). Circumcised males rated appearance as being more important (p=0.001) in contrast to uncircumcised males who did not (p=0.001). Circumcised fathers were more likely to circumcise their sons relative to uncircumcised fathers (p<0.05) and women preferred circumcision (p<0.05)., Conclusions: Our study revealed polarized esthetic preferences in the sample as a whole, with large proportions of respondents selecting the longest or shortest collar length. Preferences regarding mucosal collar length appear to be most influenced by education and religion. Overall, our study did not observe a predominant preference for mucosal collar length following circumcision. Surgeons should engage patients and/or caregivers/parents preoperatively in discussions regarding preferences and desired cosmetic outcomes.

Introduction: Procedural specialties are at higher risk for malpractice claims than non-procedural specialties. Previous studies have examined common damages and malpractice lawsuits resulting from specific procedures. Our goal was to analyze urological interventions that led to sexual dysfunction (SD) claims., Methods: The Casetext legal research platform was queried using search terms for medical malpractice and common men's health procedures between 1993 and 2020. In total, 236 cases were found, and 21 cases met the inclusion criteria: malpractice cases against a urologist or urology group, clearly stated legal outcome, and allegation of sexual dysfunction from an intervention that directly caused damages., Results: A total of 42 damages were cited in 21 lawsuits. The top three damages claimed were erectile dysfunction (ED) (14/42, 33.3%), genital pain syndrome (7/42, 16.7%), and urinary incontinence (5/42, 11.9%). The most commonly cited treatments were urinary catheter placement or removal (3/21, 14.3%), robotic-assisted laparoscopic radical prostatectomy (RALP) (3/21, 14.3%), circumcision (3/21, 14.3%), and penile implant (3/21, 14.3%). In 19 of 21 suits (90.4%), the outcome favored the defendant. Two cases favored the plaintiff: penile implant (failure to prove the patient was permanently, organically impotent prior to the procedure; missed urethral injury at time of surgery, $300 000) and vasectomy (damage to vasculature resulting in loss of testicle, $300 000)., Conclusions: Most suspected malpractice cases resulting in SD favored the defendant urologist. Interestingly, urinary catheter placement is as likely to result in litigation as other operative interventions, such as RALP, inflatable penile prosthesis, and circumcision. It is possible that thorough preoperative counselling and increased responsiveness to patients' postoperative concerns may have avoided litigation in several cases.

Introduction: We aimed to evaluate opioid prescribing patterns of urologists across the United States (U.S.) and the District of Columbia (D.C.) using publicly available data from Medicare Part D. Our secondary analysis was to identify any loco-regional trends that may exist within the U.S., Methods: We queried publicly reported information from the Part D prescriber database, which is compiled from beneficiaries enrolled within the Medicare Part D prescription drug program. Only providers with the specialty description of urologist were included in this study., Results: Between 2013 and 2017, a five-year average of 452 901 opioid claims by 9640 urologists - amounting to $5 357 114 USD and comprising 3.78% of all claims made - were identified. The state of Maine featured the highest percentage of opioid claims in relation to all claims (5.81%). West Virginia had the greatest average total opioid claims per provider (90), while Michigan featured the highest average proportion of opioid claims per provider (10.63%). The fewest opioid claims were processed within the Mid-Atlantic and New England regions., Conclusions: A multitude of factors likely contributes to variability between states. Urologists should be increasingly aware of their individual prescription tendencies and use available drug monitoring programs to reduce unnecessary prescriptions, all while providing more targeted and appropriate pain management.

Objective: To evaluate differences in perioperative clinical outcomes in men undergoing artificial urinary sphincter (AUS) implantation in primary versus replacement settings. Secondarily, we aimed to identify patient-related factors contributing to complications associated with AUS placement., Materials and Methods: A review of the American College of Surgeons-National Surgical Quality Improvement Program was performed between 2010 and 2018 identifying males undergoing AUS implantation. Subjects were further subdivided into primary implantation or removal/replacement of AUS simultaneously via current procedural terminology codes 53445 and 53447, respectively. 30-Day postoperative outcomes were compared between cohorts using t-test and Fisher's exact test. The relationship between patient factors and complications was evaluated using logistic regression., Results: A total of 1,892 patients were identified: 1,445 primary AUS placement and 447 AUS replacement procedures. Patients undergoing AUS replacement were statistically older than those undergoing primary implantation (71.4 vs 69.7 years, P < .001). AUS replacement procedures were associated with an increased rate of superficial surgical site infection (SSI) compared to primary procedures (1.3% vs 0.4%, P ¼ .042). There were no differences identified between cohorts for deep SSI, cardiopulmonary complications, reoperation, operative time, or length of stay. Logistic regression demonstrated that higher body mass index was found to be independent risk factors for any complications, and diabetes mellitus was associated with increased risk of AUS-related readmission., Conclusion: Within the perioperative period, patients undergoing replacement AUS have an increased risk of superficial SSI compared to primary AUS implantation. These findings can assist with appropriate perioperative counseling of patients undergoing primary and replacement AUS implantations.

Introduction: We aimed to describe infertility insurance coverage provided to male and female fellows working at institutions that offer advanced infertility training., Methods: Faculty and fellows working within U.S. and Canadian andrology or reproductive endocrinology and infertility (REI) programs were contacted and asked for a copy of their institutional health insurance summary of benefits. Documents were assessed for coverage of diagnosis and treatment, shared costs, and maximum lifetime coverage for infertility care., Results: Insurance policies from 24 institutions were reviewed; 16 of 24 (66%) institutions covered costs related to the diagnosis of infertility. Six institutions (25%) offered coverage for diagnosis but not treatment. There were 15 (62.5%) institutions that offered some amount of coverage for the treatment of infertility, and the average lifetime maximum was $16 100. Only six of 24 (25%) plans explicitly described a covered male-specific treatment, which included sperm extraction (12.5%), varicocele repair (4.2%), and sperm cryopreservation (8.3%)., Conclusions: For physician trainees, infertility insurance coverage is not universal, policies are not transparent, and treatment for male factor infertility is often omitted. With high costs of infertility treatment, variable insurance coverage, and debt and time constraints, residents and fellows are a particularly vulnerable population that may experience significant financial toxicity when faced with infertility.

Background: To assess whether prior interventional treatment for benign prostatic hyperplasia (BPH) influences oncologic or functional outcomes following primary whole-gland prostate cryoablation., Methods: Among 3831 men with prostate cancer who underwent primary whole-gland prostate cryoablation, we identified 160 with a history of prior BPH interventional therapy including transurethral needle ablation (n = 6), transurethral microwave thermotherapy (n = 9), or transurethral resection of the prostate (n = 145). Patients with a history of medically treated or unspecified BPH therapy were excluded from the study. Oncological and functional outcomes were compared between men with and without prior BPH interventional therapy., Results: In unadjusted analyses, prior interventional BPH therapy was associated with higher risks of postoperative urinary retention (17.5% vs. 9.6%, p = 0.001) and new-onset urinary incontinence (39.9% vs. 19.4%, p > 0.001) compared with no prior therapy. Interventional BPH therapy was not correlated with the risk of developing a rectourethral fistula (p = 0.84) or new-onset erectile dysfunction (ED) at 12 months (p = 0.08) following surgery. On multivariable regression, prior interventional BPH therapy was associated with increased risk of urinary retention (OR 1.9, 95%, p = 0.015) and new-onset urinary incontinence (OR 2.13, p < 0.001). The estimated 5 years Kaplan-Meier survival analysis showed no statistically significant difference (p = 0.3) in biochemical progression free survival between those who underwent interventional BPH therapy compared with those who did not. Local disease recurrence assessed by post cryoablation positive for-cause prostate biopsy showed no significant difference between the two groups (25.4% vs. 28.7%, p = 0.59)., Conclusions: Prior interventional BPH therapy did not affect the oncologic outcomes nor did it increase the risk of rectourethral fistula or ED in sexually performing patients prior to cryosurgery. Prior interventional BPH therapy was associated with increased risk of urinary retention and incontinence after primary whole-gland prostate cryoablation for prostate cancer.

Objective: To determine the response to a virtual educational curriculum in reconstructive urology presented during the COVID-19 pandemic. To assess learner satisfaction with the format and content of the curriculum, including relevance to learners' education and practice., Materials and Methods: A webinar curriculum of fundamental reconstructive urology topics was developed through the Society of Genitourinary Reconstructive Surgeons and partnering institutions. Expert-led sessions were broadcasted. Registered participants were asked to complete a survey regarding the curriculum. Responses were used to assess the quality of the curriculum format and content, as well as participants' practice demographics., Results: Our survey yielded a response rate of 34%. Survey responses showed >50% of practices offer reconstructive urologic services, with 37% offered by providers without formal fellowship training. A difference in self-reported baseline knowledge was seen amongst junior residents and attendings (P < .05). Regardless of level of training, all participants rated the topics presented as relevant to their education/practice (median response = 5/5). Responders also indicated that the curriculum supplemented their knowledge in reconstructive urology (median response = 5/5). The webinar format and overall satisfaction with the curriculum was highly rated (median response = 5/5). Participants also stated they were likely to recommend the series to others., Conclusion: We demonstrate success of an online curriculum in reconstructive urology. Given >50% of practices surveyed offer reconstruction, we believe the curriculum's educational benefits (increasing access and collaboration while minimizing the risk of in-person contact) will continue beyond the COVID-19 pandemic and that this will remain a relevant educational platform for urologists moving forward., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Reports of adult orchidopexy for bilateral undescended testicles (bUDT) are sparse, and fertility outcomes are not well established. Our aim was to determine prognosis for restoration of spermatogenesis among adult men (≥18 years) undergoing orchidopexy for bUDT., Methods: A systematic literature review, conforming to the PRISMA statement, was conducted using the PubMed/MEDLINE and EMBASE databases through March 2020 using search terms "adult" AND "bilateral orchidopexy" OR "bilateral cryptorchidism." Relevant referenced articles from non-indexed journal were identified by Google Scholar search and additionally included., Results: Fifty-seven publications including adult men with uncorrected bilateral UDTs were identified. Baseline semen analysis was reported in 157 men, all of whom demonstrated azoospermia. Testosterone values were reported in 82 cases and were normal in 89%. Germ cells could not be identified in 72.6% of histologic specimens from 62 testicles. Abdominal testicles more frequently lacked germ cells (90%, p = 0.038) on univariate analysis. Eleven cases identified ejaculated spermatozoa following adult bilateral orchidopexy (8 publications). Sperm extraction (TESE) during orchidopexy or orchiectomy was reported in 13 men without success. Delayed TESE (median 10 months) was performed in 22 persistently azoospermic men with success in 10 (45.5%), none of whom had abdominal testicles prior to orchidopexy. Six men experienced successful paternity via natural conception (3) or assisted reproduction (3)., Conclusion: Fertility is possible in adult men with inguinal bUDT following orchidopexy. Subsequent sperm retrieval may involve ejaculated specimens or delayed TESE. TESE performed prior to or at time of orchidopexy is unlikely to be of benefit., (© 2020 American Society of Andrology and European Academy of Andrology.)

Background: The rates of infection after inflatable penile prosthesis (IPP) range from 1% to 3%; however, with changes in antibiotic practice intraoperatively and the incorporation of local anesthetic dips, it is unclear whether this incidence of infection is affected., Aim: To evaluate whether the utilization of local anesthetic dips and antifungal solutions affect the efficacy of previously established dips across multiple species and strains., Methods: Strains of four different species of bacteria and one fungus were prepared in a standardized confluency. A standardized, and sterile protocol was used to punch out 6mm circular discs from the reservoir of a Coloplast Titan device. The discs were submerged in a standardized concentration of antimicrobials (combinations of Bactrim, Rifampin + Gentamicin, Vancomycin, Zosyn, and Amphotericin B) and plated. The zone of inhibition (ZOI) was measured at 24, 48, and 72 hours. Five repetitions of each organism was performed (>1700 discs), and the mean ZOI was calculated. Saline and DMSO were used as control on each plate., Outcomes: Main outcome was the ZOI identified with each antibiotic solution, and the secondary outcome was the efficacy of the antibiotic over the course of 72 hours., Results: Difference in antibiotic efficacy was seen when each bacterial species was evaluated separately, with rifampin and gentamicin having less efficacy towards all organisms other than S. epidermidis. When looking specifically at the Candida species, amphotericin B was significantly better than other antibiotic solutions. In regards to efficacy of antibiotics over 72 hours, all treatment groups showed a decrease in ZOI over time. However, treatment groups that included rifampin demonstrated the ability to inhibit S. aureus and S. epidermidis over the 72-hour period., Clinical Implications: To improve clinical practice and alleviate concerns that incorporation of local anesthetic and antifungals may decrease the efficacy of antibiotic solutions., Strengths and Limitations: A major strength of the study is that it is the most robust and scientifically sound study performed on this topic with approximately 1700 repetitions. It is also the first study of its kind to include a wide spectrum of bacterial and fungal strains and antibiotic solutions along with temporal data on drug elution over a 72-hour period. A limitation of the study is the in vitro model, and this needs to be validated in a clinical setting., Conclusions: Dipping prosthetics in antifungal and local anesthetic does not decrease the efficacy of the antimicrobials. The drug elution capabilities of the hydrophilic coating lasts primarily for 24-48hours. Mishra K, Bukavina L, Long L, et al. Do Antifungals and Local Anesthetic Affect the Efficacy of Antibiotic Dipping Solution?. J Sex Med 2021;18:966-973., (Copyright © 2021 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: To highlight and review encouraging preliminary studies behind several alternative products and interventions for erectile dysfunction (ED)., Recent Findings: Alternative treatments for ED are becoming more prevalent with increased consumer interest. "Natural" products are sold online, and numerous clinics offer various off-label and investigational interventions. These alternative treatments have demonstrated varying degrees of efficacy in randomized trials and meta-analyses, but none of these interventions has robust enough evidence to be considered first-line therapy. These treatments may find a role in combination with guideline treatments or may be used in novel penile rehabilitation research protocols. With growing interest in alternative treatment for men's health, an awareness of the literature is imperative for patient counsel. Alternative treatments, like L-arginine, have a growing body of evidence for efficacy in combination with PDE5i, and low-intensity shock wave therapy and stem cell therapy continue to demonstrate encouraging outcomes in ED trials.

Objective: To describe long-term quality of life (QOL) outcomes after rectourethral fistula (RUF) repair. RUF is a debilitating diagnosis and complex surgical dilemma with limited data regarding QOL after repair., Methods: Patients at a tertiary referral center undergoing transperineal RUF repair 1/2009-5/2016 were analyzed. Patients were contacted by telephone to assess QOL following repair. Descriptive analysis performed of short-term surgical data (success and complications) and long-term QOL data (novel questionnaire)., Results: Twenty one men underwent RUF surgery with 95% success after initial repair. Fifty two percent had a history of radiation and/or ablation. Four individuals (19%) experienced a Clavien-Dindo complication within 30 days, with 3 of those being grade III+. Fifteen had postoperative urinary incontinence, of whom 73% underwent artificial urinary sphincter placement. Three previously radiated individuals underwent subsequent urethral stricture surgery. At long-term follow-up (mean 45.6 ± 27.1 months), 53% reported perineal pain, 43% reported problems related to the gracilis flap, and 80% reported urinary incontinence (primarily occasional mild leakage). Twenty one percent were unable to do the things they wanted in their daily lives, while 80% reported that surgery positively impacted their life. None would have opted for complete urinary diversion., Conclusion: RUF repair leads to patient satisfaction and improved QOL, despite possible residual issues such as perineal pain and urinary incontinence. Definitive RUF repair should be offered to suitable radiated and nonradiated patients., (Copyright © 2018. Published by Elsevier Inc.)