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Background: The physician workforce in Saskatchewan depends upon the retention of locally trained physicians. Characteristics collected at the time of medical school application may predict future practice location, but these associations have not been explored., Methods: We identified the current practice location of University of Saskatchewan College of Medicine graduates who matriculated between 2000 and 2013 and extracted data from their admission applications including gender, age, high school, previous university, and current location at the time of application. We then conducted univariate and multivariate analyses to evaluate associations between these characteristics and rural- and Saskatchewan-based practice., Results: We identified the current practice location of 1,001 (98.9%) of the graduates of the included cohorts. Attending a Saskatchewan high school ( p < 0.001), a high school in a smaller population center ( p < 0.01), and a Saskatchewan university ( p < 0.001) were predictive of Saskatchewan-based practice. Attending a high school outside of Saskatchewan ( p < 0.05), a high school in a smaller population center ( p < 0.001), and living in a small population centre at the time of application (p < 0.05) were predictive of rural-based practice within or outside of Saskatchewan., Conclusion: Demographic characteristics collected at time of medical school application are associated with future Saskatchewan- and rural-based practice. These findings will guide admissions policies in Saskatchewan and may inform admission practices of other medical schools., Competing Interests: The authors of this paper have no conflicts of interest to declare., (© 2022 Ironside, Thoma, Trinder, Bueckert, Lee, Domes; licensee Synergies Partners.)

Objectives: Irreversible electroporation (IRE) is an ablation technology that uses electrical energy delivered between electrodes. If the electrodes are placed atraumatically, there is little to no risk of collateral injury, making IRE appealing for the treatment of pancreatic tumors., Methods: We report on 20 patients with pancreatic adenocarcinoma (PAC) who underwent 21 IRE in our center. There were 6 IRE for stage 2 PAC, 11 for stage 3 PAC, 1 for stage 4 PAC, and 2 patients treated with IRE for recurrence after pancreaticoduodenectomy. One patient had local progression 18 months after IRE and received a second IRE treatment. Using propensity score matching (age, sex, stage, tumor size, and chemotherapy), cases were matched 2 to 1 with patients from the Surveillance, Epidemiology, and End Results database., Results: A total of 7 cases experienced 8 complications; 4 complications were mild, and 4 were severe. Significant survival benefit was seen for patients with stage 3 PAC (27.5 vs 14.6 months for the matched group, P = 0.003); for stage 2, median survival was 15 months, and the single stage 4 patient survived 9 months after IRE treatment., Conclusions: Pancreatic cancers were safely and effectively treated with image-guided IRE in our medium-sized center., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Small renal masses (SRMs) are managed with active surveillance (AS), thermal ablation (TA), irreversible electroporation (IRE), or surgery, depending on patient and tumor factors. A novel SRM multidisciplinary clinic (SRMC), involving urologists and interventional radiologists, was established to provide patients with information on treatments options. The objective of this study was to evaluate the impact of the SRMC on treatment decision-making METHODS: Demographics, tumor characteristics, and treatment decisions were prospectively collected on patients (n=216) attending the SRMC between 2016 and 2019. A retrospective historic cohort (n=238) seen by urologists was used as a control group. Key variables were analyzed and compared. Patient satisfaction (n=27) was surveyed and responses were summarized and explored., Results: Mean age, tumor size, and pathology was similar between groups; however, the SRMC cohort had more male patients (65.7% vs. 53.8%, p=0.009). Chosen treatment modality differed significantly between cohorts (p<0.0001). Patients in the historic cohort were treated by AS (41.5%), surgery (37.9%), TA (11.9%), watchful waiting (7.9%), and IRE (0.8%). SRMC patients were treated by TA (42.2%), AS (26.7%), surgery (21.3%), IRE (7.6%), and watchful waiting (2.2%). Post-hoc analysis revealed statistically significant differences in proportions of AS, TA, IRE, and surgery between cohorts. Patients reported high satisfaction with the collaborative approach., Conclusions: A multidisciplinary approach may have an impact on patient treatment decision-making for SRMs. Consultations involving a urologist and an interventional radiologist resulted in more TA and IRE and less AS and surgery. Future studies should evaluate if these findings occur in other centers.

COVID-19 pandemic restrictions abruptly changed the way interviews for medical school admissions have been conducted. This study is unique as it highlights the first successful virtual synchronous multiple mini interview (MMI) in Canada. Our low technical incident rate, troubleshooting strategies and approach may reassure other medical schools considering conducting a virtual MMI. Success was achieved with collaboration, a strong organizational and communication strategy, learning along the way and a priori contingency plans. Virtual interviewing in academic medicine is likely here to stay, and future work to highlight the impact on applicants will help to build on the diversity mission in undergraduate medicine admissions., Competing Interests: All authors have no conflicts of interest to declare., (© 2021 Domes, Bueckert, Tetyurenko, Hall, Ironside, Stobart; licensee Synergies Partners.)

Objective: To compare racial differences in male fertility history and treatment., Design: Retrospective review of prospectively collected data., Setting: North American reproductive urology centers., Patient(s): Males undergoing urologist fertility evaluation., Intervention(s): None., Main Outcome Measure(s): Demographic and reproductive Andrology Research Consortium data., Result(s): The racial breakdown of 6,462 men was: 51% White, 20% Asian/Indo-Canadian/Indo-American, 6% Black, 1% Indian/Native, <1% Native Hawaiian/Other Pacific Islander, and 21% "Other". White males sought evaluation sooner (3.5 ± 4.7 vs. 3.8 ± 4.2 years), had older partners (33.3 ± 4.9 vs. 32.9 ± 5.2 years), and more had undergone vasectomy (8.4% vs. 2.9%) vs. all other races. Black males were older (38.0 ± 8.1 vs. 36.5 ± 7.4 years), sought fertility evaluation later (4.8 ± 5.1 vs. 3.6 ± 4.4 years), fewer had undergone vasectomy (3.3% vs. 5.9%), and fewer had partners who underwent intrauterine insemination (8.2% vs. 12.6%) compared with all other races. Asian/Indo-Canadian/Indo-American patients were younger (36.1 ± 7.2 vs. 36.7 ± 7.6 years), fewer had undergone vasectomy (1.2% vs. 6.9%), and more had partners who underwent intrauterine insemination (14.2% vs. 11.9%). Indian/Native males sought evaluation later (5.1 ± 6.8 vs. 3.6 ± 4.4 years) and more had undergone vasectomy (13.4% vs. 5.7%)., Conclusion(s): Racial differences exist for males undergoing fertility evaluation by a reproductive urologist. Better understanding of these differences in history in conjunction with societal and biologic factors can guide personalized care, as well as help to better understand and address disparities in access to fertility evaluation and treatment., (Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Erectile dysfunction (ED) impacts the wellness and quality of life of millions of Canadians. An evaluation focused on the identification of reversible and irreversible underlying factors is recommended for patients presenting with ED. Through a shared decision-making model framework, the goal of ED treatment is to improve functional outcomes and enhance sexual satisfaction while minimizing adverse effects associated with treatment. Given that ED is assessed and treated by multiple different types of health practitioners, the purpose of this guideline is to provide the best available evidence to facilitate care delivery through a Canadian lens. After a narrative review of ED assessment and treatment for general readership, five key clinical questions relating to priority areas of ED are assessed using the GRADE and evidence-to-decision-making frameworks.

Introduction: Urological presentations are commonly seen in primary care and urologists are concerned that educational gaps exist in undergraduate curricula in Canadian medical schools. A pan-Canadian survey of undergraduate urology education directors (UUEDs) was used to determine the current status of undergraduate urology education in Canada., Methods: In the fall of 2018, a survey was administered to all 17 UUEDs representing every Canadian medical school. The survey assessed multiple factors, including the timing and duration of urologist-led instruction, the perceived adequacy of urological content in the curriculum, and the level of preparedness of graduating students., Results: The response rate was 100%. Variation in the duration (mean total instructional hours: 22.5±17.2 [5-75] hours) and timing of formal urological instruction was seen. The majority of schools covered core content areas, however, erectile dysfunction, urotrauma, and pediatric urology topics were under-represented. One school had a mandatory urology clerkship rotation (one week), while the other 16 schools offered a selective, with 24.3% of students completing this experience. The majority of UUEDs (64.7%) believed the curricular time devoted to urology was inadequate, 29.4% felt that their graduates were unprepared to diagnose and treat common urological problems, and 76.5% strongly agreed or agreed that a national urology curriculum would be useful., Conclusions: There was significant variability in the duration of instruction and delivery of urological topics in Canadian medical schools. There was a perceived need for more urological instruction by most UUEDs, who welcomed a more standardized national curriculum as a strategy to address this need.

Introduction: For medical students, determining which aspects of the Canadian Residency Matching Service (CaRMS) application are the most important when applying to residency programs can be challenging. Due to the lack of current and reliable information on the selection criteria of Canadian urology residency programs, we surveyed each program about which criteria are the most important when selecting future residents in order to provide medical students with more transparency and programs with a better idea of how their criteria compare to those of others., Methods: An electronic survey was sent to all 13 Canadian urology residency programs (both program directors and selection committee members). It asked respondents to rate each aspect of the application on a five-point Likert scale. Following a 100% response rate from program directors, the same survey was sent to selection committee members. A numeric mean score was calculated for each individual aspect surveyed to create an overall rank list of the components. Independent samples t-tests (two groups) were used to compare the scores of program directors vs. program committee members and of francophone programs vs. anglophone programs., Results: Forty-three urologists involved in the application process answered. The three most important aspects were rotation performance at the respondent's institution (4.95±0.21), quality of reference letters from a urologist (4.60±0.62), and interview performance (4.49±0.63). There were no statistically significant differences between program directors and committee members for mean score of any aspect surveyed. Compared to anglophone programs, francophone programs gave statistically more significant importance to French proficiency (p<0.001) and pre-clinical academic performance (p=0.0272), while giving less importance to English proficiency (p<0.001)., Conclusions: Canadian urology residency programs are similar in that they rank "clinical performance during a rotation at their school" as the most important selection criteria when choosing a future urology trainee. Graduate degrees, career plans, and reference letters from non-urologists have less impact when choosing future urology residents. Francophone schools and anglophone schools differ in the importance of language proficiency and preclinical grades as selection criteria for urology residency. This study will provide future urology applicants with more information and transparency when applying to urology programs in Canada and be of use to urology residency programs that must now publish their selection criteria.

Objective: To characterize the referral patterns and characteristics of men presenting for infertility evaluation using data obtained from the Andrology Research Consortium., Design: Standardized male infertility questionnaire., Setting: Male infertility centers., Patient(s): Men presenting for fertility evaluation., Intervention(s): Not applicable., Main Outcome Measure(s): Demographic, infertility history, and referral data., Result(s): The questionnaires were completed by 4,287 men, with a mean male age of 40 years ± 7.4 years and female partners age of 37 years ± 4.9 years. Most were Caucasian (54%) with other races being less commonly represented (Asian 18.6%, and African American 5.5%). The majority (59.7%) were referred by a reproductive gynecologist, 19.4% were referred by their primary care physician, 4.2% were self-referred, and 621 (14.5%) were referred by "other." Before the male infertility investigation, 12.1% of couples had undergone intrauterine insemination, and 4.9% of couples had undergone in vitro fertilization (up to six cycles). Among the male participants, 0.9% reported using finasteride (5α-reductase inhibitor) at a dose used for androgenic alopecia, and 1.6% reported exogenous testosterone use., Conclusion(s): This broad North American patient survey shows that reproductive gynecologists are the de facto gateway for most male infertility referrals, with most men being assessed in the male infertility service being referred by reproductive endocrinologists. Some of the couples with apparent male factor infertility are treated with assisted reproductive technologies before a male factor investigation. The survey also identified potentially reversible causes for the male infertility including lifestyle factors such as testosterone and 5α-reductase inhibitor use., (Copyright © 2019 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Irreversible electroporation (IRE) is a novel technology used in the minimally invasive treatment of small solid organ tumours. Currently, there is a paucity of literature studying treatment of small renal masses (SRMs) with IRE. Our pilot study is the first case series in Canada to use IRE in the treatment of SRMs., Methods: This retrospective cohort pilot study includes five patients (three females and two males) who presented with a SRM that was deemed not amendable to any other treatment than a radical nephrectomy or IRE. The IRE procedures were carried out by an interventional radiologist in conjunction with a urologist using the Angiodynamics NanoKnife IRE device., Results: Mean tumour size was 28 mm (range 18-39), with a mean R.E.N.A.L. nephrometry score of 8.4±0.55. Over a mean followup of 22.8 months (range 14-31), four out of the five patients did not have a radiological recurrence. No adverse events were reported after the five IRE procedures. Renal function was stable post-IRE, with no to negligible decreases in estimated glomerular filtration rate detected (range +2 to -13 mL/min/1.73 m 2 )., Conclusions: Our pilot study demonstrates that renal percutaneous IRE is safe to use in the context of challenging-to-treat SRMs. Early radiological and renal function outcomes are encouraging, but further study is required to assess oncological success. The small sample size, retrospective nature of the study, relatively short followup, and the lack of routine renal biopsy to confirm malignancy are the major limitations noted.

Introduction: Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care protocols that are designed to shorten recovery time and reduce complication rates. 1,2 An ERAS protocol was implemented in the Saskatoon Health region for radical cystectomy patients in 2013. This study evaluates the safety and efficacy of the protocol for patients having radical cystectomy for bladder cancer., Methods: Length of stay, early in-hospital complication rates, 30-day readmission rates, age, and gender were collected for patients seen for bladder cancer requiring radical cystectomy in Saskatoon between January 2007 and December 2016. Of these patients, 176 were pre-ERAS implementation (control group) and 84 were post-ERAS implementation (experimental group). The data from each variable was compared between the groups using a Z-test., Results: There was no significant difference in age or gender of patients between the groups. Average length of stay pre-ERAS was 14.25±14.57 days, which is significantly longer than the post-ERAS average of 10.91±8.56 days (p=0.043). There was no significant difference in 30-day readmission rate (19.87% pre-ERAS vs. 19.05% post-ERAS; p=0.873) or complication rate (51.7% pre-ERAS vs. 46.4% post-ERAS; p=0.425)., Conclusions: The implementation of an ERAS protocol for radical cystectomy reduces length of stay, with no effect on early complication rates or 30-day readmission rates. This indicates that the protocol is safe for patients when compared to previous practices and is an effective means of reducing length of stay.

Objectives: The effect of point-of-care ultrasound (US) training on clinical reasoning in undergraduate medical education remains largely unknown, with concerns arising about possible confusion among learners when such clinical tools are introduced too early. We studied the effect of a urology point-of-care US module on the performance of questions designed to assess clinical reasoning in urinary tract obstruction and voiding dysfunction., Methods: All second-year medical students at the University of Saskatchewan (Regina [n = 36] and Saskatoon [n = 61]) were enrolled in the study. Each cohort participated in the urology point-of-care US module concurrently with its Foundations in the Kidney and Urinary Tract course. The Regina cohort completed the point-of-care US module 1 week before the Saskatoon cohort, thus allowing for a control-intervention comparison of script concordance question scores to evaluate the effect that the urology point-of-care US module had on clinical reasoning skills. Secondary outcomes included program evaluation metrics, such as overall course performance, urology point-of-care US objective structured clinical examination performance, and student course evaluation data., Results: The introduction of the urology point-of-care US module was not associated with a deterioration in scores on script concordance questions. There were no statistically significant differences between the Regina and Saskatoon students in their responses to the script concordance questions. There were statistically significant increases in student self-reported achievement of learning objectives, with the effect size being medium to large (Cohen d, 0.5-0.8)., Conclusions: Point-of-care US training complements standard undergraduate classroom teaching of urology. Students effectively learned the skills to apply point-of-care US in their assessment of patients, and this process did not interfere with achieving the course objectives., (© 2018 by the American Institute of Ultrasound in Medicine.)

Objective: To educate primary health care professionals about the diagnosis and treatment of postobstructive diuresis (POD), a rare but potentially lethal complication associated with the relief of urinary obstructions., Sources of Information: The main concepts and clinical evidence reviewed in this article were derived from a literature search of PubMed and Google Scholar. Expert opinion was used to supplement recommendations in areas with little evidence., Main Message: Urinary retention is a frequently encountered presentation seen by all physicians. Most family physicians are comfortable treating these patients, initiating investigations, and organizing appropriate follow-up. This article reviews a rare but potentially lethal complication known as POD. Postobstructive diuresis is a polyuric response initiated by the kidneys after the relief of a substantial bladder outlet obstruction. In severe cases this condition can become pathologic, resulting in dehydration, electrolyte imbalances, and death if not adequately treated. Primary care physicians should be familiar with this potential clinical entity, especially as they are generally the first to encounter and treat these patients., Conclusion: Physicians aware of POD will be able to identify patients at risk and arrange the appropriate monitoring after relieving a urinary obstruction. Early diagnosis and treatment of pathologic POD will prevent mortality.

Epithelioid hemangioma is a rare benign vascular tumour that atypically involves the penis and usually presents as a painful nodule. A 35-year-old man presented with a 5-month history of painful erections without a clinically apparent lesion or deformity. Magnetic resonance imaging (MRI) with pharmacologically induced erection demonstrated a 1.3-cm nodular lesion deep to the skin at the base of his penis. Following local excision of the lesion, which was diagnosed as an epithelioid hemangioma, the patient was symptom free. This case demonstrates a rare etiology of painful erections with a unique presentation. To the authors' knowledge, it is also the first report of MRI with intracavernosal injection of trimix to assess for a specific cause of painful erections.

Most giant pheochromocytomas do not present with classic symptoms, as documented by published case reports. Given this, clinicians have to consider a wide differential diagnosis for any retroperitoneal mass and perform screening tests to rule out a pheochromocytoma. We describe the largest pheochromocytoma reported in Canada, where the patient presented with a palpable abdominal mass and dyspnea. The 19 × 18 × 12-cm right retroperitoneal mass was biochemically active and was radiologically and pathologically consistent with a giant pheochromocytoma. We present this case and review the relevant current literature.

Prostate cancer usually metastasizes to the regional lymph nodes, and distal metastases to supraclavicular lymph nodes are rarely reported, especially as an initial presentation. Limited case reports describe cervical lymphadenopathy as the initial presentation of metastatic prostate cancer, and often with widely disseminated disease. Patients with this initial presentation rarely undergo digital rectal examination or serum prostate-specific antigen (PSA) level measurement as part of their initial investigations. A high index of suspicion is necessary to make the diagnosis of prostate cancer in this clinical setting. We present a rare case of prostate carcinoma presenting with supraclavicular lymph node enlargement at the initial diagnosis. A review of the relevant literature is provided.

Introduction: In an effort to reduce the incidence of postoperative surgical site infections (SSIs), many hospitals have adopted a strict practice of preoperative hair removal using clippers, as opposed to razors. However, the skin of the male genitalia is delicate, elastic with irregular skin folds and may be ill-suited for clippers., Aim: To compare shave quality and the degree of skin trauma using two methods of preoperative hair removal on the scrotal skin: clippers vs. razors., Methods: Patients undergoing surgery involving the male genitalia requiring preoperative hair removal were randomized to hair removal using clippers or a razor. Immediately following hair removal, a standardized digital photograph was taken of the male genitalia. All digital photos were evaluated in a blinded fashion by groups of urologic surgeons and surgical nurses using a standardized five-point global rating scale. The incidence of SSIs was monitored., Main Outcome Measures: Primary outcomes included blinded global ratings of (i) the completeness of the preoperative hair removal within the surgical field and (ii) degree of skin trauma following hair removal. The incidence of SSIs within 3 months of surgery was monitored throughout the study period., Results: Two hundred fifteen consecutive patients were randomized (107 clipper, 108 razor). Overall, preoperative hair removal on the male genitalia using a razor resulted in significantly less skin trauma (P = 2.5E-10) and a more complete hair removal within the surgical field (P = 0.017) compared with clippers. SSIs were identified in four patients during follow-up (1.8%--two using clippers; two, razors)., Conclusions: Our data suggest that preoperative hair removal on the scrotal skin using a razor results in less skin trauma and improved overall shave quality with no apparent increased risk of SSIs. Based on these findings, surgeons should be permitted their choice of razors or clippers for preoperative preparation of the male genitalia., (© 2012 International Society for Sexual Medicine.)

Objective: To determine the incidence of bacteriospermia and elevated seminal leukocytes (ESL) in a subfertile male population and correlate these results with semen parameters., Design: Retrospective cohort study., Setting: Canadian tertiary-level male infertility clinic and university-affiliated andrology and microbiology laboratories., Patient(s): Four thousand nine hundred thirty-five nonazoospermic subfertile men., Intervention(s): Analysis and concurrent culture of 7,852 semen samples., Main Outcome Measure(s): Incidence of bacteriospermia and ESL and comparison of semen parameters between these groups., Result(s): The rate of bacteriospermia was 15% (22 species), and the rate of ESL was 19%, with no statistical correlation between these groups. Bacteriospermic patients (without ESL) had a statistically significant deterioration in DNA fragmentation index (DFI) only, compared with patients without bacteriospermia and ESL (24.1 vs. 21.8%). ESL alone was associated with a statistically significant deterioration in sperm concentration (20.6 vs. 55.3 × 10(6)/mL), motility (21.8 vs. 26.9%), normal morphology (12.3 vs. 17.4%), and DFI (26.5 vs. 21.8%), with no additional deterioration identified with bacteriospermia., Conclusion(s): Bacteriospermia and ESL were prevalent, but not statistically associated, in subfertile men. Bacteriospermia alone was associated with an increase in DFI only, but the presence of ESL was the dominant factor associated with deterioration in semen parameters., (Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: The post-vasectomy pain syndrome is a rare but serious and debilitating complication of vasectomy. For men with the post-vasectomy pain syndrome vasectomy reversal is a surgical option after medical management has failed. However, there is a paucity of data in the literature defining its therapeutic efficacy. In this study we better define the role and effect of vasectomy reversal in the treatment of men with the post-vasectomy pain syndrome., Materials and Methods: Three urologists in Toronto, Ontario performed 149 publically funded vasectomy reversals between January 2000 and September 2010. The electronic health records were reviewed and 23 of the 149 (15%) procedures were performed for the post-vasectomy pain syndrome. Of these men who underwent 14 vasovasostomies 13 completed a telephone conducted questionnaire (response rate 56%). Patient demographics, preoperative and postoperative pain scores, and quality of life were retrospectively assessed., Results: Orchialgia occurred a mean ± SD of 19 ± 42.5 months after vasectomy and the men (mean age 43.8 ± 5.2 years) experienced pain for 50.3 ± 34.9 months before vasovasostomy. After vasovasostomy improvement of pain occurred in 93% (13 of 14) and 50% were rendered pain-free with an average improvement in pain intensity scores of 65% (p <0.005). Of the men 15% (2 of 13) had a recurrence of pain to baseline but overall 79% (11 of 14) had a durable positive response. Quality of life was significantly improved after vasovasostomy (p <0.005) and 93% (13 of 14) of the patients said they would undergo the same operation again., Conclusions: Vasovasostomy is an effective treatment modality for the post-vasectomy pain syndrome, and it can achieve robust and durable long-term improvement in pain intensity and quality of life., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the utility and cost of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) screening in infertile males., Design: Cohort study., Setting: Canadian tertiary-level male infertility clinic and university-affiliated laboratories., Patient(s): 5,588 male infertility patients., Intervention(s): CT and NG testing on 8,972 urine and semen samples., Main Outcome Measure(s): Prevalence of CT and NG infection in infertile males versus general male population in Canada over 8 years (2003-2010) and the reagent cost to detect one case of CT or NG., Result(s): In infertile males, the prevalence rate for CT and NG was 0.304% and 0.0537%, which was statistically significantly lower (3.4- and 8.1-fold lower, respectively) than the age-adjusted general population prevalence. With the reagents costing $86.20 per patient tested, the reagent cost alone to diagnose one case of CT or NG was $38,669., Conclusion(s): The prevalence of CT and NG in this study are among the lowest reported in the male infertility literature. These findings question the utility of CT/NG screening in this low-risk population and emphasize that decisions about the utility of screening must be based on the prevalence rates of the disease in the studied population., (Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the clinical outcomes of intracavernosal injection (ICI) use in an undifferentiated group of men with erectile dysfunction at various stages after radical prostatectomy., Methods: Retrospective charts, mailed questionnaires, and a telephone survey of patients after radical prostatectomy prescribed ICI by a single urologist from January 2006 to January 2008. The patient demographics and prostate cancer profiles, current ICI use patterns, adverse outcome, and clinical efficacy were collected., Results: A total of 117 patients completed the questionnaire. The mean age was 65±6.2 years, and the patients had undergone radical prostatectomy 4.1±2.7 years earlier. Most patients had hypertension (38%) and dyslipidemia (26%); 51% of the patients actively used ICI, with a median of 3 attempts monthly. Sixty-eight percent of all patients were sexually active (98% of ICI users vs 36% of ICI nonusers, P<.001). In the sexually active patients, ICI was associated with significantly greater International Index of Erectile Function scores (20.8±4.1 vs 16.0±6.9, P=.008). ICI was most frequently discontinued because of patient-perceived ineffectiveness (48%), pain (21%), and prolonged erections (11%). Twenty-eight percent of patients had erections lasting longer than they had wished at some point in their treatment, with 10% incidence of priapism., Conclusion: ICI use among patients after prostatectomy can be highly effective but has a significant attrition rate (49%). The identification of reasons for discontinued use can aid healthcare providers to support patients in the early period after adoption of ICI and to direct their counseling more effectively., (Copyright © 2012 Elsevier Inc. All rights reserved.)

There have been tremendous advances in both the diagnosis and treatment of male factor infertility; however, the mechanisms responsible to recreate spermatogenesis outside of the testicular environment continue to elude andrologists. Having the ability to 'grow' human sperm would be a tremendous advance in reproductive biology with multiple possible clinical applications, such as a treatment option for men with testicular failure and azoospermia of multiple etiologies. To understand the complexities of human spermatogenesis in a research environment, model systems have been designed with the intent to replicate the testicular microenvironment. Currently, there are both in vivo and in vitro model systems. In vivo model systems involve the transplantation of either spermatogonial stem cells or testicular xenographs. In vitro model systems involve the use of pluripotent stem cells and complex coculturing and/or three-dimensional culturing techniques. This review discusses the basic methodologies, possible clinical applications, benefits and limitations of each model system. Although these model systems have greatly improved our understanding of human spermatogenesis, we unfortunately have not been successful in demonstrating complete human spermatogenesis outside of the testicle.

Despite recent advances in surgical technique using laparoscopic and robotic approaches for the management of early organ-confined prostate cancer, most contemporary reports demonstrate significant rates of erectile dysfunction comparable to standard open approaches. Controversy remains related to many of the pre-and postoperative management strategies, including agents to enhance nerve recovery, erectogenic drugs, antioxidants, vasoactive injectables, vacuum erection devices and nerve grafting procedures. Additionally, the optimal timing of these interventions and their duration, dose, frequency and outcome thresholds remain ill-defined. In our paper, we provide a comprehensive literature review involving both the basic and clinical data surrounding rehabilitative approaches.

Background: Diabetic men generally have reduced efficacy with PDE-5 inhibitors (PDE5i) for the treatment of erectile dysfunction (ED)., Objective: To determine whether chronic vardenafil exposure alters cavernous protein expression predicting improved erectile function in diabetes., Design: Forty-two adult male Sprague Dawley rats with streptozotocin-induced (50mg/kg IP) diabetes for 4 wk, were exposed to either vehicle or vardenafil for 6 wk. Assessments compared the impact of vardenafil given at 1h and 20 h to erectile function and cellular alterations and downstream translation of cavernous protein profiles were aimed., Intervention: Vehicle or vardenafil 0.5mg/kg/day by oral gavage for 6 wk., Measurements: Erectile function, penile tissue morphology, protein expression and surface enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI) protein profiling were determined., Results and Limitations: A significant increase of intracavernous pressure was seen in both treatment arms compared to diabetic rats not receiving vardenafil. Immunohistochemical staining showed improved endothelial and smooth muscle cell staining with chronic vardenafil use. Western blot analysis demonstrated increased endothelial cell eNOS and smooth muscle alpha-actin protein content. SELDI protein profiling showed enhanced proteins expression at molecular weights of 14.7, 20, 41.9, 66.2, and 83.9 kDa in the chronically treated vardenafil group., Conclusions: Vardenafil was effective in treating diabetic-induced ED with the greatest effect achieved through chronic dosing, with no additive effect measured with the final acute dose. Changes noted in the histology and protein expression indicate that vardenafil may have a protective effect in this disease state. This finding may serve as a basis for further work evaluating the utility of chronic vardenafil dosing in diabetic men.

Introduction: Peyronie's disease (PD) continues to be a major source of sexual dysfunction among the 3-9% of affected men. The challenge in treating PD is determining the natural history and clinical course for the individual patient. Currently, there exists no reliable means to predict whether a penile plaque of PD will progress, regress, or remain stable. This represents a significant deficiency in contemporary management, one that may be addressed with newer technologies such as proteomic profiling., Aim: This review assesses the potential use of protein alterations measured by various novel technologies, to predict progression, regression, or stabilization of PD in an affected individual., Methods: A comprehensive literature review of the past decade in the field of gene profiling and protein expression of PD was performed., Main Outcome Measures: A critical analysis of the existing worldwide literature evaluating surface-enhanced laser desorption/ionization time of flight mass spectrometry (SELDI-TOF-MS or SELDI) and other proteonomic techniques., Results: SELDI and other technologies can provide the clinician with innovative data indicating the presence of unique individual factors that act to suppress or promote the fibrotic process in PD. Determining the clinical implications of altered protein expression in an individual is not yet defined., Conclusions: The area of proteomics has begun to revolutionize the study of medicine in the postgenomic era, by allowing researchers to study the role that proteins play in health and disease. Applying this knowledge clinically has already led to innovative discoveries in early cancer detection in a number of malignancies, including prostate, ovarian, and bladder. Prior to the widespread use and acceptance of proteomic technology in PD, a critical assessment of its therapeutic and diagnostic value will be required.

Background: Continuing medical education for referring physicians is an essential part of raising the profile of plastic surgery and improving patient care. The authors conducted a prospective cohort study to assess the educational needs of emergency and primary care physicians who refer patients to the on-call plastic surgeon., Methods: The following information was collected for telephone referrals from emergency and primary care physicians over a 1-year period: date, location of referral center, population of referral center, distance between referral center and tertiary care hospital, patient age, presenting problem, anatomical location of the problem, and treatment plan proposed by the plastic surgeon. In addition, the 50 physicians who most frequently referred patients were surveyed to identify which topics they perceived to be of the highest educational utility and which were frequently encountered., Results: There were a total of 1077 referrals to on-call plastic surgeons, mostly for trauma (83 percent) and injuries involved primarily the upper extremity (65 percent) or head and neck regions (26 percent). Five percent or more of all referrals involved mandible, phalangeal, metacarpal, or zygomatico-orbital complex fractures, minor burns, flexor tendon injuries, single digits requiring revision of an amputation, and extensor tendon injuries. Referring physicians reported that the topics of most educational utility were management of hand infections, minor burns, nasal fractures, boxer's fractures, complex facial lacerations, frostbite, metacarpal fractures, and scaphoid fractures., Conclusions: To have the greatest potential affect on changing physicians' behavior and improving patient care, continuing medical education should focus on traumatic injuries to the upper extremity and head and neck regions. A prioritized list of topics should include management of minor burns, hand fractures, hand infections, nasal infections, and complex facial lacerations.

Objective: To assess the quality of care of acute myocardial infarction (AMI) in a rural health region., Design: Clinical audit employing multiple explicit criteria of care elements for emergency department and in-hospital AMI management. The audit was conducted using retrospective chart review., Setting: Twelve acute care health centres and hospitals in the East Central Health Region, a rural health region in Alberta, where medical and surgical services are provided almost entirely by family physicians., Participants: Hospital inpatients with a confirmed discharge diagnosis of AMI (ICD-9-CM codes 410.xx) during the period April 1, 2001, to March 31, 2002, were included (177 confirmed cases)., Main Outcome Measures: Quality of AMI care was assessed using guidelines from the American College of Cardiology and the American Heart Association and the Canadian Cardiovascular Outcomes Research Team and Canadian Cardiovascular Society. Quality of care indicators at three stages of patient care were assessed: at initial recognition and AMI management in the emergency department, during in-hospital AMI management, and at preparation for discharge from hospital., Results: In the emergency department, the quality of care was high for most procedural and therapeutic audit elements, with the exception of rapid electrocardiography, urinalysis, and provision of nitroglycerin and morphine. Average door-to-needle time for thrombolysis was 102.5 minutes. The quality of in-hospital care was high for most elements, but low for nitroglycerin and angiotensin-converting enzyme (ACE) inhibitors, daily electrocardiography, and counseling regarding smoking cessation and diet. Few patients received counseling for lifestyle changes at hospital discharge. Male and younger patients were treated more aggressively than female and older patients. Sites that used care protocols achieved better results in initial AMI management than sites that did not. Stress testing was not readily available in the rural region studied., Conclusion: Quality of care for patients with AMI in this rural health region was high for most guideline elements. Standing orders, protocols, and checklists could improve care. Training and resource issues will need to be addressed to improve access to stress testing for rural patients. Clinical audit should be at the core of a system for local monitoring of quality of care.