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Nicholas A Deebel,1 Kyle Scarberry,2 Collette A O’Connor,1 Rahul Dutta,1 Ethan Matz,1 Colleen A Hanlon,3 Ryan P Terlecki1 1Department of Urology, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA; 2Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; 3Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, USACorrespondence: Ryan P Terlecki, Department of Urology, Atrium Health Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, Tel +1 336 716 4131, Fax +1 336 716 9042, Email rterlecki@wakehealth.eduPurpose: Kratom (Mitragyna speciosa) exhibits μ-receptor agonism and is used as an opioid substitute. While opioids are known to inhibit sexual behavior, less is known regarding kratom. We conducted a pilot study to assess the subjective impact of kratom upon male sexual health including erectile and ejaculatory function.Patients and Methods: Twitter and Reddit (r/Kratom) were accessed to disseminate our survey featuring validated instruments (the International Index of Erectile Function, IIEF, and the premature ejaculation diagnostic tool, PEDT). Sexual health prior to and after 4 weeks of kratom use was assessed.Results: Most males surveyed (n = 165) were 18– 40 years old (84.9%), with 95.8% of respondents using it at least weekly and 82.4% using kratom for ≥ 1 year. Reasons for use included treating pain (39.4%), and mental health conditions (63.6%). Kratom was associated with a positive (37.7%) and negative (20.5%) impact on sexual health. Kratom subjectively increased time to ejaculation in 104 (66.6%) patients, perceived as positive by 62 (59.6%). Seventy-eight patients answered questions about premature ejaculation. The median (with interquartile range, IQR, following;) pre-kratom and kratom use scores were 13.0; 8.0 and 6.5; 5.0, respectively (p < 0.001). Ejaculation before 5 minutes improved after kratom (51.3% vs 12.8%) (p < 0.0001). Following kratom use, patients reported lack of frustration with ejaculation prior to desire (21.8% vs 61.5%) (p < 0.001). The erectile function domain of the IIEF was statistically significantly different however – clinically similar pre-kratom use (29.0; 5.75) versus 27.0; 6.75 during kratom use (p = 0.037).Conclusion: Clinicians treating male sexual health should be aware of kratom and its potential effect on ejaculatory and erectile function.Keywords: kratom, Mitragyna speciosa, premature ejaculation, analgesia, sexual function

Introduction and Hypothesis: Operating room turnover times are highly variable, with longer times having a significant negative impact on hospital costs, surgeon volume, and satisfaction. The primary aim of this randomized trial was to examine the impact of a verbalized time goal on the likelihood of meeting institutional goals., Methods: This is a prospective, single-blind, randomized study conducted across four operative sites: inpatient main campus and three outpatient centers. Sequential cases for the same surgeon in the same room were randomized to receive a verbal prompt versus usual care, in which no goal setting was verbalized. Multivariate and univariate statistical analyses were performed., Results: From July through October 2022, five attending surgeons randomized 88 cases (44 verbal prompt, 44 usual care). Of these, 30 were at the main inpatient hospital. The case mixture included 36% vaginal, 27% endoscopy, 8% open, 10% robotic, and others. Average turnover time was 51.7 and 35.3 min for inpatient and outpatient cases respectively. Overall, only 39.8% of cases hit the institutional turnover time goal. Verbal prompting did not significantly increase the likelihood of achieving the institutional goal (38.4% vs 43.4% p = 0.352) except for in minor surgery (64.0 vs 39.0%, p = 0.0477). A verbal prompt reduced turnover time in major surgery (59.7 vs 47.8 min, p = 0.0445)., Conclusion: Our academic center achieved goal turnover times in only 39.8% of cases. Although verbal prompting did not significantly improve the likelihood of meeting institutional goals in the group as a whole, some subgroups were significantly improved., (© 2023. The International Urogynecological Association.)

Autologous engineered urethral constructs are a promising treatment option for definitive management of long and complex urethral strictures, with the prospect of eliminating stricture recurrence., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To assess chat generative pre-trained transformer's (ChatGPT) performance on the American Urological Association Self-Assessment Study Program (AUA SASP) and stratify performance by question stem complexity., Methods: Questions from the 2021-2022 AUA SASP program were administered to ChatGPT version 3 (ChatGPT-3). Questions were administered to the model utilizing a standardized prompt. The answer choice selected by ChatGPT was then used to answer the question stem in the AUA SASP program. ChatGPT was then prompted to assign a question stem order (first, second, third) to each question. The percentage of correctly answered questions was determined for each order level. All responses provided by ChatGPT were qualitatively assessed for appropriate rationale., Results: A total of 268 questions were administered to ChatGPT. ChatGPT performed better on 2021 compared to the 2022 AUA SASP question set, answering 42.3% versus 30.0% of questions correctly (P < .05). Hundred percent of answer explanations provided appropriate, relevant rationale regardless of whether the answer was correct. Further stratification included assessment by question order level. ChatGPT performed progressively better on the 2021 question set with decreasing order levels, with first-order questions reaching 53.8% (n = 14). However, differences in proportions did not reach statistical significance (P > .05)., Conclusion: ChatGPT answered many high-level questions correctly and provided a reasonable rationale for each answer choice. While ChatGPT was unable to answer numerous first-order questions, future language processing model learning may lead to the optimization of its fund of knowledge. This may lead to the utilization of artificial intelligence like ChatGPT as an educational tool for urology trainees and professors., Competing Interests: Declaration of Competing Interest Nicholas Deebel, MD: No relevant conflict of interest. Ryan Terlecki, MD: paid consultant to Boston Scientific (not relevant to this manuscript)., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To stratify ergonomic risk in a urologic microsurgeon using the 4K-3D exoscope versus the operating microscope (OM) with wearable technology., Methods: The surgeon was calibrated with wearable sensor inertial measurement units (IMUs) on the head and upper arms. Each inertial measurement units contained an accelerometer, magnetometer, and gyroscope to measure surgeon joint angle change during microscopic procedures for male fertility. The validated modified rapid upper limb assessment was used to determine the proportion of time spent in ranges of risk. Categories 1-4 were assigned for the head and upper extremities (4= highest ergonomic risk). Chi-squared analysis was used to analyze differences in proportions., Results: A total of 500 and 479 minutes from 4K-3D exoscope and OM guided surgeries were analyzed. The 4K-3D exoscope significantly favored upper arm category 1 positioning compared to the OM (56.2% vs 37.7%; P < .0001). The OM exposed the surgeon to higher category 3 positioning (14.6% vs 1.6%; P <.0001). More time was spent with the neck "extended" using the 4K-3D exoscope (51.8% vs 19.5%; P < .0001) with 67% of neck extension between 0-10° (category 1). Overall, more time was spent with the neck in risk group 1-2 with the OM (P < .0001)., Conclusion: The 4K-3D exoscope offers favorable ergonomic positioning for the upper extremities which may reduce work stress-related injury. More operative time was spent with the neck in mild extension with 4K-3D exoscope utilization. However, the OM favored longer operative times in low-risk neck ergonomic positions., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Efforts to understand and unlock the body's potential for regeneration have increased dramatically in recent years. So-called "biohacking" hopes to improve functionality and reverse disease processes., Objectives: This review will seek to summarize the available data for the use of platelet-rich plasma, cellular therapies, and other novel therapeutics within sexual medicine., Methods: The PubMed database search was performed using the keywords "Stem cell therapy in Erectile dysfunction (ED)", "Gene therapy in ED", "Novel therapeutics for ED", and "Biohacking". Popular news articles for regulation of stem cell therapy were reviewed., Results: Research efforts have managed to produce an array of novel therapeutics, including stem cell therapy and platelet-rich plasma. Although the use of these items has been largely focused within specialties other than urology, applications involving sexual medicine have been documented and appear to be increasing., Conclusion: Despite evidence of these technologies being adopted within clinical practices as revenue-generators, quality data to support efficacy are quite limited. Matz EL, Scarberry K, Terlecki R. Platelet-Rich Plasma and Cellular Therapies for Sexual Medicine and Beyond. Sex Med Rev 2022;10:174-179., (Copyright © 2020 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this article is to describe the indications and proper technique for RUG and MRI, their respective image findings in various disease states, and the common surgical techniques and imaging strategies employed for stricture correction., Results: Because of its length and passage through numerous anatomic structures, the adult male urethra can undergo a wide array of acquired maladies, including traumatic injury, infection, and neoplasm. For the urologist, imaging plays a crucial role in the diagnosis of these conditions, as well as complications such as stricture and fistula formation. While retrograde urethrography (RUG) and voiding cystourethrography (VCUG) have traditionally been the cornerstone of urethral imaging, MRI has become a useful adjunct particularly for the staging of suspected urethral neoplasm, visualization of complex posterior urethral fistulas, and problem solving for indeterminate findings at RUG., Conclusions: Familiarity with common urethral pathology, as well as its appearance on conventional urethrography and MRI, is crucial for the radiologist in order to guide the treating urologist in patient management.

Introduction: The prevalence of erectile dysfunction (ED) is substantial and continues to rise. Current therapeutics for ED consist of oral medications, intracavernosal injections, vacuum erection devices, and penile implants. While such options may manage the disease state, none of these modalities, however, restore function. Stem cell therapy has been evaluated for erectile restoration in animal models. These cells have been derived from multiple tissues, have varied potential, and may function via local engraftment or paracrine signaling. Bone marrow-derived stem cells (BMSC) and adipose-derived stem cells (ASC) have both been used in these models with noteworthy effects., Aim: Herein, we will review the pathophysiology of ED, animal models, current and novel stem-cell based therapeutics, clinical trials and areas for future research., Methods: The relevant literature and contemporary data using keywords, "stem cells and erectile dysfunction" was reviewed., Main Outcome Measure: Examination of evidence supporting the association between erectile dysfunction and adipose derived stem cells, bone marrow derived stem cells, placental stem cells, urine stem cells and stem cell therapy respectively., Results: Placental-derived stem cells and urine-derived stem cells possess many similar properties as BMSC and ASC, but the methods of acquisition are favorable. Human clinical trials have already demonstrated successful use of stem cells for improvement of erectile function., Conclusion: The future of stem cell research is constantly being evaluated, although, the evidence suggests a place for stem cells in erectile dysfunction therapeutics. Matz EL, Terlecki R, Zhang Y, et al. Stem Cell Therapy for Erectile Dysfunction. Sex Med Rev 2019;7:321-328., (Copyright © 2018 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: We identified preoperative differences between patients undergoing incontinent vs continent diversion, and compared 30-day complication outcomes between the 2 procedures., Methods: Using the NSQIP ® (National Surgical Quality Improvement Program) database we identified patients undergoing urinary diversion incorporating bowel, with or without cystectomy, between 2010 and 2012. We compared preoperative characteristics, surgical parameters and 30-day postoperative outcomes. We stratified patients based on the continence status of the diversion as incontinent vs continent., Results: We identified 1,959 urinary diversions in the NSQIP database, including 1,568 incontinent diversions (80.0%) and 391 continent diversions (20.0%). Significantly higher rates of chronic obstructive pulmonary disease (9.1% vs 4.3%), previous cardiac surgery (4.3% vs 1.8%), hypertension (63.3% vs 47.1%) and disseminated disease (4.7% vs 2.1%) were noted in patients undergoing incontinent diversion. Patients undergoing continent diversion were significantly more likely to have received preoperative chemotherapy (10.5% vs 5.2%). Operative time was longer for continent diversion (388 vs 336 minutes). Postoperative urinary tract infection (13.8% vs 7.9%) and sepsis rates (11.5% vs 7.9%) were significantly higher with continent diversion, whereas transfusion rates were higher with incontinent diversion (45.2% vs 37.1%). Thirty-day readmission rates (18.2% vs 15.6%), length of stay (10.2 vs 10.7 days), presence of at least 1 NSQIP captured complication (61.4% vs 64.0%) and mortality (1.5% vs 2.1%) were not statistically different between continent diversion and incontinent diversion., Conclusions: Urinary diversion incorporating bowel continues to carry a significant risk of postoperative morbidity. While continent diversion offers potential long-term advantages, these must be balanced against longer operative times and higher rates of postoperative infectious complications.

Chronic testicular pain (CTP) is a complex pain syndrome that is widely variable in presentation and etiology. Many cases of CTP are thought to be associated with neuropathy and recent data suggest an inflammation-mediated process is more common among patients with CTP. Deficiencies in vitamin B12 and testosterone are common in chronic pain syndromes may play a role in CTP. A retrospective review of men treated for CTP by a single provider over a 2-year period was performed. Patients with serum screening of testosterone and B12 were selected. Patients with total testosterone below 300 ng/dl, free testosterone below 46 pg/ml, or B12 below 400 pg/ml were deemed deficient and offered repletion. Efficacy of treatment was measured based on patient report with a minimum follow-up of either 3 months or resolution of pain symptoms. One hundred and fifty-four (154) men with CTP were identified, with 125 assessed for testosterone and B12 levels. Of these, 95 patients (76%) were deemed deficient. Fifty-six (56) patients elected to receive B12/testosterone replacement. In patients with sufficient follow-up, 24 patients (65%) reported significant improvement of symptoms, 6 patients (16%) reported some improvement, and 7 patients (19%) reported no improvement. The prevalence of testosterone and B12 deficiencies in this study is much higher than that reported for the general population. In addition, when chemical deficiencies were corrected, greater than 80% of patients with sufficient follow-up reported some improvement in pain. This suggests that screening of B12 and testosterone should be incorporated into the assessment of patients with CTP.

Purpose: Performance of minimally-invasive surgery (MIS) is increasing relative to open surgery. We sought to compare the contemporary rates of short-term complications of open versus laparoscopic renal and ureteral surgery in pediatric patients., Materials and Methods: A retrospective cross-sectional analysis of the National Surgical Quality Improvement Program Pediatrics database was performed of all cases in 2014 identified using CPT procedure codes for nephrectomy, partial nephrectomy (PN), ureteroneocystostomy (UNC), and pyeloplasty, and reviewed for postoperative complications. Univariate analysis was performed to determine 30-day complications, with comparison between open and MIS approaches. Receiver operator curve (ROC) analysis was performed to determine differences in body surface area (BSA) and age for open versus MIS., Results: Review identified 207 nephrectomies, 72 PN, 920 UNC, and 625 pyeloplasties. MIS was associated with older age and larger BSA except for cases of UNC. Apart from PN, operative durations were longer with MIS. However, only PN was associated with significantly longer length of hospital stay (LOS). There was no difference in incidence of all other 30-day complications. When evaluating BSA via ROC, the area under the curve (AUC) was found to be 0.730 and was significant. Children with a BSA greater than 0.408 m 2 were more likely to have MIS (sensitivity, 66.9%; specificity, 69.3%). Regarding age, the AUC was 0.732. Children older than 637.5 days were more likely to have MIS (sensitivity, 72.8%; specificity, 63.3%)., Conclusions: Pediatric MIS is associated with longer operative time for nephrectomy, but shorter LOS following PN. Surgical approach was not associated with difference in short-term complications., Competing Interests: CONFLICTS OF INTEREST: The authors have nothing to disclose.

Introduction: In the era of minimally invasive surgery, endoscopic and percutaneous interventions for urinary tract stones have become a mainstay, and the need for open stone surgery (OSS) has decreased. We sought to determine the contemporary incidence of OSS among urologists in the United States., Methods: Case logs submitted for certification to the American Board of Urology from 2005 to 2015 were queried for Current Procedural Terminology codes relevant to OSS. Cases were analyzed for the associated practice type, practice area population, geographic region, provider subspecialty, and certifying status of the reporting urologist., Results: A total of 334 cases of OSS were identified, with 73.4% performed by urologists self-identified as generalists. The most common subspecialists performing OSS were endourologists (12.3%). Most cases were done in the private practice setting (80.4%), and in practice areas with populations exceeding 1,000,000 (43.2%). OSS was more commonly reported by urologists applying for recertification than initial certification. Thirty open stone cases were reported each year on average, and there was no decrease in stone cases over time based on linear regression analysis (R 2  = 0.06). OSS was most commonly performed in the Western Section of the American Urological Association (AUA) (25.1%) and least commonly performed in the Northeastern Section (1.5%). A chi-square analysis was performed, and the Western Section had a significantly higher number of OSSs than expected as its urologists represent only 17% of the total AUA membership (p < 0.01). The Northeastern Section comprises 7% of the AUA membership but only performed 1.5% of OSSs that were significantly lower than expected (p < 0.001)., Conclusions: Domestic performance of OSS remains stable. It is unclear as to whether the majority of these cases could be served by less-invasive technologies or whether the volume represents a true nadir. Future work may be warranted to assess attitudes, training, and feasibility of minimally invasive stone management in areas where OSS is most common.

Introduction: Domestically the estimated annual cost of medical malpractice is $55.6 billion. As surgical providers in a high risk subspecialty, urologists are at particularly high risk. Interventions for nephrolithiasis are especially common in practice, and understanding the risks associated with high volume procedures is critical for quality improvement and cost containment., Methods: Using the Westlaw legal database we identified all legal briefs with the search terms "medical malpractice" and "kidney stone" or "nephrolithiasis" for dates between January 2000 and December 2015. Each case was evaluated for alleged cause of malpractice, resulting injury and indemnity payments., Results: The initial search yielded 55 cases, which was decreased to 29 after exclusions. Most cases (15, 52%) were decided in favor of the defendant, while the remaining suits led to indemnity payments, including 6 cases that were settled and 8 with verdicts for the plaintiff. Of named defendants 75% were urologists. The mean settlement amount was $158,400 while the mean indemnity payment for verdicts decided in favor of the plaintiff was $124,400. The most commonly alleged breach of duty was negligent performance in surgery (15 cases), followed by negligent postoperative care (6 cases), and failure to diagnose and treat (5 cases). The most commonly claimed damage was death (13 cases)., Conclusions: Malpractice cases related to the management of nephrolithiasis most commonly involve allegations of negligent performance in surgery, negligent postoperative care, or failure to diagnose or treat. Urologists account for 75% of named defendants and should be aware of factors that increase the risk of litigation.

Objective: To determine the trend in surgical management of male stress urinary incontinence (SUI) in the context of the rate of radical prostatectomy (RP) as reported by a national database. Traditionally, the artificial urinary sphincter (AUS) has been the gold standard, but the male sling represents a newer and popular alternative. Refinements in prostate surgery may reduce the incidence and degree of subsequent SUI., Materials and Methods: A retrospective cross-sectional analysis was performed using the National Inpatient Survey database, which captures discharge data from inpatient and overnight admissions. Cases were identified by their International Classification of Diseases, Ninth Revision procedure codes. We queried the codes 58.93 (implantation of AUS), 59.4 (suprapubic sling operation), 59.5 (retropubic urethral suspension), and 59.6 (paraurethral suspension). We also queried 60.5 (RP) for comparison. Data were collected from January 2000 to December 2012 and weighted to a national average using National Inpatient Survey guidelines., Results: A total of 32,416 anti-incontinence operations (20,790 AUS and 11,625 sling procedures) were performed over the study period. There was a significant downward trend in the total number of incontinence procedures (F(1,11) = 6.15, P = .03). However, when stratifying the data by procedure type, only AUS placement demonstrated a significant decline (F(1,11) = 21.70, P <.01), whereas sling procedures significantly increased (F(1,11) = 12.95, P <.01). There was no significant change in the annual incidence of RP., Conclusion: Inpatient surgery for male SUI is decreasing overall. Placement of the AUS declined significantly, whereas sling placement became more common. Future study will determine the etiology of these trends., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To analyze the trend in inpatient vs outpatient performance of anterior urethroplasty and examine outcomes using data from the National Surgical Quality Improvement Program database., Methods: A retrospective cross sectional analysis was performed using the National Surgical Quality Improvement Program database. Cases of single-stage anterior urethroplasty from 2006 to 2013 were identified using the International Classification of Diseases, Ninth Revision, procedure code 53410. Univariate analysis was performed to compare 30-day complication rates for inpatient and outpatient cases. A linear regression model was created for all years with greater than 50 reported cases., Results: A total of 326 anterior urethroplasties were reported; 222 (68.1%) were inpatient procedures, and 104 (31.9%) were outpatient procedures. The most common complication, urinary tract infection, was consistent between inpatient (2.7%) and outpatient (2.9%) procedures. The rate of wound dehiscence was significantly higher among outpatient cases (1.92% vs 0%, P = .03). There were no significant differences in the rates of wound infection, bleeding, graft failure, deep vein thrombosis, pneumonia, or sepsis. The linear regression model shows a significant increase in outpatient procedures (R 2  = 0.91) and equivalent decrease in inpatient procedures (R 2  = 0.91) for the last 3 years of the study period. Resident involvement was associated with a decreased rate of reoperation (0% vs 8.3% P <.001)., Conclusion: There has been a shift in the performance of anterior urethroplasty toward outpatient management. Overall, complication rates appear low. Future research is necessary to determine how to decrease overall cost of single-stage urethroplasty without compromising quality of care., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Context: Mesh-related complications following transvaginal management of pelvic organ prolapse (POP) and/or stress urinary incontinence (SUI) have received significant attention in the last decade., Objective: We sought to identify patient, product, and technical factors associated with an increased risk of complications after mesh-based transvaginal repair of anterior POP and SUI. In this review we clarify the different pattern of complications after POP and SUI repairs. Our aim is to provide a practical evidence-based guide for physicians to prevent and, if necessary, manage product-associated complications in a stepwise manner., Evidence Acquisition: We conducted a comprehensive PubMed search of all English-language articles published from 2010 to June 2016, using these search terms: mesh, pelvic organ prolapse, and stress urinary incontinence. Expert opinion is also provided., Evidence Synthesis: Mesh-related complications are much lower after repair of SUI compared with POP, despite its more frequent use. Vaginal exposure is the most common mesh-specific complication. Patients may present with vaginal discharge, dyspareunia, pain, recurrent urinary tract infection, and/or hematuria. Conversely, patients may be asymptomatic. Small asymptomatic mesh exposures (<0.5cm) may be treated conservatively. Larger exposures will require partial, if not complete, excision with reconstruction. Any mesh encountered within the urinary tract must be fully excised. Following excision, pain may persist in up to 50% of patients., Conclusions: Vaginal extrusion, persistent pain, and urethral and/or bladder erosion are the three most common product-specific complications following mesh-based repair for SUI or POP. Conservative therapies may be attempted, but most patients ultimately require partial or complete mesh excision., Patient Summary: We reviewed the recent literature on mesh-related complications after repair of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Vaginal exposure, persistent pain, and erosion into the urinary tract are the most common. These often require surgical management, best suited to a urologist with training and experience in this area. Evidence supports mesh use for correction of SUI, whereas the indication for POP repair remains controversial., (Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: The litigious nature of the American medical environment is a major concern for physicians, with an estimated annual cost of $10 billion., Objective: The purpose of this study is to identify causes of litigation in cases of testicular torsion and what factors contribute to verdicts or settlements resulting in indemnity payments., Methods: Publicly available jury verdict reports were retrieved from the Westlaw legal database (Thomson Reuters, New York, NY). In order to identify pertinent cases, we used the search terms "medical malpractice" and "testicular torsion" with date ranging from 2000 to 2013. Jury verdicts, depositions, and narrative summaries were evaluated for their medical basis, alleged malpractice, findings, and indemnity payment(s) (if any)., Results: Fifty-two cases were identified that were relevant to this study. Fifty-one percent of relevant cases were found in favor of the defendant physician, with the remaining 49% involving an indemnity payment (13% of which were settled). The most commonly sued medical providers were emergency physicians (48% of defendants), with urologists being second most common and making up 23% of the defendant pool. Emergency physicians were significantly more likely to make indemnity payments than urologists., Conclusion: Testicular torsion is a delicate condition and requires expertise in evaluation and treatment. When emergency physicians choose not to consult an urologist for possible torsion, they leave themselves open to litigation risk. When an urologist is involved in torsion litigation, they are rarely unsuccessful in their defense. Finally, ultrasound is no guarantee for success against litigation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Erectile dysfunction has plagued humanity for millennia. For years, treatment had been in the hands of mental health professionals. It was not until the 1970s that urologists created a modality that was marketable, reproducible, and consistently successful at treating impotence, the Small-Carrion Penile Prosthesis., Aim: We present the evolution of the malleable/semi-rigid penile prosthesis, concentrating our efforts reviewing and critiquing the pivotal article published by Drs. Michael P. Small, Hernan M. Carrion, and Julian A. Gordon. We then discuss its continued advancement, current-day utilization, and the future of the malleable prosthesis., Methods: From the early 1900s, surgeons have been toying with the idea of creating a penile implant. These initial attempts utilized rib cartilage, and eventually synthetic materials, including acrylic, silicone, and polyethylene., Results: In 1975, Drs. Carrion and Small presented their initial experience of 31 patients utilizing their silicone implant. In their manuscript titled, "The Small-Carrion Penile Prosthesis: New Implant for the Management of Impotence," they discuss their technique, perioperative management of complications, and results., Conclusions: The malleable penile prosthesis continued to evolve throughout the years to the current day Genesis and Spectra. Although the current market is dominated by the inflatable penile prosthesis, there are specific situations where the malleable is ideally utilized. The pivotal article by Drs. Carrion and Small helped pave the way for the "New Era" of penile prosthetics and still remains one of the most impactful contributions to the management of erectile dysfunction., (© 2015 International Society for Sexual Medicine.)

Introduction and Aim: Complications related to inflatable penile prosthesis (IPP) and artificial urinary sphincter (AUS) reservoirs are rare, potentially life threatening, and poorly described in the literature. As more devices are implanted, the incidence of reservoir-related complications may increase, and it will be important to recognize the relevant signs and symptoms., Methods and Main Outcome Measures: We present a case series of reservoir-related complications presenting to our institution for treatment. We also reviewed all accounts of reservoir-related complications within the urologic literature., Results: Three cases of reservoir-related complications are presented. Case 1 involves erosion of an intact AUS reservoir into the cecum of a patient with a history of myelomeningocele and bladder augmentation. Case 2 involves an IPP reservoir causing vascular compression, resulting in open exploration and repositioning of the reservoir. Case 3 involves intraperitoneal migration of a retained IPP reservoir to a subhepatic area, which was then removed laparoscopically. Literature review yielded descriptions of eight cases of intestinal complications, five cases of vascular complications, but zero reports of migration to a subhepatic area. Other notable complications include 20 reported cases of reservoir erosion into the bladder and inguinal herniation of the reservoir., Conclusion: Complications involving urologic prosthesis reservoirs, although rare, can have serious implications for patients. A high index of suspicion and familiarity with treatment options is required in order to allow timely diagnosis and appropriate treatment. Patients with prior major abdominal surgeries seem to be more prone to intestinal complications of reservoirs and warrant special concern. Cui T, Terlecki R, and Mirzazadeh M. Infrequent reservoir-related complications of urologic prosthetics: A case series and literature review. Sex Med 2015;3:334-338.

Introduction: Erectile dysfunction (ED) is a common problem with significant impact on patient quality of life. Penile prosthesis implantation provides an effective treatment for ED but as an invasive procedure carries with it an increased risk of medicolegal liability., Aim: To investigate factors associated with malpractice litigation surrounding penile prosthesis implantation., Methods: The Westlaw legal database was used to perform an advanced search for case reports using the term "medical malpractice" in combination with "penile" or "penis" and "prosthesis" or "implant" with dates between the January 1990 and December 2013., Main Outcome Measures: Each report was examined for trial information including patient demographics, device model and indications, alleged breach of duty, alleged damages, progression to trial, case outcome, and plaintiff award(s)., Results: The initial search yielded 76 cases that were narrowed to 40 after exclusions. There were 23 (57.5%) cases that were found in favor of the defendant, while 17 (42.5%) cases led to indemnity payment to the plaintiff including two cases (5.0%) that were settled out of court and 15 (37.5%) favoring the plaintiff in front of a jury. The mean settlement received was $335,500 compared with the mean indemnity award of $831,050 for verdicts decided in favor of the plaintiff (P = 0.68). The most common breach of duty was error in surgical decision making, present in 20 cases (48.8%). Informed consent was an issue in 13 filings (31.7%), and postoperative infection was seen in 13 cases (31.7%). In cases that identified the type of implant used, 58.3% were malleable implants, and 41.7% were inflatable devices., Conclusions: The main issues involved in malpractice litigation for penile prosthesis implants included surgical performance, informed consent, and postoperative management. Urologists must be aware of these potential issues in order to minimize their malpractice liability., (© 2014 International Society for Sexual Medicine.)

Background: Prospective studies suggested an association between pioglitazone (Actos) use and the development of bladder cancer. Cancer pathology among pioglitazone users has not been characterized. We chose to compare the surgical pathology among diabetic users and non-users, as well as non-diabetic patients who underwent radical cystectomy for bladder cancer., Methods: Our single-center, prospectively-maintained bladder cancer database was reviewed. Patient demographics, surgical pathology, and outcomes were evaluated. Information regarding diabetic history and use of pioglitazone was determined from chart analysis and patient interview., Results: From April 2005 to October 2011, 204 patients undergoing radical cystectomy were identified. Of these, 33 (16.2%) were diabetic and 171 (83.8%) had no history of diabetes. Among diabetic patients, 9 (27.3%) had a history of pioglitazone use. Median duration of therapy was 14 (6-120) months. Pathology in non-diabetic patients was T1 in 17 (9.9%), T2 in 38 (22.2%), T3 in 44 (25.7%), and T4 in 31 (18.1%). Pathology among diabetic non-users was T1 in 1 (4.2%), T2 in 7 (29.2%), T3 in 7 (29.2%), and T4 in 4 (16.7%). Pathologic stage among diabetic users was T1 in 1 (11.1%), T2 in 3 (33.3%), T3 in 3 (33.3%), and T4 in 1 (11.1%). Lymph node involvement in non-diabetics, diabetic non-users, and diabetic users was 25.7%, 33.3%, and 33.3%, respectively. Cancer-specific death was seen in 60.3% of non-diabetics, 58.3% of diabetic non-users, and 75% of diabetic users., Conclusions: Diabetics have similar stage distribution regardless of pioglitazone use. Lymph node metastases rates and cancer specific death were similar across all groups. Additional studies will serve to better characterize this relationship.

Purpose: We assessed patient perceptions of regular intermittent self-dilation in men with urethral stricture., Materials and Methods: We constructed and distributed a visual analog questionnaire to evaluate intermittent self-dilation via catheterization by men referred for urethral stricture management at a total of 4 institutions. Items assessed included patient duration, frequency, difficulty and pain associated with intermittent self-dilation as well as interference of intermittent self-dilation with daily activity. The primary outcome was patient perceived quality of life. Multivariate analysis was performed to assess factors that affected this outcome., Results: Included in the study were 85 patients with a median age of 68 years, a median of 3.0 years on intermittent self-dilation and a median frequency of 1 dilation per day. On a 1 to 10 scale the median intermittent self-dilation difficulty was 5.0 ± 2.7, the median pain score was 3.0 ± 2.7 and median interference with daily life was 2.0 ± 1.3. Overall quality of life in patients with stricture was poor (median score 7.0 ± 2.6 with poor quality of life defined as 7 or greater). On univariate analysis younger age (p <0.01), interference (p = 0.03), pain (p <0.01) and difficulty performing intermittent self-dilation (p = 0.03) correlated with poor quality of life in a statistically significant manner. On multivariate analysis only difficulty catheterizing (p <0.01) and younger age (p = 0.05) were statistically significant predictors. Patients with stricture involving the posterior urethra had a statistically significant increase in difficulty and decrease in quality of life (each p = 0.04)., Conclusions: Most patients with urethral stricture who are on intermittent self-dilation rate difficulty and pain as moderate, and inconvenience as low but report poor quality of life., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Urethral strictures are one of the most common urological problems, yet the natural limitations of wound healing and the physiologic demands on the anatomic structures combine to also make urethral strictures one of the most challenging urological problems to manage. Proper wound healing demands well approximated edges because prolonged inflammation and granulation, required to close large, deep wounds, will result in excess collagen production, fibrosis, and the formation of a scar or, in the urethra, a stricture. Biomaterials have successfully been used to approximate the ECM of several different tissue types and can define a three dimensional space suitable for the formation of new tissues with both appropriate structure and appropriate function. Biomaterials can be broadly categorized as either synthetic polymers or tissue matrices, each with their advantages and limitations. Recent studies utilizing cell seeded natural biomaterials in urethral repair has yielded some promising results. However, advancements in the use of alternative sources of cells for matrix seeding and cell-seeded synthetic materials hold the possibility of even better results in the future.

Objective: To evaluate and compare the outcomes of transvaginal repair of benign, primary, and recurrent vesicovaginal fistulas (VVFs) treated without tissue interposition because, historically, tissue interposition with a vascularized flap has been advocated in both transabdominal and transvaginal repairs of recurrent VVFs., Methods: A retrospective chart review was conducted of 73 consecutive women with VVF and treated by a single surgeon (B.J.F.) between January 2003 and May 2012. Patients with a malignant etiology and/or prior irradiation were excluded as they required a more complex repair. All included VVFs were treated by a transvaginal approach with partial vaginal cuff excision without a tissue interposition. Patients were followed in our clinic postoperatively for 1 year and by telephone survey thereafter., Results: Forty-nine patients met inclusion criteria: 25 primary and 24 recurrent. There was no statistical difference in patient age, fistula size, time to repair, or fistula etiology between the 2 groups. There has been no fistula recurrence in either group. Forty-one of 49 patients (84%) were discharged the same day as their surgery., Conclusion: Benign, recurrent VVFs are not synonymous with other complex fistulas that typically require tissue interposition. Our study demonstrates that transvaginal repair of benign, recurrent VVFs without tissue interposition can be equally successful as primary repairs without tissue interposition. The number of prior repairs should not be an independent factor in the use of tissue interposition, as previously suggested. We advocate an individualized approach to each VVF, only using tissue interposition when appropriate., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: We evaluated patients who underwent surgery for implant malfunction to determine whether retaining the reservoir was associated with an increased risk of erosion or infection. We also reviewed the literature to study possible risk factors for reservoir erosion., Materials and Methods: We reviewed the records of 85 patients who underwent 98 procedures for replacement of a malfunctioning 3-piece penile implant. Of these patients 13 underwent 2 replacement procedures. At the time of primary surgery the reservoir was placed in either the retropubic space or extraperitoneally in the lower lateral abdomen if the patient had undergone prior pelvic surgery. During surgery for replacement of the malfunctioning implant the cylinders and pump were removed, and the reservoir of the original 3-piece device was retained. During followup patients were assessed for implant function and the development of any complication such as infection and/or reservoir erosion into the bladder or bowel., Results: Infection developed in 1 patient and implant malfunction occurred in 13 but no patient had erosion of the retained reservoir. All 85 patients had a functioning implant at a mean followup of 50 months (range 12 to 148). Review of the literature suggests that prior pelvic surgery and infection are major risk factors for reservoir erosion., Conclusions: Retaining the reservoir during replacement of malfunctioning 3-piece implants is not associated with a significant risk of erosion and routine removal is not necessary. Prior pelvic surgery and infection appear to be risk factors for reservoir erosion.