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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

Parkinson's disease (PD) is often most recognized for motor symptoms but associated non-motor symptoms such as sexual dysfunction can significantly impact quality of life. This condition involves a hormonal disruption and has a predilection for male patients, yet there are no formal guidelines for screening or management of sexual health pathology in these patients. While prior publications have addressed the presence of sexual dysfunction (SD) among men with PD, there has been a paucity of work examining the hypothalamic-pituitary-gonadal (HPG) axis and the interplay between dopamine, prolactin (PRL), and testosterone. This review provides an overview of data extracted from the existing peer-reviewed literature regarding hormonal and sexual health changes in men with PD and the impact of dopaminergic and/or androgen replacement therapy. Furthermore, while some research suggests that PD patients are at higher risk for prolactin elevation and testosterone deficiency, heterogeneity of the data limits extrapolation. Additionally, data related to pharmacologic optimization of the HPG axis in this patient population is similarly limited. Prospective studies are needed to better characterize the hormonal pathophysiology of PD as it relates to sexual dysfunction such that men at risk can be effectively identified so as to offer interventions that may improve quality of life., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Competing Interests: Declaration of Competing Interest None Declared.

Introduction: The prostatic urethral lift (PUL) is a popular surgical option for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). Prior 5-year data from the multicenter L.I.F.T. trial suggested durability and a surgical retreatment rate of 13.6% at five years. We assessed the proportion of patients who had ongoing medical or surgical BPH management following PUL., Methods: With institutional review board approval, cases of PUL performed from 2015-2020 at our academic institution were retrospectively reviewed for management of BPH following PUL., Results: A total of 209 men were identified, with followup available for 198 (95%). Mean age was 68.9 years and mean followup was 18.5 months. Mean prostate size was 43 g. Patients were discharged from recovery in 97% of cases, with 29% discharged with indwelling or intermittent catheterization. The rate of 30-day complications was 18%, with 89% graded Clavien I-II. Postoperatively, mean improvements in International Prostate Symptom Score (IPSS) and quality of life subscore (QoL) were 5.3 and 1.1 points, respectively. Unplanned emergency room or clinic visits within 30 days of the procedure occurred in 14% and 17% of men, respectively, with 4% requiring hospital readmission. In followup, α-blockers and/or 5α-reductase inhibitors were continued or initiated postoperatively for 44% of men; 20% of men required repeat surgical intervention at a mean of 19.2 months (1.4-56.4), consisting of repeat PUL (30%), transurethral resection of prostate (28%), or thulium laser enucleation (18%). Overall, 53% of men needed medication and/or repeat surgery for BPH following PUL, and this was independent of age, race, prostate volume, intravesical prostate protrusion, baseline IPSS and QOL, stricture, number of implants used, or a history of urinary retention (p>0.05)., Conclusions: Most men undergoing PUL require ongoing medical and/or surgical management for BPH. Patients should be counseled as to the likelihood of failure as a unimodal therapy long-term.

Objective: To determine the safety and efficacy of hourly, high dose phenylephrine (>1000 μg) for acute ischemic priapism (AIP) through monitoring adverse hemodynamic events amongst risk profiles., Methods: An IRB-approved retrospective review of patients with AIP from 2010 to 2020. Patients were stratified to a low or high dose phenylephrine group based on cumulative, hourly dose of ≤1000 μg and > 1000 μg respectively and examined for successful resolution of their AIP. The safety profile of phenylephrine for patients at risk for adverse hemodynamic events was examined., Results: A total of 123 patients were identified with a median age of 40 (range: 7-76) years with median time from AIP onset to presentation of 11 (2-168) hours. A total of 97 men received phenylephrine (78.9%) and detumescence was achieved nonoperatively in 62 of these men (63.9%) with a mean priapism duration of 8.7 hours. Those resolving with phenylephrine administration had a mean duration of 8.8 ± 5.6 vs 57.3 ± 37.1 hours without resolution P < .001. Among low and high dose phenylephrine groups (500 and 2000 μg respectively), the median duration of AIP was 10 and 12 hours respectively without a difference in AIP resolution (P > .05). Twenty-one patients (17.1%) were deemed at risk for phenylephrine complication of which 4 (4.1%) had phenylephrine discontinued due to hemodynamic changes., Conclusion: Nonoperative resolution of AIP with phenylephrine does not appear to be dose-dependent and hemodynamic changes secondary to phenylephrine administration may be underreported. Future work should utilize standardized risk assessment and periprocedural monitoring for hemodynamic change., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing., Methodology: A comprehensive search of the literature on acute ischemic priapism and non-ischemic priapism (NIP) was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. A search of the literature on NIP, recurrent priapism, prolonged erection following intracavernosal vasoactive medication, and priapism in patients with sickle cell disease was conducted by Pacific Northwest Evidence-based Practice Center for articles published between 1946 and February 19, 2021. Searches identified 4117 potentially relevant articles, and 3437 of these were excluded at the title or abstract level for not meeting inclusion criteria. Full texts for the remaining 680 articles were ordered, and ultimately 203 unique articles were included in the report., Results: This Guideline provides a clinical framework for the treatment (non-surgical and surgical) of NIP, recurrent ischemic priapism, and priapism in patients with sickle cell disease. The treatment of patients with a prolonged erection following intracavernosal vasoactive medication is also included. The AUA guideline on the diagnosis of priapism and the treatment of acute ischemic priapism was published in 2021., Conclusions: All patients with priapism should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event should be provided early intervention when indicated. NIP is not an emergency and treatment must be based on patient objectives, available resources, and clinician experience. Management of recurrent ischemic priapism requires treatment of acute episodes and a focus on future prevention of an acute ischemic event. Sickle cell disease patients presenting with an acute ischemic priapism event should initially be managed with a focus on urologic relief of the erection; standard sickle cell assessment and interventions should be considered concurrent with urologic intervention. Treatment protocols for a prolonged, iatrogenic erection must be differentiated from protocols for true priapism.

Although the artificial urinary sphincter (AUS) is widely regarded as the "gold standard" for surgical correction of male stress urinary incontinence, long-term durability for symptom control is variable. A significant number of men will experience a decline in device-related improvement over time. With erosion of initial success, men sufficiently bothered by recurrent incontinence not caused by device malfunction may seek surgical revision. Secondary surgery requires careful consideration on the part of the prosthetic urologist and a keen awareness of sound surgical techniques. The armamentarium for revision has traditionally consisted of strategies involving cuff downsizing and/or relocation, modification of the pressure regulating balloon, urethral wrapping, addition of a tandem cuff, or use of transcorporal cuff placement. These options will be presented in view of their evidence and theoretical advantages and disadvantages. In addition, we will discuss a newer approach of growing popularity that serves to challenge existing dogma and shift the paradigm of AUS revision surgery., (© 2020. The Author(s), under exclusive licence to Springer Nature Limited.)

Purpose: Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing. Acute ischemic priapism, characterized by little or no cavernous blood flow and abnormal cavernous blood gases (ie, hypoxic, hypercarbic, acidotic) represents a medical emergency and may lead to cavernosal fibrosis and subsequent erectile dysfunction., Materials and Methods: A comprehensive search of the literature was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. Searches identified 2948 potentially relevant articles, and 2516 of these were excluded at the title or abstract level for not meeting inclusion criteria for any key question. Full texts for the remaining 432 articles were reviewed, and ultimately 137 unique articles were included in the report., Results: This Guideline was developed to inform clinicians on the proper diagnosis and surgical and non-surgical treatment of patients with acute ischemic priapism. This Guideline addresses the role of imaging, adjunctive laboratory testing, early involvement of urologists when presenting to the emergency room, discussion of conservative therapies, enhanced data for patient counseling on risks of erectile dysfunction and surgical complications, specific recommendations on intracavernosal phenylephrine with or without irrigation, the inclusion of novel surgical techniques (eg, tunneling), and early penile prosthesis placement., Conclusions: All patients with priapism should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event should be provided early intervention. Treatment of the acute ischemic patient must be based on patient objectives, available resources, and clinician experience. As such, a single pathway for managing the condition is oversimplified and no longer appropriate. Using a diversified approach, some men may be treated with intracavernosal injections of phenylephrine alone, others with aspiration/irrigation or distal shunting, and some may undergo non-emergent placement of a penile prosthesis.

Erectile dysfunction affects an increasing number of men. The mainstays of management include oral medications, local erectogenic agents, and surgical placement of prosthetic devices. Newer technologies such as stem cell and gene therapy have been investigated as a means to restore spontaneous erectile capacity. Mesenchymal stem cells are thought to produce a local immunomodulatory and pro-repair milieu at the area of injury or needed repair. Gene therapy involves targeting the erectogenic pathway to augment factors involved in producing a natural erection. Such therapies are considered experimental and should be used in the setting of a clinical trial with appropriate oversight., Competing Interests: Disclosure R.P. Terlecki: Consultant/Advisory Board/Grant support for Boston Scientific; Grant support for Department of Defense. E.L. Matz: nothing to disclose., (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.)

INTRODUCTION Inter-institutional re-review of prostate needle biopsy (PNBx) material is required at many institutions before definitive treatment, but adds time and cost and may not significantly alter urologic management. We aim to determine the utility of universal PNBx re-review on influencing the decision to recommend definitive local therapy for patients with prostate cancer., Materials and Methods: From 2017-2020, 590 prostate biopsy specimens from outside institutions were re-reviewed at our center for patients considering prostatectomy. Clinical and pathologic characteristics from initial and secondary review were analyzed. Potential for change in treatment candidacy (CTC) was determined by re-diagnosis to non-malignant tissue or change in candidacy for active surveillance (AS) versus definitive treatment (i.e. prostatectomy or radiation therapy). Thus, the following scenarios were considered CTC: downgrading to non-malignant tissue, downgrading ISUP Grade Group (GG) ≥ 2 to GG1, and upgrading GG1 to GG ≥ 2. Any changes between GG2 to GG5 were not considered CTC, as definitive treatment would be offered to all groups., Results: Overall, 55 patients (9.3%) had potential for CTC based on secondary review, all of whom had initial pathologic GG (iGG) ≤ 2. Of the 152 patients with iGG1, 8 were downgraded to no malignancy and 41 were upgraded to GG2 or GG3. Of the 185 patients with iGG2, 6 were downgraded to GG1. No patients with iGG ≥ 3 qualified for a CTC. Features associated with CTC included iGG, number of positive cores, and highest core percentage. Upon multivariable analysis, only iGG1 diagnosis was predictive of CTC (OR 23.66, p < 0.001)., Conclusion: Second review may be helpful in determining need for definitive treatment in patients with GG1 and GG2 prostate cancer, i.e. those considering AS. This process appears unnecessary in GG3+ patients, as management for patients considering surgery would not change. This may allow for judicious redirection of hospital resources.

Background: Adverse outcomes secondary to ischemic priapism (IP) are associated with time to presentation and management., Aim: To characterize patterns in presentation delay as a function of etiology and patient education regarding IP risk., Methods: Following institutional review board approval, charts of IP patients presenting to our institution from 2010 to 2020 were reviewed. One episode of IP per patient was included for analysis., Outcomes: Priapism duration in patients presenting with IP., Results: We identified 123 unique patients with IP. Common etiologies included erectogenic intracavernosal injection (24%), trazodone (16%), and other psychiatric medications (16%). Patients with sickle cell anemia or trait and intracavernosal injection-related IP presented sooner than idiopathic cases and those from psychiatric medication (P < .001). Etiology and provider education on IP risk were associated with presentation ≥ 24 hours. Upon multivariate analysis, only a lack of provider education was independently associated with presentation ≥ 24 hours., Clinical Implications: Men who received provider-based education on the risk of IP associated with their condition or medication regimen were more likely to seek prompt medical attention for IP and, therefore, less likely to require surgery., Strengths & Limitations: This manuscript represents one of the largest series on priapism, an area of urologic practice in need of more evidence-based guidance. The numbers are not inflated by including multiple episodes per patient, and the data collected include etiology, time to presentation, and treatment. Limitations include a retrospective chart review study design at a single institution., Conclusion: Educational initiatives on the risk of IP associated with particular disease states and medications should target at-risk individuals, as well as prescribers of medications associated with IP. Dutta1 R, Matz1 EL, Overholt TL, et al. Patient Education Is Associated With Reduced Delay to Presentation for Management of Ischemic Priapism: A Retrospective Review of 123 Men. J Sex Med 2021;18:385-390., (Copyright © 2020 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: We hypothesize that men with diabetes mellitus whose inflatable penile prosthesis (IPP) implantation is delayed for unacceptably high hemoglobin A1c (HbA1c) will have durable improvements in their glycemic control after achieving acceptable HbA1c levels for surgery., Methods: Per institutional protocol, an A1c <9% must be documented prior to IPP placement. After IRB approval, a single surgeon IPP database was retrospectively queried for data specific to diabetes mellitus management. Men without HbA1c values at ≥1-year follow-up were excluded. Univariate and multivariate statistical analyses were performed to assess associations with sustained HbA1c control., Results: From January 2011 to March 2019, 138 diabetics undergoing IPP were identified. Thirty-seven were excluding for insufficient follow-up. Nineteen of the 101 analyzed men (18.8%) were delayed a median 4 months (range 2-17) for elevated HbA1c values (median 10.1, range 9.1-12.3). Following improvements, median preoperative HbA1c remained higher (8.2% vs 7.0%) in delayed men (P < .001). Among delayed recipients, 11 (58%) improved without medication changes while insulin was newly initiated (5) or dosage was increased (5) in 42%. At 32 months follow-up, a HbA1c <9% was similarly maintained in delayed and nondelayed men (74% vs 87%, P = .17). Delayed men more commonly required insulin therapy at follow-up (89.5% vs 54.9%, P = .008), but had a similar median change in BMI (+0.1 vs +0.1, P = .65). Device infection occurred in 1 nondelayed patient (0.7%)., Conclusion: Men who improve HbA1c for IPP surgery are likely to demonstrate persistent improvement. IPP implantation appears to be safe in diabetic men with HbA1c <9%., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To evaluate the findings of magnetic resonance imaging (MRI) of the ipsilateral hip(s) as part of the workup of men with chronic orchialgia (CO)., Methods: Following IRB approval, a retrospective chart review was performed from a single surgeon database of all men with a diagnosis of CO from June 2018 to October 2019 who underwent subsequent hip MRI evaluation., Results: Ten men were identified. Median age was 51 years and median duration of pain was 10 months. MRI was obtained after testis pathology was ruled out. Pain was noted in the groin (100%) and hip (50%). Hip MRI identified overt labral tears in 8 men (10/12 hips evaluated, 83%) and labral fraying in the remaining 2 (16.7%). Standard plain film radiography was performed in 6 men prior to MRI, all of which were negative. Following MRI, 5 men underwent hip injection with steroid and local analgesic with lasting resolution (2 men) or significant improvement in pain (2 men; 80%, follow-up 3-15 months). Two men had complete resolution of pain with 8 weeks of physical therapy., Conclusion: Hip MRI has a high rate of diagnosis of labral tear in appropriately selected men referred to the urologist for CO. Identification of orthopedic pathology may avoid unnecessary antibiotics, opiates, or urological surgery. Referrals to orthopedics and/or physical therapy for intervention may lead to resolution of pain., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Penile plication is highly successful in appropriately selected patients with Peyronie's disease; however, a minority of patients experience residual curvature or delayed recurrence of curvature. Revision surgery outcomes are seldomly reported., Aim: To determine the efficacy of salvage penile plication for the correction of residual and recurrent curvature., Methods: Our institutional review board-approved prospective single-surgeon database of patients with Peyronie's disease was reviewed for cases performed from 2011 to 2019. Patients requiring salvage procedures were analyzed. A successful salvage was defined by residual curvature <20° with patient-reported satisfaction. Potential etiologies for initial plication failure were examined., Main Outcome Measure: The outcomes of this study are subjective and patient-reported success of salvage plication., Results: Data analysis identified 134 men treated surgically for Peyronie's disease. Management involved plication in 105 (78.4%), incision and grafting in 14 (10.4%), excision and grafting with inflatable penile prosthesis in 7 (5.2%), plication with inflatable penile prosthesis in 6 (4.5%), or grafting, plication, and inflatable penile prosthesis in 2 (1.5%). Mean preoperative degree of curvature before initial surgery was 55° (30°-90°). Of this cohort, 5.2% (n=7) required salvage plication for a median residual or recurrent curvature of 45° (35°-90°). Initially, 3 men (43%) received an 8-dot plication, 3 (43%) underwent 16-dot plication, and 1 (14%) received plaque incision and grafting. Among salvage patients, 4 (57%) had initially satisfying results followed by recurrence of curvature and 3 (43%) desired correction of residual curvature. Salvage plication entailed an 8-dot plication in 3 (42.9%) and a 16-dot plication procedure in 4 (57.1%). The median time to salvage surgery was 9 (3-15) months, with all patients showing intraoperative resolution of curvature. At a median follow-up of 12 (1-20) months, 6 (85.7%) patients reported satisfaction with residual curvature <20°., Conclusion: Patients with residual or delayed recurrence of curvature after plication for Peyronie's disease can be effectively managed with salvage plication. Deebel NA, Scarberry K, Dutta R, et al. Salvage Penile Plication Is an Effective Modality for Resolving Residual Curvature After Surgery for Peyronie's Disease. Sex Med 2020;8:686-690., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Human placental stem cells (PSCs) enhance histological and functional recovery in a rodent erectile dysfunction (ED) model. We tested the hypothesis that bioactive factors secreted by PSC (i.e., the secretome) mediate functional recovery and that acellular-conditioned media (CM) from PSC culture (PSC-CM) could be used independently to facilitate functional and histological recovery. To identify factors relative to efficacy of PSC, a comparison of CM from PSC and three additional human stem cell populations was performed. CM from human PSC, amniotic fluid stem cells (AFSCs), adipose-derived stem cells (ADSC), and human umbilical vein endothelial cells (HUVECs) was assayed using a semi-quantitative human cytokine antibody array. Male rats, after surgically created ED by neurovascular injury, were randomly divided into four groups: vehicle control (phosphate-buffered saline [PBS]), PSC, PSC-CM, and serum-free media control (SFM) as control. Functional data on intracorporal and mean arterial pressure were obtained, and histological architecture was examined 6 weeks after single injection. PSCs were found to secrete at least 27 cytokines and growth factors at a significantly higher level than the other three cell types. Either single injection of PSC-CM or PSC significantly improved erectile functional recovery and histological architecture compared with SFM or PBS. Injection of the secretome isolated from human PSC improves erectile functional recovery and histological structure in a rat model of neurovascular injury-induced ED. Further characterization of the unique protein expression within the PSC-CM may help to identify the potential for a novel injectable cell-free therapeutic for applicable patients., (© 2020 John Wiley & Sons, Ltd.)

Purpose: To provide an overview of the state of tissue engineering relative to male erectile tissue and the implications for treatment of penile pathology., Methods: A PubMed review of the relevant peer-reviewed literature pertaining to engineering of penile tissues was performed., Results: There are multiple pathologies that threaten form and/or function of the penis. Management of disease rarely offers a path to true restoration. Historical efforts to correct structural defects have largely relied on synthetic materials, commercially prepared allograft or xenograft constructs, or autologous tissue substitutes. These approaches have traditionally suffered from less-than-optimal clinical outcomes and degrees of patient morbidity that may be preventable. Prior work in tissue engineering of corpora cavernosa has demonstrated the ability to produce functional tissue in small and large animal models. A human clinical trial is currently underway., Conclusions: Varied conditions pathologically affecting the penis warrant development of more sophisticated tissue-based solutions. Animal models have demonstrated efficacy in restoring functional corpora cavernosa, and upcoming clinical trials will serve to determine safety and efficacy in humans.

Background: In the novel coronavirus disease 2019 (COVID-19) pandemic, social distancing has been necessary to help prevent disease transmission. As a result, medical practices have limited access to in-person visits. This poses a challenge to maintain appropriate patient care while preventing a substantial backlog of patients once stay-at-home restrictions are lifted. In practices that are naïve to telehealth as an alternative option, providers and staff are experiencing challenges with telemedicine implementation. We aim to provide a comprehensive guide on how to rapidly integrate telemedicine into practice during a pandemic., Methods: We built a toolkit that details the following 8 essential components to successful implementation of a telemedicine platform: provider and staff training, patient education, an existing electronic medical record system, patient and provider investment in hardware, billing and coding integration, information technology support, audiovisual platforms, and patient and caregiver participation., Results: Rapid integration of telemedicine in our practice was required to be compliant with our institution's COVID-19 task force. Within 3 days of this declaration, our large specialty-care clinic converted to a telemedicine platform and we completed 638 visits within the first month of implementation., Conclusions: Effective and efficient integration of a telemedicine program requires extensive staff and patient education, accessory platforms to facilitate video and audio communication, and adoption of new billing codes that are outlined in this toolkit., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The penile prosthesis has been used for men with erectile dysfunction for nearly 5 decades. Although many articles examine various outcome measures, wide variability exists in the quality of these studies., Aim: We sought to critically evaluate the most referenced literature related to penile prosthesis outcomes over the last 10 years., Methods: A PubMed search of the indexed English literature was performed using the search terms "prospective," "penile prosthesis," and "outcomes", and all relevant publications from 2009 to 2019 were reviewed. In addition, we performed a Google Scholar search for the same interval using the search term "penile prosthesis outcomes" to evaluate manuscripts which have been most commonly cited. The most heavily cited manuscripts were sorted for relevancy using Google's internal algorithm, and then, the articles were reviewed by the authorship team for appropriateness of the subject matter. Articles with less than 10 citations were excluded. We used the Oxford Center for Evidence-Based Medicine Criteria as part of our evaluation of the published data involving independent research, as opposed to review articles summarizing previously published findings., Results: We evaluated the most-cited literature of the past decade relevant to penile prosthesis outcomes and reported the major findings in regards to infection, erosion, extrusion, device reliability, and satisfaction (both the patient and partner). The majority of these studies are retrospective in nature., Clinical Implications: From our review of the most commonly cited studies, there was no high-level evidence published in this area within the last 10 years. There are multiple barriers to producing these types of studies in the evaluation of penile prosthesis outcomes., Strengths & Limitations: Using the most commonly cited articles allows us to understand the data that are being cited in other new publications. Focusing on the most cited articles on penile prosthesis outcomes in the last 10 years is a limitation as there have been many more studies published in this area., Conclusion: While many studies have examined penile prosthesis outcomes, most of the heavily cited literature consists of low-level evidence. Higher quality research is necessary to better assess penile prosthesis outcomes. Chouhan JD, Pearlman AM, Kovell RC, et al. A Quality Analysis of the Last Decade's Most Heavily Cited Data Relative to Outcomes After Penile Prosthesis Placement. J Sex Med 2020;17:861-869., (Copyright © 2020 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Unplanned and potentially avoidable clinic encounters, emergency department visits and readmissions burden the health care system. We identified and characterized unplanned health care utilization during the 90-day global period following urological prosthetic surgery., Methods: Records of patients undergoing penile prosthesis implantation and/or artificial urinary sphincter placement by a single surgeon between January 2011 and November 2016 were retrospectively reviewed. Unplanned visits to the urology clinic, emergency department and/or hospital for each patient within 90 days of surgery were identified and characterized., Results: Of the 288 surgeries performed during the designated study period 214 were for inflatable penile prosthesis, 59 for artificial urinary sphincter and 15 for a combination. There were 58 unplanned in-global clinic encounters, 13 emergency department visits and 7 hospital readmissions. Unplanned clinic visits were most common for additional teaching, voiding issues and incision concerns, presenting an average of 39 days postoperatively. Emergency department visits were most commonly due to voiding issues and incision concerns, presenting an average of 25 days postoperatively. Hospital readmissions were most common for complications and incision concerns, presenting an average of 23 days postoperatively., Conclusions: Most unplanned visits during the 90-day global period following urological prosthetic surgery do not require hospital readmission. Improved preoperative counseling, instruction before hospital discharge and/or scheduled phone contact with patients during recovery may reduce unnecessary resource use.

Introduction: The human placenta provides a bountiful and noncontroversial source of stem cells which have the potential for regeneration of injured tissue. These cells may restore erectile function after neurovascular tissue injury such as that seen in radical pelvic surgeries and pelvic trauma., Aim: To determine the effect of human placenta-derived stem cells on erectile function recovery and histological changes at various time points in a cavernous nerve injury rat model and to study the fate of injected stem cells throughout the regenerative process., Methods: Human placental stem cells (PSCs) were dual labeled with monomeric Katushka far red fluorescent protein (mKATE)-renLUC using a lentivirus vector. A pelvic neurovascular injury-induced erectile dysfunction model was established in male, athymic rats by crushing the cavernous nerves and ligating the internal pudendal neurovascular bundles, bilaterally. At the time of defect creation, nonlabeled PSCs were injected into the corpus cavernosum at a concentration of 2.5 × 10 6  cells/0.2 mL. The phosphate-buffered saline-treated group served as the negative control group, and age-matched rats (age-matched controls) were used as the control group. Erectile function, histomorphological analyses, and Western blot were assessed at 1, 6, and 12 weeks after model creation. The distribution of implanted, dual-labeled PSCs was monitored using an in vivo imaging system (IVIS). Implanted cells were further tracked by detection of mKATE fluorescence in histological sections., Main Outcome Measure: The main outcome measure includes intracavernous pressure/mean arterial pressure ratio, neural, endothelial, smooth muscle cell regeneration, mKATE fluorescence, and IVIS imaging., Results: The ratio of intracavernous pressure to mean arterial pressure significantly increased in PSC-injected rats compared with phosphate-buffered saline controls (P < 0.05) at the 6- and 12-week time points, reaching 72% and 68% of the age-matched control group, respectively. Immunofluorescence staining and Western blot analysis showed significant increases in markers of neurons (84.3%), endothelial cells (70.2%), and smooth muscle cells (70.3%) by 6 weeks in treatment groups compared with negative controls. These results were maintained through 12 weeks. IVIS analysis showed luminescence of implanted PSCs in the injected corpora immediately after injection and migration of cells to the sites of injury, including the incision site and periprostatic vasculature by day 1. mKATE fluorescence data revealed the presence of PSCs in the penile corpora and major pelvic ganglion at 1 and 3 days postoperatively. At 7 days, immunofluorescence of penile PSCs had disappeared and was diminished in the major pelvic ganglion., Clinical Implications: Placenta-derived stem cells may represent a future "off-the-shelf" treatment to mitigate against development of erectile dysfunction after radical prostatectomy or other forms of pelvic injury., Strength & Limitations: Single dose injection of PSCs after injury resulted in maximal functional recovery and tissue regeneration at 6 weeks, and the results were maintained through 12 weeks. Strategies to optimize adult stem cell therapy might achieve more effective outcomes for human clinical trials., Conclusion: Human PSC therapy effectively restores the erectile tissue and function in this animal model. Thus, PSC therapy may provide an attractive modality to lessen the incidence of erectile dysfunction after pelvic neurovascular injury. Further improvement in tissue regeneration and functional recovery may be possible using multiple injections or systemic introduction of stem cells. Gu X, Thakker PU, Matz EL, et al. Dynamic Changes in Erectile Function and Histological Architecture After Intracorporal Injection of Human Placental Stem Cells in a Pelvic Neurovascular Injury Rat Model. J Sex Med 2020;17:400-411., (Copyright © 2019 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Flexible cystoscopy is routinely performed as an outpatient procedure. The use of disposable sheaths can increase cystoscope life span and reduce staff costs. The primary end point of this study was to evaluate procedure related discomfort and pain, physician maneuverability, residual bioburden and reprocessing time. The secondary end point was to analyze the cost-effectiveness of a flexible cystoscope with a disposable sheath compared to a standard flexible cystoscope., Methods: This randomized clinical trial was performed with women older than 18 years, with intact cognition and 7 days antibiotic-free who were referred to outpatient clinic for cystoscopy. Patients underwent cystoscopy with a standard flexible cystoscope or flexible cystoscope with disposable sheath. Urinalysis and culture were performed before and 14 days after cystoscopy. Patients filled out a pain/discomfort visual analog scale. Physicians filled out a 5-point Likert scale for the elements of ease of insertion, manipulation, optical quality and overall use. Reprocessing time and costs were compared between both cystoscopes., Results: A total of 60 patients were included in the study, comprised of 30 who underwent standard flexible cystoscopy and 30 who underwent flexible cystoscopy with a protective sheath. Patient discomfort/pain was equivalent in both groups. The Likert scores were similar except for ease of insertion, which was higher with protective sheaths (p <0.02). Protective sheaths were associated with lower reprocessing time and costs (p <0.001)., Conclusions: The use of protective sheaths effectively reduced procedure and staff related costs without causing any additional patient discomfort or pain. The learning curve of the sheathed scope may explain the difference reported by physicians regarding the ease of insertion.

Objective: To characterize national trends in procedural management of renal trauma., Background: Management of renal trauma has evolved to favor a more conservative approach. For patients requiring intervention, there is a paucity of information to characterize the nature of procedural therapy administered., Methods: A retrospective cross-sectional analysis was performed using data contained within the National Trauma Data Bank. The National Trauma Data Bank is a voluntary data repository managed by the American College of Surgeons, containing data regarding trauma admissions at 747 level I to V trauma centers throughout the United States and Canada. Participants included any patient with renal trauma requiring intervention from 2002 to 2012. They were identified according to International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, with codes 866.00 through 866.03 for blunt renal trauma, and codes 866.10 through 866.13 for penetrating trauma. Cases were separated into those requiring nephrectomy, renorrhaphy, or endovascular repair based on ICD-9 procedure code. The number of cases performed each year and yearly trends as measured by linear regression., Results: A total of 4296 cases were reported during the study period. Of these cases, 2635 involved blunt trauma and 1661 involved penetrating injury. There was a significant increase in the percentage of cases managed by endovascular means for both blunt and penetrating trauma (R = 0.92, P < 0.01; and R = 0.86, P < 0.01, respectively). This was primarily at the expense of nephrectomy, with cases showing significant decline in both groups., Conclusions: National trends for procedural management of renal trauma are toward less invasive interventions. These trends suggest favorable change towards renal preservation and decreased morbidity, potentially facilitated, in part, by improved radiographic staging and endovascular techniques, and also increased provider awareness of the safety and value of conservative management.

Introduction: The artificial urinary sphincter (AUS) has long been regarded as the gold standard for surgical correction of male stress urinary incontinence (SUI). Despite impressive rates of initial success for restoration of continence, durability may wane to the point of considering revision surgery., Aim: To provide a review of existing data as well as personal experience regarding patient selection, surgical technique, and postoperative troubleshooting for the AUS., Methods: A systematic review of the peer-reviewed literature was performed to identify relevant and contemporary articles regarding perioperative and long-term management of the AUS. Additional input is presented based on clinical experience of the senior author., Main Outcome Measure: The main outcome measures are durability, patient satisfaction, mechanical failure, and urethral erosion., Results: In addition to a thorough history and examination, preoperative screening should include office cystoscopy to rule out bladder neck contracture in patients with a history of radical prostatectomy. Perineal cuff placement appears superior to alternative approaches. Prior radiation and use of the 3.5-cm cuff are risk factors for future erosion. Newer findings suggest that subsequent recurrence of SUI may be due to restrictive encapsulation, rather than true atrophy, with implications for revision surgery., Conclusion: The AUS remains an excellent option for surgical correction of moderate to severe male SUI. Detailed preoperative evaluation and patient selection are critical. The challenge of downstream recurrent SUI after AUS can be effectively managed for most patients with a structured approach. Chouhan JD, Terlecki RP. A User's Guide for Surgery Involving the Artificial Urinary Sphincter. Sex Med Rev 2019;7:167-177., (Copyright © 2018 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Numerous factors are associated with changes in practice patterns, some provider specific (eg age, gender, training, practice type, sense of well-being) and others extrinsic (eg changes in reimbursement, medicolegal environment, government involvement). Through the American Urological Association Leadership Program we evaluated trends in same specialty referral patterns among U.S. urologists., Methods: We queried case logs from the American Board of Urology and analyzed case trends from 2005 to 2015. Additionally, we surveyed practicing urologists regarding perceived trends in referral patterns during the last 5 years and their opinion regarding principal drivers of change., Results: The number of female urologists is increasing, as is subspecialization. Open surgical cases are decreasing in number as laparoscopic, robotic and percutaneous procedures are increasing. Female urology procedures have decreased dramatically. Survey results suggest that compared to 5 years ago, urologists are increasingly likely to refer cases to another provider for all queried operations other than transurethral benign prostatic hyperplasia procedures. Cases within oncology and reconstruction/prosthetics were associated with the highest reported avoidance. The most common factors influencing the decision to refer were surgical training (48.1%), change in practice type (36.7%), complications (25.5%), medicolegal concerns (22.2%) and reimbursement (21%)., Conclusions: Trends in urological referral patterns show an increased likelihood of referral for common urological surgical procedures, regardless of subspecialty or disease. While most referrals are reportedly directed to academic medical centers, there appears to be an increasing trend toward internal referral among practices. The most commonly cited factor for referral was surgical training, which has implications for physician education.

Urethrocavernous fistula is rarely reported, though should be considered within the differential diagnosis for men who present with urethral bleeding, particularly at time of erection. Ultrasonography with concomitant intracavernosal injection can be considered to confirm the diagnosis. Here we report a case of urethrocavernous fistula in a 48 year old man without preceding traumatic event., (Copyright © 2018. Published by Elsevier Inc.)

Introduction: We determined the incidence of NSQIP (National Surgical Quality Improvement Project) indexed complications by tumor size and investigated the related financial implications based on contemporary reimbursement schedules., Methods: Transurethral bladder tumor resection procedures performed from 2010 to 2012 were identified and stratified by size specific CPT coding. Preoperative characteristics, surgical parameters and 30-day perioperative outcomes were compared using chi-square analysis and Student's t-test. Financial data for all inpatient transurethral bladder tumor resections performed during the most recent fiscal year at our institution were collected and analyzed, and a comparison was made using up-to-date Medicare reimbursement schedules., Results: We identified 8,116 cases, including 3,533 coded as small (43.3%), 2,734 medium (33.5%) and 1,849 large (22.6%). Large resections required longer operative time (small-25.8 minutes, medium-33.0 minutes, large-49.0 minutes, p <0.01) and length of stay (small-0.67 days, medium-1.1 days, large-1.9 days, p <0.006), and had higher rates of transfusion (small-0.74%, medium-1.5%, large-3.7%, p <0.001), sepsis (small-0.23%, medium-0.44%, large-0.92%, p <0.05), renal insufficiency (small-0.17%, medium-0.15%, large-0.60%, p <0.01) and 30-day mortality (small-0.2%, medium-1%, large-1.8%, p <0.05) independent of preoperative parameters. Large resections were also associated with higher rates of 30-day readmission (small-4.3%, medium-6.3%, large-9.4%, p <0.001) and reoperation (small-2.1%, medium-2.7%, large-4.5%, p <0.001). Institutional data demonstrate that the most common Diagnosis Related Group classification results in an operating loss when treating Medicare beneficiaries., Conclusions: Urologist selected coding directly correlates with NSQIP indexed postoperative complications. Many cases of transurethral bladder tumor resection with associated complications may result in financial loss for the performing institutions. Efforts to improve quality of care and reimbursement seem warranted.

Purpose: Primary care providers harbor misconceptions regarding penile prosthetic surgery, largely overestimating the rate of infection. Rates of infection following surgery for primary placement and revision are estimated as 1% to 3% and 10% to 18%, respectively. Our objective was to determine the contemporary incidence of infection following inflatable penile prostheses surgery at an academic training center where surgeons-in-training are routinely involved., Materials and Methods: Review of a prospectively collected single-surgeon database was performed. All cases of inflatable penile prostheses placement from January 2011 through June 2017 were reviewed. Information regarding training level of assistant surgeon(s) was collected, and follow-up data was compiled regarding postoperative infections and need for revision surgery., Results: Three hundred nine cases meeting inclusion criteria were identified. Mean patient age was 64.2 years, and mean follow-up was 28.7 months. Distribution involved 257 (83.2%) for primary placement, 45 (14.6%) for removal/replacement, and 7 (2.3%) in setting of prior device removal. Diabetes was noted in 31.1% of men. Surgeon-in-training involvement was noted in 100% of cases. Infection was confirmed in a patient who had skin breakdown over an area of corporal reconstruction with polytetrafluoroethylene. The overall postoperative infection rate was 0.3%., Conclusions: In this series from an academic training center, infection following penile prosthetic surgery is low, similar to other centers of excellence, even with 100% involvement of surgeons-in-training. This data should be used to better inform primary care providers and members of the general public potentially interested in restoration of sexual function., Competing Interests: CONFLICTS OF INTEREST: Dr. Amy M. Pearlman is a consultant for American Medical System/Boston Scientific. Dr. Ryan P. Terlecki is a consultant for and receives grant funding from American Medical Systems/Boston Scientific. These conflicts of interest have, in no way, influenced the results of our work. Dr. Kara E. McAbee has no conflicts of interest to disclose.

Purpose: Rate of continence after artificial urinary sphincter (AUS) placement appears to decline with time. After appropriate workup to exclude inadvertent device deactivation, development of urge or overflow incontinence, and fluid loss, many assume recurrent stress urinary incontinence (rSUI) to be secondary to nonmechanical failure, asserting urethral atrophy as the etiology. We aimed to characterize the extent of circumferential urethral recovery following capsulotomy and that of pressure regulating balloon (PRB) material fatigue in men undergoing AUS revision for rSUI., Materials and Methods: Retrospective review of a single surgeon database was performed. Cases of AUS removal/replacement for rSUI involving ventral subcuff capsulotomy and intraoperative PRB pressure profile assessments were identified., Results: The described operative approach involving capsulotomy was applied in 7 patients from November 2015 to September 2017. Mean patient age was 75 years. Mean time between AUS placement and revision was 103 months. Urethral circumference increased in all patients after capsulotomy (mean increase 1.1 cm; range 0.5-2.5 cm). Cuff size increased, remained the same, and decreased in 2, 3, and 2 patients, respectively. Six of 7 patients underwent PRB interrogation. Four of these 6 PRBs (66.7%) demonstrated pressures in a category below the reported range of the original manufacturer rating., Conclusions: Despite visual appearance to suggest urethral atrophy, subcuff capsulotomy results in increased urethral circumference in all patients. Furthermore, intraoperative PRB profiling demonstrates material fatigue. Future multicenter efforts are warranted to determine if capsulotomy, with or without PRB replacement, may simplify surgical management of rSUI with reductions in cost and/or morbidity., Competing Interests: CONFLICTS OF INTEREST: Ryan Patrick Terlecki is a consultant and receives grant funding from American Medical Systems/Boston Scientific, and Amy Marcia Pearlman and Alison Marie Rasper are consultants for American Medical Systems/Boston Scientific. But this has made no influence on this work in relation with the company or its products. These relationships have made no influence on the outcome of this work.

Background: Proximal corporal perforation at time of dilation, although rare, may occur due to factors related to patient anatomy, presence of intra-cavernosal fibrosis, and/or surgical technique., Aim: To describe tools and techniques designed to prevent and identify proximal corporal perforation, and maneuvers to minimize the risk of subsequent cylinder migration once proximal perforation has been recognized, such that the operation may proceed and result in an acceptable outcome., Methods: We discuss tips for prevention, recognition, and management of proximal corporal perforation by presenting a review of the literature as well as our preferences based on a high-volume experience with penile prosthesis surgery., Outcomes: Described techniques aim to minimize risk of cylinder migration in the absence of true proximal repair., Results: Although proximal perforation may be obvious at times, particularly with a sudden loss of resistance during dilation, discrepant corporal measurements and/or dissimilar proximal deflection of the dilator should also increase the index of suspicion. Numerous techniques have been employed to theoretically reduce the risk of cylinder migration in the setting of proximal corporal perforation. These include formal corporal repair (historical), windsock repairs with non-absorbable grafts, absorbable plugs, and suture fixation of the rear tip extender or shod material covering implant tubing., Clinical Translation: Intra-operative recognition of proximal corporal perforation, coupled with understanding of surgical strategies to minimize the risk of future device migration, may allow completion of an operation that still results in an optimal outcome., Conclusions: Techniques described to prevent proximal migration are not strongly evidence-based, but rooted in logic and supported by high-volume implanters. Intra-operative perforation of the proximal corpora, although rare, can threaten the success of penile implant surgery, though the techniques described herein have been developed to mitigate the potential for subsequent device migration, allowing surgery to proceed and to achieve the desired clinical result. Pearlman AM, Terlecki RP. Proximal Corporal Perforation During Penile Prosthesis Surgery: Prevention, Recognition, and Review of Historical and Novel Management Strategies. J Sex Med 2018;15:1055-1060., (Copyright © 2018 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare opioid requirements before and after cystectomy for end-stage Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) using a statewide tracking system., Methods: Narcotic prescriptions were captured using the North Carolina Controlled Substance Reporting System for patients at a single institute undergoing cystectomy with urinary diversion (CWUD) for refractory, end-stage IC/BPS between 2010 and 2017. Values were documented for the year before and the year after surgery (excluding 30 days postoperatively to account for surgical pain) and converted to morphine equivalents (ME). Values were compared using Student t test., Results: Following CWUD, there was a mean decrease in opioid receipt per patient of 6535 ME/year (P = .321). 8/26 (31%) had not filled any opiate prescriptions for the preceding 3 months at time of manuscript writing., Conclusion: In certain patients with end-stage, refractory IC/BPS, CWUD can help reduce opioid requirements., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To assess the utility of the Manufacturer And User Facility Device Experience (MAUDE) database in objectively capturing adverse events for transvaginal mesh in the United States., Materials and Methods: We reviewed 1,103 individual medical device reports submitted to the MAUDE database that inspired the United States (US) Food and Drug Administration's 2008 Public Health Notification. Entries were compiled into a categorical database that reported manufacturer, brand, reporter type, report source, and type of adverse event., Results: There were numerous examples of missing, duplicated, and non-standardized entries. Analysis revealed 64 reports with duplicated information, and six reports representing multiple patients. Forty-seven percent of medical device reports did not identify a reporter source. At least 28% of reported devices are no longer on the US market. There was wide variability in the quality and completeness of submitted reports and true adverse event rates could not be accurately calculated because the number of total cases was unknown., Conclusions: The MAUDE database was limited in its ability to collect, quantify, and standardize real-life adverse events related to transvaginal mesh. While it functions to collect information related to isolated adverse events, systematic limitations of the MAUDE database, that no doubt extend to other medical devices, necessitate the development of new reporting systems. Alternatives are under development, which may allow regulators to more accurately scrutinize the safety profiles of specific medical devices., Competing Interests: CONFLICTS OF INTEREST: Dr. Ryan P. Terlecki is a paid consultant for Boston Scientific Corp. The authors have no acknowledgments.

Introduction: Reports of robot-assisted pyeloplasty have increased. However, it is unclear if this change is due to increased diagnosis of adult ureteropelvic junction obstruction, a shift in management based on presumed efficacy, a desire to maximize robot use or some combination thereof. Therefore, we acquired and analyzed data on a national scale to determine the incidence of interventions to correct ureteropelvic junction obstruction in adults and to characterize trends in procedure selection., Methods: Patients older than 18 years with ICD-9 procedure codes 55.87 (pyeloplasty) and 55.11 (endopyelotomy) were included in the study, with attention to those designated laparoscopic robotic assistance (17.42). Data were collected for the period from January 2000 through December 2012, and weighted to a national average using Nationwide Inpatient Sample guidelines., Results: A total of 47,992 pyeloplasties were identified. Pyeloplasty rates exhibited a significant increase during this period [F(1,11)=41.38, p <0.01] and endopyelotomy rates exhibited a significant decrease [F(1,11)=64.7, p <0.01]. A higher percentage of pyeloplasties were performed robotically in 2012 vs 2009 (54% vs 44%, p <0.010)., Conclusions: Rates of pyeloplasty appear to be increasing at the expense of endopyelotomy. The percentage of pyeloplasty cases performed robotically is increasing but it is unclear if this is due to superior results or a need for increased robot use.

Purpose: Autologous platelet rich plasma (PRP) is used increasingly in a variety of settings. PRP injections have been used for decades to improve angiogenesis and wound healing. They have also been offered commercially in urology with little to no data on safety or efficacy. PRP could theoretically improve multiple urologic conditions, such as erectile dysfunction (ED), Peyronie's disease (PD), and stress urinary incontinence (SUI). A concern with PRP, however, is early washout, a situation potentially avoided by conversion to platelet rich fibrin matrix (PRFM). Before clinical trials can be performed, safety analysis is desirable. We reviewed an initial series of patients receiving PRFM for urologic pathology to assess safety and feasibility., Materials and Methods: Data were reviewed for patients treated with PRFM at our center from November 2012 to July 2017. Patients were observed immediately post-injection and at follow-up for complications and tolerability. Where applicable, International Index of Erectile Function (IIEF-5) scores were reviewed before and after injections for ED and/or PD. Pad use data was collected pre/post injection for SUI., Results: Seventeen patients were identified, with a mean receipt of 2.1 injections per patient. Post-procedural minor adverse events were seen in 3 men, consisting of mild pain at injection site and mild penile bruising. No patients experienced complications at follow-up. No decline was observed in men completing pre/post IIEF-5 evaluations., Conclusions: PRFM appears to be a safe and feasible treatment modality in patients with urologic disease. Further placebo-controlled trials are warranted., Competing Interests: CONFLICTS OF INTEREST: The authors have nothing to disclose.

Penile transplantation is a novel approach to management of penile loss in the developing field of composite tissue allotransplantation (CTA). Prior management for significant penile loss has been free flap phalloplasty with issues related to function, cosmesis, and functional loss from the location of flap harvest. Transplantation has been an evolving field with advancement in CTA over the past several decades leading to the option of penile transplant. Management of penile injury with replantation provided some preliminary groundwork on the technical aspects for penile transplantation. Additionally, penile transplantation raises many ethical, emotional, and psychological considerations with need for patience amidst ongoing advancement within the field., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objective: In 2012 the US Preventive Services Task Force released recommendations against prostate specific antigen (PSA) based screening for prostate cancer, but did not fully address screening via digital rectal exam (DRE). As such, many practitioners continue to perform DRE in attempts to identify men with clinically significant prostate cancer (CSPC). This study seeks to determine the value of DRE in detecting CSPC in the era of PSA-based screening., Methods: Data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Screening Trial, a nationwide population-based study evaluating cancer screening programs and their impact on cancer mortality, was analyzed for PSA, DRE, and cancer status. In the screening arm of the PLCO, 38,340 men received annual PSA and DRE examinations for the first 3 years. Those with an abnormal test result were referred to their individual care provider for biopsy. The ability of DRE to detect CSPC, defined as intermediate risk or higher based on National Comprehensive Cancer Network guidelines and age ≤75, was evaluated in the context of both normal and abnormal PSA., Results: A total of 5064 men had abnormal DRE in the setting of normal PSA, of whom 99 (2%) were diagnosed with CSPC. When both PSA and DRE were abnormal, 218 (20%) participants were diagnosed with CSPC (RR = 2.06 [1.78-2.39] versus abnormal PSA alone)., Conclusions: DRE screening in the setting of normal PSA captured an additional 2% of men with CSPC. This incremental gain suggests that routine DRE screening subjects a large number of men to invasive, potentially uncomfortable examinations for relatively minimal gain. Key limitations: Our conclusions are based on data derived from the PLCO study which has been criticized on the basis of inconsistent biopsies following positive screening tests, lack of end of study biopsies to determine population disease burden, and low numbers of black men.

Purpose: The relationship between erectile dysfunction and endothelial dysfunction has been described and is associated with adverse cardiac events. Endothelial dysfunction is believed to precede erectile dysfunction. Our objective was to characterize the prevalence of subjective erectile dysfunction, endothelial dysfunction and commonly related comorbidities in a population of men undergoing wellness screening., Materials and Methods: A total of 205 men presented for wellness screening. They underwent testing for endothelial dysfunction via peripheral arterial tonometry and completed a health screening questionnaire. Reactive hyperemia index scores were generated by peripheral arterial tonometry testing. A reactive hyperemia index score of 1.67 or less defined endothelial dysfunction. The Student t-test and Fisher exact test were performed for continuous and categorical variables, respectively. The association of endothelial dysfunction, erectile dysfunction and various comorbidities was calculated using univariate and multivariable analyses., Results: Of 205 men 47 reported subjective erectile dysfunction. Median age was 44 years old. The mean reactive hyperemia index in patients with erectile dysfunction was significantly lower than in patients without erectile dysfunction (1.63 vs 1.87, p = 0.001). Endothelial dysfunction was more common in men with than without erectile dysfunction (55% vs 36%, p = 0.027). Multivariable analysis revealed that men with erectile dysfunction and obesity were twofold more likely to have concomitant endothelial dysfunction (OR 2.45, 95% CI 1.13-4.24, p = 0.02 and OR 2.08, 95% CI 1.16-3.75, p = 0.01, respectively)., Conclusions: Among middle-aged men presenting for wellness screening erectile dysfunction and obesity independently predicted endothelial dysfunction, a known risk factor for long-term adverse cardiac events., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Prostate cancer is the most common malignancy among the male survivorship population in the United States, representing 44% of approximately 7 million survivors. In the era of modern medicine and value-based care, successfully treating only the cancer is not sufficient. The cancer survivor represents an individual in need of restoration and protection against future events. A well-designed and well-supported survivorship program not only meets a mandate for accreditation, it logically translates into better patient care. This review summarizes the history of the survivorship movement, outlines some key elements of a survivorship program, and highlights the opportunity to apply these principles to improve cancer-related care, develop relationships with colleagues that may allow increased identification of men at risk, and expand both the experience and outcomes of individual specialists within men's health.

Introduction: Use of supplements is common among men seeking urologic evaluation for sexual health matters. With a dizzying array of formulations available and little regulation on the dosage, purity, or ingredients found in these products, the health effects of nutraceuticals are often confusing to patients and medical practitioners alike., Aim: In this review, we set out to concisely summarize the data on ingredients found within the top-selling nutraceutical agents marketed for men's sexual health in order to provide a clinical guide for urologists., Methods: We used sales data from the most popular retail provider of men's health supplements to identify the top-selling products marketed toward improvement of men's sexual health. We summarized the available information related to the ingredients, dosage, cost, and mechanism of action for these substances and performed an extensive literature search to identify and review the current evidence available for each of the most common ingredients found in these nutraceuticals., Results: The top-selling nutraceuticals marked for men's sexual health contain a blend of multiple supplements (up to 33 in one formulation identified), the most common being ginseng, tribulus, zinc, horny goat weed, B complex vitamins/trace minerals, fenugreek, L-arginine, maca, DHEA, ginkgo, and yohimbine. The currently available medical literature evaluating the efficacy of these substances is generally of low quality., Conclusions: Despite the dearth of evidence supporting nutraceutical agents in the men's health arena, these substances are still commonly used by patients. As these products can affect the health and well-being of men presenting to a urology clinic, a familiarity with commonly used agents can help the urologist appropriately counsel their patients., (© 2015 International Society for Sexual Medicine.)

Patients who develop bladder neck contracture (BNC) after surgical treatment for prostate cancer often present with progressive lower urinary tract symptoms. Multiple risk factors contribute to BNC development including patient-related factors and technical considerations at the time of surgery. Initial management begins with endoscopic therapies, including dilation, transurethral incision (TUIBNC), and injection of adjunctive agents. When BNC remains refractory to these therapies, surgical reconstruction of the vesicourethral anastomosis or urinary diversion can be considered in select cases. This review presents an outline of the management of BNC after radical prostatectomy (RP), highlighting the recent literature related to the subject.

To describe the novel technique of ventral inlay substitution urethroplasty for the management of male anterior urethral stricture disease. A 58-year-old gentleman with multifocal bulbar stricture disease measuring 7 cm in length was treated using a ventral inlay substitution urethroplasty. A dorsal urethrotomy was created, and the ventral urethral plated was incised. The edges of the urethral plate were mobilized without violation of the ventral corpus spongiosum. A buccal mucosa graft was harvested and affixed as a ventral inlay to augment the caliber of the urethra. The dorsal urethrotomy was closed over a foley catheter. No intraoperative or postoperative complications occurred. Postoperative imaging demonstrated a widely patent urethra. After three years of follow-up, the patient continues to do well with no voiding complaints and low postvoid residuals. Ventral inlay substitution urethroplasty appears to be a safe and feasible technique for the management of bulbar urethral strictures.