Shift Work Sleep Disorder and Night Shift Work Significantly Impair Erectile Function.

OBJECTIVES: Here we examine the association between shift work sleep disorder (SWSD) and erectile dysfunction (ED) in shift workers. METHODS: Men presenting to a single andrology clinic between January 2014 and July 2017 completed validated questionnaires: International Index of Erectile Function (IIEF), Patient Health Questionnaire-9 (PHQ-9), and the nonvalidated SWSD Questionnaire. Men were also asked about shift work schedule, comorbidities, phosphodiesterase 5 (PDE5) inhibitor use, and testosterone use. Serum total testosterone values were determined for each visit. Linear regression was performed controlling for testosterone use, testosterone levels, PDE5 inhibitor use, age, and comorbidities to determine the effect of SWSD on ED as assessed using the IIEF. RESULTS: Of the 754 men completing questionnaires, 204 reported nonstandard shift work (begins before 7 am or after 6 pm, regularly extends out of that frame, or rotates frequently) and 48 were found to have SWSD using a screening questionnaire. Nonstandard shift work alone did not result in worse IIEF-EF scores (P = .31), but those who worked nonstandard shifts and had SWSD demonstrated IIEF-EF scores 2.8 points lower than men without SWSD (P < .01). When assessing for the type of shift work performed, men who worked night shifts had IIEF-EF scores 7.6 points lower than men who worked during the day or evening (P < .01). Testosterone use improved IIEF-EF scores for men with SWSD by 2.9 points, ameliorating the effect of SWSD on ED. However, baseline testosterone levels were not associated with worse erectile function in this cohort. CONCLUSION: Men with SWSD have worse erectile function, with men who work night shifts having even poorer erectile function. These findings suggest that circadian rhythm disturbance may significantly impact erectile function. While testosterone therapy may partly reverse the effects of SWSD, shift work is a potential risk factor for ED and should be assessed for as part of the evaluation of men with ED. Rodriguez KM, Kohn TP, Kohn JR, et al. Shift Work Sleep Disorder and Night Shift Work Significantly Impair Erectile Function. J Sex Med 2020;17:1687-1693.

Increased Risk of Hypogonadal Symptoms in Shift Workers With Shift Work Sleep Disorder.

OBJECTIVE: To examine the association between shift work sleep disorder (SWSD), a primary circadian rhythm disorder characterized by excessive day-time sleepiness associated with shift work, and hypogonadal symptoms in shift workers. METHODS: Men presenting to an andrology clinic between July 2014 and June 2017 completed questionnaires assessing shift work schedule, SWSD risk, and hypogonadal symptoms ([quantitative] Androgen Deficiency in the Aging Male [qADAM, ADAM]). The impact of nonstandard shift work and SWSD on responses to qADAM and ADAM was assessed using ANOVA and linear regression. RESULTS: About 24.1% (619/2571) of men worked nonstandard shifts. Of those, 196 (31.7%) were considered to have SWSD. Controlling for age, comorbidities, and testosterone (T) levels, nonstandard shift workers had qADAM scores 1.12 points lower than day-time workers (P <.01). Subgroup analysis of nonstandard shift workers showed that those with SWSD had qADAM scores 5.47 points lower than men without SWSD (P <.01). In this same subgroup analysis, SWSD was independently associated with lower T levels (mean decrease 100.4 ng/dL, P <.01) when controlling for age, comorbidities, and prior T supplementation. CONCLUSION: Nonstandard shift workers with SWSD have even worse hypogonadal symptoms and lower T levels than day-time workers and nonstandard shift workers without SWSD. This suggests that poor sleep habits, as identified by SWSD, may contribute to the more severe hypogonadal symptoms seen in nonstandard shift workers.

Variability in penile duplex ultrasound international practice patterns, technique, and interpretation: an anonymous survey of ISSM members.

Penile duplex ultrasound (PDU), combined with pharmacologic stimulation of erection, is the gold standard for the evaluation of multiple penile conditions. A 30-question electronic survey was distributed to members of the International Society for Sexual Medicine (ISSM). The survey assessed the variability in current PDU practice patterns, technique, and interpretation. Chi-square test was used to determine the association between categorical variables. Approximately 9.5% of all 1996 current ISSM members completed the survey. Almost 80% of members surveyed reported using PDU, with more North American practitioners utilizing PDU than their European counterparts (94% vs 69%, p < 0.01). Approximately 62% of PDU studies were performed by a urologist and more than 76% were interpreted by a urologist. Although almost 90% of practitioners reported using their own protocol, extreme variation in the technique existed among respondents. Over ten different pharmacologic mixtures were used to generate erections, and 17% of respondents did not repeat dosing for insufficient erection. Urologists personally performing PDU were more likely to assess the cavernosal artery flow using recommended techniques with the probe at the proximal penile shaft (73% vs 40%) and at a 60-degree angle or less (68% vs 36%) compared with non-urologists (p < 0.01). Large differences in PDU diagnostic thresholds were apparent. Only 38% of respondents defined arterial insufficiency with a peak systolic velocity < 25 cm/s, while 53% of respondents defined venous occlusive disease with an end diastolic velocity > 5 cm/s. This is the first study to assess the variability in the PDU protocol and practice patterns, and to pinpoint areas of improvement. As in other surveys, recall bias, generalizability, and response rate (9.5%) are inherent limitations to this study. Although most respondents report utilizing a standardized PDU protocol, widespread variation exists among practitioners in terms of both technique and interpretation, limiting accurate diagnosis and appropriate treatment of penile conditions.

Workforce Characteristics in Urology.

INTRODUCTION: In this study we holistically describe and characterize the current state of urology practice by evaluating compensation, workload and practice factors as they relate to our demographic makeup as a specialty. METHODS: We collaborated with the American Urological Association to query its domestic membership of practicing urologists regarding socioeconomic, workforce and quality of life issues. The survey consisted of 26 questions and took approximately 13 minutes to complete. A total of 733 responders had complete data for the factors statistically analyzed in the study. RESULTS: Mean yearly compensation for urologists surveyed was $404,755 and median compensation was $380,000 (IQR $300,000-480,000). Female respondents had a significantly lower median yearly compensation vs males ($318,422 vs $400,000) on univariate and multivariate analysis. Respondents reported a median of 60 work hours per week (IQR 50-60) and the median number of call days per month was 7 (IQR 5-10). Of the respondents 62% indicated that they use advanced practice providers in their practice. In addition, 30% reported employed status, 49% reported self-employed status and 21% reported academic status. Overall 20% of respondents plan to retire within 5 years and 40% within 10 years. CONCLUSIONS: Higher income was associated with greater job satisfaction and hourly wage appeared to decrease at increased work hours per week. Several workplace and demographic factors drive compensation, number of hours worked per week, number of call days per month and job satisfaction.

Penile prosthesis in the management of erectile dysfunction following cancer therapy.

Erectile dysfunction (ED) is a common problem in older men and occurs with even greater frequency following the treatment of pelvic malignancies. Inflatable penile prosthesis (IPP) implantation is a safe and effective form of definitive ED treatment for those men who fail more conservative measures, and it can be used with similar outcomes in men following cancer therapy. Although many of these men remain dissatisfied with other therapeutic options for ED, IPPs are underutilized in this population. This review will discuss the current practice patterns, outcomes and nuances to surgical technique regarding the use of IPPs in patients with ED following cancer therapy.

Vasectomy reversal: decision making and technical innovations.

Vasectomy is the method of contraception chosen by more than 500,000 American men annually, and by upwards of 8% of married couples worldwide. However, following the procedure, nearly 20% of men express the desire for children in the future, and approximately 2-6% of American men will ultimately undergo vasectomy reversal (VR). VR is a complex microsurgical procedure. Intraoperative decision-making, surgical technique, and postoperative management are each critical step in achieving high success rates. The aim of this article is to provide a detailed description of the operative and perioperative procedures employed by surgeons performing VRs.

Advanced Practice Providers in U.S. Urology: A National Survey of Demographics and Clinical Roles.

INTRODUCTION: Projections suggest a significant shortage of urologists coupled with an increasing burden of urological disease due to an aging population. To meet this need, urologists have increasingly partnered with advanced practice providers. However, to this point the advanced practice provider workforce has not been comprehensively evaluated. Understanding the impact of advanced practice providers on the urology workforce is essential to maximize collaborative care as we strive for value and quality in evolving delivery models. METHODS: A 29-item, web based survey was administered to advanced practice providers identified by the AUA (American Urological Association), UAPA (Urological Association of Physician Assistants) and SUNA (Society of Urologic Nurses and Associates), querying many aspects of their practice. RESULTS: A total of 296 advanced practice providers completed the survey. Advanced practice nurses comprised 62% of respondents while physician assistants comprised the remaining 38%. More than two-thirds of the respondents were female and median age was 46 years. Only 6% reported having participated in formal postgraduate urological training. Advanced practice providers were evenly divided between institutional and private practice settings, and overwhelmingly in urban or suburban environments. The majority of advanced practice providers practice in the ambulatory setting (74%) and characterize their practice as general urology (72%). Overall 81% reported performing procedures independently, with 63% performing some procedures considered to be of moderate or high complexity. CONCLUSIONS: Advanced practice providers are active in the provision of urological care in many roles, including complex procedures. Given future workforce needs, advanced practice providers will likely assume additional responsibilities. As roles shift we must ensure we have the necessary educational and training opportunities to equip this vital part of our workforce.

Projecting the Urology Workforce Over the Next 20 Years.

OBJECTIVE: To forecast the size and composition of the urologist and urology advanced care provider (ACP; nurse practitioner, physicians' assistant) workforce over the next 20 years. METHODS: Current urologist workforce was estimated from the American Board of Urology certification data and the 2014 American Urological Association (AUA) Census. Incoming workforce was estimated from the American Board of Urology and AUA residency match data. Estimates of the ACP workforce were extracted from the 2012 AUA Physician Survey. Full-time equivalent (FTE) calculations were based on a 2014 urology workforce survey. Workforce projections were created using a stock and flow population model with multiple alternative forecast scenarios. RESULTS: Slight growth in overall (urologist + ACP) workforce FTEs is expected, from 14,792 in 2015 to 15,160 in 2035. A significant decline in urologist FTEs is likely, from 11,221 in 2015 to 8859 in 2035. ACPs should increase markedly, from 8,710 in 2015 to 15,369 in 2035. Female urologists should increase by 2035, from the current 7.0% to 18.6% of urologist workforce. Alternate scenarios were evaluated, with forecasted FTEs in 2035 ranging from 14,066 to 17,675. In 2035, workforce shortage predictions range from 12% to 46%. CONCLUSION: With a decrease in urologists over the coming decades, urologists and ACPs may not meet future demand. This forecast highlights the need for discussion and planning among leadership in the field to find creative solutions for this impending workforce shortage.

Undergoing varicocele repair before assisted reproduction improves pregnancy rate and live birth rate in azoospermic and oligospermic men with a varicocele: a systematic review and meta-analysis.

OBJECTIVE: To evaluate how varicocele repair (VR) impacts pregnancy (PRs) and live birth rates in infertile couples undergoing assisted reproduction wherein the male partner has oligospermia or azoospermia and a history of varicocele. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Azoospermic and oligospermic males with varicoceles and in couples undergoing assisted reproductive technology (ART) with IUI, IVF, or testicular sperm extraction (TESE) with IVF and intracytoplasmic sperm injection (ICSI). INTERVENTION(S): Measurement of PRs, live birth, and sperm extraction rates. MAIN OUTCOME MEASURE(S): Odds ratios for the impact of VR on PRs, live birth, and sperm extraction rates for couples undergoing ART. RESULT(S): Seven articles involving a total of 1,241 patients were included. Meta-analysis showed that VR improved live birth rates for the oligospermic (odds ratio [OR] = 1.699) and combined oligospermic/azoospermic groups (OR = 1.761). Pregnancy rates were higher in the azoospermic group (OR = 2.336) and combined oligospermic/azoospermic groups (OR = 1.760). Live birth rates were higher for patients undergoing IUI after VR (OR = 8.360). Sperm retrieval rates were higher in persistently azoospermic men after VR (OR = 2.509). CONCLUSION(S): Oligospermic and azoospermic patients with clinical varicocele who undergo VR experience improved live birth rates and PRs with IVF or IVF/ICSI. For persistently azoospermic men after VR requiring TESE for IVF/ICSI, VR improves sperm retrieval rates. Therefore, VR should be considered to have substantial benefits for couples with a clinical varicocele even if oligospermia or azoospermia persists after repair and ART is required.

Gender Differences in Compensation, Job Satisfaction and Other Practice Patterns in Urology.

PURPOSE: The proportion of women in urology has increased from less than 0.5% in 1981 to 10% today. Furthermore, 33% of students matching in urology are now female. In this analysis we characterize the female workforce in urology compared to that of men with regard to income, workload and job satisfaction. MATERIALS AND METHODS: We collaborated with the American Urological Association to survey its domestic membership of practicing urologists regarding socioeconomic, workforce and quality of life issues. A total of 6,511 survey invitations were sent via e-mail. The survey consisted of 26 questions and took approximately 13 minutes to complete. Linear regression models were used to evaluate bivariable and multivariable associations with job satisfaction and compensation. RESULTS: A total of 848 responses (660 or 90% male, 73 or 10% female) were collected for a total response rate of 13%. On bivariable analysis female urologists were younger (p <0.0001), more likely to be fellowship trained (p=0.002), worked in academics (p=0.008), were less likely to be self-employed and worked fewer hours (p=0.03) compared to male urologists. On multivariable analysis female gender was a significant predictor of lower compensation (p=0.001) when controlling for work hours, call frequency, age, practice setting and type, fellowship training and advance practice provider employment. Adjusted salaries among female urologists were $76,321 less than those of men. Gender was not a predictor of job satisfaction. CONCLUSIONS: Female urologists are significantly less compensated compared to male urologists after adjusting for several factors likely contributing to compensation. There is no difference in job satisfaction between male and female urologists.

Factors Related to Job Satisfaction in Urology.

INTRODUCTION: There is little information on job satisfaction in the extant literature in urology. The purpose of this study is to examine 1) the current state of job satisfaction among urologists in the United States, and 2) the demographic and work place factors that have the greatest influence on satisfaction. METHODS: We collaborated with AUA (American Urological Association) to query its domestic membership of practicing urologists regarding socioeconomic, work force and quality of life issues. A total of 848 responses were collected for a total response rate of 13%. Linear regression models were used to evaluate bivariable and multivariable associations with job satisfaction scores on a 1 to 5 scale. RESULTS: Of providers 70% reported being satisfied, 63% reported that they would choose medicine again and 83% would choose urology again. Age and job satisfaction did not demonstrate a linear association on statistical analysis but rather a U-shaped relationship. On bivariate analysis significant factors associated with higher job satisfaction included younger and older age, higher income (p = 0.047), fewer call days (p = 0.006), fellowship training (p = 0.006) and academic practice (overall p = 0.002). On multivariate analysis age (younger and older ages) and academic practice remained significant predictors of job satisfaction (p = 0.01) as did higher income (p = 0.038). CONCLUSIONS: The current study helps describe the current state of job satisfaction among American urologists and examined work place factors that influence satisfaction. Income, hours worked, academic practice and age each have a significant impact on job satisfaction for the practicing urologist. Keeping abreast of the drivers of job satisfaction is critical to ensure that urologists continue to care for patients, perform research, educate future physicians and provide service to their communities.

Reduced Resident Work Hours in Urology: The History and Impact of Duty Hour Restrictions.

INTRODUCTION: The ACGME first mandated duty hour restrictions for resident physicians in 2003, setting a limit of 80 hours per week. While the goals of this and later reforms were to improve patient care and safety, the outcomes have been mixed. In this review we report on the history of duty hour regulations and how these changes have impacted resident and patient outcomes. METHODS: A literature search was performed, and articles discussing surgical training, resident duty hours, resident wellness and patient outcomes were reviewed. RESULTS: After implementation of duty hour restrictions in 2003, the Harvard Work Hours Health and Safety Group published 3 hallmark studies that suggested duty hour restrictions were associated with improved outcomes. A recently published systematic review reported mixed results from the growing body of research. While 71% of the reviewed studies reported improvement in resident wellness, only 4% illustrated an improvement in resident education, 19% reported improved patient safety outcomes and 13% demonstrated improved patient morbidity. CONCLUSIONS: Resident duty hour restrictions were based on a body of evidence illustrating that fatigue and sleeplessness negatively impact decision making, resident wellness and patient care. While initial outcomes suggested that these regulations resulted in better resident and patient outcomes, more recent evidence suggests otherwise. There is very little urology specific evidence addressing these matters.

Low testosterone has a similar prevalence among men with sexual dysfunction due to either Peyronie's disease or erectile dysfunction and does not correlate with Peyronie's disease severity.

INTRODUCTION: Low testosterone (T) has been suggested as a risk factor for Peyronie's disease (PD) that may correlate with disease severity. Low T is common in men with sexual dysfunction but its role in the pathogenesis of PD remains unclear. AIM: The aim of this study was to compare the prevalence of low T (<300 ng/dL) in patients presenting with PD or erectile dysfunction (ED), as well as disease severity between men with PD and either low T or normal T (≥300 ng/dL). METHODS: Retrospective review of 300 men with either PD or ED was conducted. Men were excluded for combined PD and ED, psychogenic ED, or prior T use. For men with PD, plaque size, degree of curvature, and surgical correction rate were compared. MAIN OUTCOME MEASURES: The main outcome measures were (i) mean T levels in men with PD or ED and (ii) plaque size, degree of curvature, and surgical correction rates among men with PD and either low T or normal T. RESULTS: Eighty-seven men with PD and 98 men with ED were identified. Men with PD had mean total T and free T of 328 ng/dL and 11.5 ng/dL, while men with ED had mean levels of 332 ng/dL and 12.1 ng/dL, respectively (P > 0.05). Of PD men, 52.9% had low T, compared with 45.9% of men with ED (P = 0.35). T levels did not correlate with plaque size or degree of curvature in the PD group (P > 0.05). CONCLUSIONS: Men with sexual dysfunction characterized by either PD or ED had similarly low T levels, and low T did not correlate with PD severity or surgical correction rate. The comparable prevalence of low T in men with PD or ED suggests the high rate of low T in PD men may be related to a common process among men with abnormal erectile physiology and not specifically causative in plaque formation.

Economic impact of training and career decisions on urological surgery.

PURPOSE: Medical students and residents make career decisions at a relatively young age that have significant implications for their future income. While most of them attempt to estimate the impact of these decisions, there has been little effort to use economic principles to illustrate the impact of certain variables. MATERIALS AND METHODS: The economic concept of net present value was paired with available Medical Group Management Association and Association of American Medical Colleges income data to calculate the value of career earnings based on variations in the choice of specialty, an academic vs a private practice career path and fellowship choices for urology and other medical fields. RESULTS: Across all specialties academic careers were associated with lower career earnings than private practice. However, among surgical specialties the lowest difference in value between these 2 paths was for urologists at only $334,898. Fellowship analysis showed that training in pediatric urology was costly in forgone attending salary and it also showed a lower future income than nonfellowship trained counterparts. An additional year of residency training (6 vs 5 years) caused a $201,500 decrease in the value of career earnings. CONCLUSIONS: Choice of specialty has a dramatic impact on future earnings, as does the decision to pursue a fellowship or choose private vs academic practice. Additional years of training and forgone wages have a tremendous impact on monetary outcomes. There is also no guarantee that fellowship training will translate into a more financially valuable career. The differential in income between private practice and academics was lowest for urologists.

Levels of Evidence and Clinical Guidelines-Considerations for the Practicing Urologist.

INTRODUCTION: It is important for urologists to remain up-to-date regarding research and clinical guidelines within their specialty. This has become increasingly difficult as the volume of research increases while the quality of evidence has not followed suit. It is, therefore, important for urologists to understand the methodology of critical appraisal of evidence, for both the assessment of individual journal articles as well as the construction of organizational clinical guidelines. METHODS: The methodology for clinical guideline creation used by the American Urological Association (AUA) is reviewed along with that of the U.S. Preventive Services Task Force (USPSTF). Two popular grading schemas are then reviewed to provide an overview of existing methods for the critical analysis of research. We conclude with a description of the Grading of Recommendations Assessment Development and Evaluation (GRADE)-a classification system that attempts to unify various grading systems and is rapidly gaining popularity among well-reputed national organizations. RESULTS: The AUA uses a systematic and evidence-based approach to creating clinical guidelines. The USPSTF is similar to the AUA in its approach to reviewing the literature and creating guidelines. The Centre for Evidence Based Medicine offers a novel approach to evidence-based literature review, providing a metric for the analysis of the literature to answer specific clinical questions. GRADE is working toward the development of a more transparent and standardized approach to the creation and reporting of clinical guidelines. CONCLUSIONS: A number of organizations have attempted to standardize and clarify the literature review process to provide physicians with tools to critically evaluate higher quality evidence and apply guidelines to clinical practice. As urologists, we must understand how national organizations review the literature and develop clinical guidelines. Additionally, we must develop our own process for reviewing the literature in order to answer questions that have not yet been addressed by these organizations. Kirby EW, Borawski KM, and Smith AB. Levels of evidence and clinical guidelines-Considerations for the practicing urologist. Sex Med Rev 2013;1:17-23.

A study of cognitive dysfunction in patients having carotid endarterectomy performed with regional anesthesia.

BACKGROUND: In previous studies, we found that approximately 25% of patients having carotid endarterectomy with general anesthesia (CEA general) develop cognitive dysfunction compared with a surgical control Group 1 day and 1 mo after surgery. In this study, we tested the hypothesis that patients having CEA with regional anesthesia (CEA regional) will develop significant cognitive dysfunction 1 day after surgery compared with a control group of patients receiving sedation 1 day after surgery. We did not study persistence of dysfunction. METHODS: To test this hypothesis, we enrolled 60 patients in a prospective study. CEA regional was performed with superficial and deep cervical plexus blocks in 41 patients. The control group consisted of 19 patients having coronary angiography or coronary artery stenting performed with sedation. A control group is necessary to account for the "practice effect" associated with repeated cognitive testing. The patients from the CEA regional group were enrolled at New York Medical Center and the control group at Columbia-Presbyterian Medical Center. The cognitive performance of all patients was evaluated using a previously validated battery of neuropsychometric tests. Differences in performance, 1 day after compared with before surgery, were evaluated by both event-rate and group-rate analyses. RESULTS: On postoperative day 1, 24.4% of patients undergoing CEA regional had significant cognitive dysfunction, where "significant" was defined as a total deficit score > or =2 SD worse than the mean performance in the control group. CONCLUSIONS: Patients undergoing CEA regional had an incidence of cognitive dysfunction which was not different than patients having CEA general as previously published and compared with a contemporaneously enrolled group.