Testosterone Therapy is Associated With Depression, Suicidality, and Intentional Self-Harm: Analysis of a National Federated Database.

BACKGROUND: Long-term use of testosterone can be associated with mood destabilizing effects. Most studies investigating psychiatric complications of anabolic steroids have used small samples, but a comprehensive assessment of the risk of developing mental health disorders after testosterone use has not been performed at the population level. AIM: To determine whether testosterone therapy is associated with major depressive disorder or suicide attempts in men. METHODS: We conducted a retrospective cohort study of 70.3 million electronic health records collected from 46 healthcare organizations encompassing flagship hospitals, satellite hospitals, and outpatient clinics since 2008 to determine whether testosterone use is associated with major depressive disorder and suicide attempts in a large population. We included men 18 or older who either used testosterone or did not, defined by reported use, insurance claim, or prescription use of testosterone documented in the electronic health record. We propensity-score matched by age, race, ethnicity, obesity, and alcohol-related disorder. Additionally, a sub-group analysis was performed in testosterone deficient (<300 ng/dL) men comparing those with TD on testosterone therapy to a control group of men with TD who are not using testosterone. OUTCOMES: We determined measures of association with a new diagnosis of major depressive disorder and suicide attempt or intentional self-harm following testosterone use within 5 years. RESULTS: A total of 263,579 men who used testosterone and 17,838,316 men who did not were included in the analysis. Testosterone use was independently associated with both Major Depressive Disorder (OR 1.99, 95% CI 1.94-2.04, P < .0001) and Suicide Attempt/Intentional Self-Harm (OR 1.52, 95% CI 1.40-1.65, P < .0001). Results remained significant in testosterone deficient sub-group analysis. CLINICAL IMPLICATIONS: Men who use testosterone should be screened for and counseled about risks of depression and suicidality. STRENGTHS AND LIMITATIONS: Strengths of this study include a large sample size, the ability to account for chronology of diagnoses, the use of propensity score matching to control for potentially confounding variables, and the consistency of results with sub-group analyses. Limitations include the potential for incorrect coding within the electronic health record, a lack of granular information regarding testosterone therapy adherence, the possibility that unrecorded testosterone or anabolic steroid use were prevalent but not captured within the control group, and a lack of data regarding testosterone withdrawal. CONCLUSION: Testosterone use is independently associated with new-onset mental health disorders. Future studies are necessary to elucidate the role that androgen withdrawal plays and whether a causal relationship exists. Nackeeran S, Patel MS, Nallakumar DT, et al. Testosterone Therapy is Associated With Depression, Suicidality, and Intentional Self-Harm: Analysis of a National Federated Database. J Sex Med 2022;19:933-939.

Systematic Review of the Impact of Varicocele Grade on Response to Surgical Management.

PURPOSE: We evaluated the impact of varicocele grade on the response to varicocelectomy or spermatic vein embolization. MATERIALS AND METHODS: We systematically reviewed the published English language literature to identify studies on changes in semen quality and pregnancy outcomes after varicocele treatment, stratified by varicocele grade. Descriptive statistics and continuous random effects models were used to study the impact of varicocele grade and the surgical approach on the response to treatment. Result heterogeneity among studies was analyzed using the I2 statistic. Quality assessment of nonrandomized studies was done with the Newcastle-Ottawa Scale. Publication bias was analyzed using funnel plots and the Egger test. RESULTS: We identified 20 studies describing the outcome of varicocele treatment stratified by varicocele grade in a total of 2,001 infertile men with varicocele. A microsurgical approach (inguinal, subinguinal and/or Palomo) was used in 11 of the 20 studies (55%). Varicocele treatment was associated with improvements in sperm concentration and overall motility in patients with all grades of varicocele. Semen quality improvements were directly related to varicocele grade. The mean sperm concentration improvement in men with grades 1, 2, 2-3 and 3 varicoceles were 5.5, 8.9, 12.7 and 16.0 million sperm per ml, respectively. The mean improvement in the percent of overall motility in men with grades 1, 2, 2-3 and 3 varicoceles was 9.6%, 10.6%, 10.8% and 17.7%, respectively. Pregnancy outcomes were assessed but could not be analyzed systematically due to the lack of adequate published data. CONCLUSIONS: Mean improvements in the sperm concentration and the percent of overall motility after treatment of grade 1 varicocele were statistically significant but small in magnitude. In contrast, mean improvements in the sperm concentration and the percent of overall motility after treatment of grade 2-3 varicoceles were greater and highly likely to be clinically significant. Incorporating varicocele grade into shared decision making discussions with affected couples may improve the ability to select patients who are the best candidates for treatment.

Urology Resident Involvement in Patient Safety and Quality Improvement Activities.

PURPOSE OF REVIEW: To assess current urology resident engagement in patient safety and quality improvement (PSQI) and how to improve resident involvement in PSQI. RECENT FINDINGS: Overall urology resident participation in PSQI is low, especially when compared to other non-surgical residency programs. Multiple methods have been successfully implemented to increase resident participation in PSQI. Patient safety and quality improvement are extremely important to the progression of both urology and the healthcare community. True and meaningful participation in PSQI is lacking for many urology residents. However, there are easily adopted methods to improve resident involvement in this area of healthcare. These methods include direct communication and access between residents and hospital PSQI boards, resident-led safety councils, monetary incentives, formal training, and PSQI resident support teams.

Alvimopan usage increasing following radical cystectomy.

PURPOSE: Alvimopan (Entereg), a peripherally acting opioid receptor antagonist, is effective in reducing the rate of postoperative ileus and length of hospital stay in patients undergoing colorectal surgery, and is now approved for use after radical cystectomy (RC). Using data from Vizient (formerly University Health System Consortium), we assessed the utilization of alvimopan and its effect on perioperative factors after RC. METHODS: The Vizient database, contributed to by over 200 US academic hospitals, was evaluated from 2014 to 2016. Patients who had undergone radical cystectomy were included. Alvimopan exposure and postoperative outcomes were collected. RESULTS: 7472 patients underwent cystectomy in the 3 years examined, with 3391 (45.4%) patients receiving alvimopan over this time period. The use of alvimopan increased from 35 to 59%. The receipt of alvimopan was associated with a decrease in perioperative morbidity (10.53% vs 19.23%, p = 0.027). CONCLUSION: This study, the largest to examine the real-world utilization of alvimopan since FDA approval for RC, shows that alvimopan utilization has increased substantially and is associated with reduced perioperative morbidity in patients undergoing cystectomy.

Sub-Coronal Inflatable Penile Prosthesis Placement With Modified No-Touch Technique: A Step-by-Step Approach With Outcomes.

INTRODUCTION: The surgical treatment of disorders of male sexual function requires specific exposure to correct the underlying problem safely and efficiently. Currently, sub-coronal exposure is used for treatment of phimosis, Peyronie's disease plaque (PDP), and semirigid penile prosthesis insertion. Infra-pubic and scrotal incisions are used for inflatable penile prosthesis (IPP) placement. However, men who present with several disorders might require multiple procedures and surgical incisions. AIM: To report a prospective review of our surgical experience and outcomes with a single sub-coronal incision for IPP placement with a modified no-touch technique. This approach allows for access to the entire corporal body for multiple reconstructive procedures. METHODS: Two hundred men had IPPs placed through a sub-coronal incision using our modified no-touch technique. The penis was degloved to the level of the penoscrotal junction and the dartos muscle was everted and secured to the drapes. This allowed exclusion of the scrotal and penile skin from the operative field. After artificial erection, the patient's corpora were inspected for PDP and other abnormalities. Penoscrotal IPP models were placed in all cases with insertion proximal to the penoscrotal junction. After placement of the IPP, the abnormalities were repaired. MAIN OUTCOME MEASURES: Feasibility of the procedure, operative times, complication rate, utilization of accessory, reconstructive procedures, and post-operative penile length. RESULTS: Of the 200 men who had IPP placement, 92 had PDP that was treated, 106 (53%) consented to circumcision, 24 (12%) had their reservoir placed ectopically, and 31 (16%) had a prosthesis exchanged through the sub-coronal technique. Mean operative time was 73 minutes (39-161 minutes). CONCLUSION: Specialists in the surgical treatment of disorders of male sexual function can perform multiple procedures safely and easily through a modified no-touch single sub-coronal incision. This approach allows access to the entire corporal body, providing excellent visibility and allowing the surgeon to perform multiple penile reconstructive surgeries through a single incision.

Utilization and perioperative complications of laparoscopic cryoablation vs. robotic partial nephrectomy for localized renal tumors.

OBJECTIVE: To compare the utilization, perioperative complications and predictors of LCA versus RPN in the treatment of localized renal tumors. METHODS: From the Nationwide Inpatient Sample we identified patients undergoing RPN or LCA for the treatment of localized renal tumors from October 2008 through 2010. Patient and hospital-specific factors which predict postoperative complications and use of LCA were investigated. RESULTS: 14,275 patients with localized renal tumors were identified: 70.3% had RPN and 29.7% had LCA. LCA was more common in older patient and at hospitals without robotic consoles. No difference was identified in perioperative complications (0.2% vs. 0.2%), transfusion (5.1% vs. 6.2%), length of stay (2.9 vs. 3.0 days) or median cost ($41,753 vs. $44,618) between the groups, LCA vs. RPN. On multivariate analysis sicker patients were more likely to have LCA (OR 1.34, p=0.048) and sicker patients had greater postoperative complications (OR 3.30, p<0.001); LCA did not predict more complications (OR 1.63, p=0.138) and LCA was performed at hospitals without RCs (OR 0.02, p<0.001). Limitations include observational study design, inability to assess disease severity, operative time, or body mass index, which may affect patient selection and outcomes. CONCLUSIONS: More patients had RPN vs. LCA; surgical technique was not predictive of postoperative complications. As technology develops to treat localized renal tumors, it will be important to continue to track outcomes and costs for procedures including RPN and LCA.

The role of pelvic lymphadenectomy in non-muscle invasive bladder cancer.

INTRODUCTION: We evaluated whether the extent of lymphadenectomy at the time of radical cystectomy for non-muscle invasive bladder cancer (NMIBC) impacts recurrence free survival. MATERIALS AND METHODS: We conducted an IRB approved retrospective analysis of patients with clinical NMIBC who underwent radical cystectomy from 1990-2010. Patients were stratified based on extent of lymph node dissection using total lymph node yield as a surrogate indicator of lymph node dissection extent, with cut off analyses performed at 0, 8, 10, and 20 nodes removed. Analyses of recurrence free survival (RFS) were performed using log-rank analysis and multivariate Cox regression. RESULTS: One hundred and ninety-six patients with NMIBC met the inclusion criteria for this study, with no differences in RFS detected in those who had ≥ 10 nodes compared to < 10 nodes removed (p = 0.63). Upon multivariate analysis, ≥ 10 nodes removed (HR 1.00; p = 0.99) was not significantly associated with decreased RFS, while high grade tumor (HR 3.22; p = 0.05) and positive margin status (HR 3.87; p = 0.04) were. The median number of nodes removed was 8 (range 0-45), with no difference in RFS using this as a cut off point (p = 0.19). The removal of ≥ 20 nodes did not predict worse survival compared to < 20 nodes removed (p = 0.07). CONCLUSIONS: Although the extent of lymphadenectomy has been associated with improved survival in patients undergoing radical cystectomy for muscle invasive bladder cancer, we were unable to detect an impact of lymph node dissection extent on RFS in patients with NMIBC. This finding emphasizes that when determining extent of lymph node dissection in radical cystectomy, one size does not fit all.

Patient Portal Engagement Affects Postvasectomy Semen Analysis Completion.

OBJECTIVE: To identify factors that affect completion of postvasectomy semen analysis (PVSA) in men receiving telehealth prevasectomy counseling. Telehealth visits have become increasingly common for prevasectomy consultations. Prior studies have shown that men prefer telehealth vasectomy consultations over in-person options. Postvasectomy semen testing should be completed to confirm sterilization. METHODS: Three hundred and seventy-one men aged 19 and older who saw a single physician for a telehealth prevasectomy consultation and completed an in-office vasectomy were included in the study. Demographic information such as age, patient relationship status, and distance from the clinic were accessed via electronic medical record. Patients were assessed based on their engagement with electronic preprocedure instructions, and the primary outcome measured was completion of PVSA. RESULTS: 45.6% of men completed a PVSA. There was no significant difference in completion of the PVSA between those who opened their electronic instructions before their vasectomy and those who did not (46.1% vs 44.4%, P = .77). Of those who messaged the clinic for any reason at least once after their consultation, 62% completed their PVSA; 41% who did not contact the clinic completed the PVSA (P = .0009). CONCLUSION: While there was no difference in completion of PVSA in patients who opened their instructions vs those who did not, patients with a higher level of engagement with the patient portals were more likely to complete their semen test. By understanding factors influencing patient compliance with postvasectomy semen testing, healthcare professionals can develop targeted interventions to ensure safe and successful outcomes.

Attention-deficit hyperactivity disorder medication use is associated with testosterone hypofunction-results from a national claims database analysis.

Male hypogonadism is not a risk associated with attention-deficit hyperactivity disorder (ADHD) stimulant medications, but recent studies have explored this connection. Though the pathophysiologic connection remains unclear, we predicted that long-term use of ADHD stimulant medications could increase the risk of hypogonadism in post-pubertal males. Utilizing TriNetX, LLC Research Network data from January 2000 through December 2019, men older than 18 with ADHD receiving long-term stimulant medication (>36 monthly prescriptions) were selected for the study population. Two control groups were constructed: individuals with ADHD but no stimulant medication use, and individuals without ADHD or stimulant medication use. A diagnosis of testicular hypofunction (ICD-10: E29.1) within five years of long-term ADHD stimulant medication use was the chosen primary outcome. After propensity score matching, 17,224 men were analyzed in each group. Of the men with long-term ADHD stimulant medication use, 1.20% were subsequently diagnosed with testicular hypofunction compared to 0.67% of individuals with ADHD without stimulant medication use (RR: 1.78, 95% CI: 1.42-2.23) and 0.68% in men without ADHD or stimulant medication use (RR: 1.75, 95% CI: 1.39-2.19). Therefore, chronic ADHD stimulant medication use was found to be significantly associated with a subsequent diagnosis of testicular hypofunction.

Money Talks: The Shifting Effect of Limiting Monetary Incentives for Urology Resident Research.

OBJECTIVE: To assess incentive changes on resident publication behavior. In 2020, we demonstrated the positive effect of an unlimited $1000 publishing incentive for Urology residents. Following this publication, institutional changes led to a limit of a single $1000 publishing incentive per resident per year. METHODS: The PubMed database was assessed to quantify average resident primary authorship and average overall publications. Average primary authorships and total PubMed listings were then compared by year before any incentive (June 2008-June 2016), during unlimited incentive (July 2016-October 2020), and after the limited financial incentive (November 2020-June 2023). RESULTS: Scholarly activity from 30 out of 30 possible residents was evaluated. The average PubMed research participation for the program per year increased significantly from 2.44 preincentive to 8.0 when the incentive was unlimited but decreased to 4.0 when the incentive was limited (P = .026). Similarly, the average PubMed primary resident authorships per year increased from 1.0 preincentive to 6.25 during the unlimited incentive period but decreased to 2.0 when the incentive was limited (P < .001). CONCLUSION: Our data showed an unlimited monetary incentive resulted in a significant increase in average primary resident authorship and average resident participation for publications to PubMed. The limited monetary incentive model resulted in a significant decrease on resident publication and participation in research compared to unlimited incentives. However, limited monetary incentives have a positive, though restricted, effect on Urology resident publication and participation in research compared to no incentive.

Cryoablation of the penile nerves for chronic penile pain.

We present a unique case of a 39-year-old male with a 20-year history of chronic penile pain. Unfortunately, there are currently very limited reports on how best to manage chronic penile pain, as chronic penile pain is a diagnosis of exclusion without any apparent disease. Here, we describe our patient's clinical presentation of chronic penile pain, history of previously failed medical and procedural treatments, and eventually completion of cryoablation of the penile nerves. In this case study, we demonstrated that targeted cryoablation of the penile nerves is a potential treatment option for chronic penile pain that failed medical management. We also discuss the anatomy and innervation of the penis as it relates to sensation of chronic penile pain and subsequent cryoablation of the penile nerves.

Early Career Publication Trajectory of Male Infertility Fellows During and After Fellowship.

BACKGROUND: Improving evidence-based medicine through research contribution is an important aspect of fellowship training. Prior studies have investigated the research activity of urology fellows during and after fellowship. The main objective of this study was to specifically explore the publication productivity of male infertility fellows both during fellowship and in the first 5 years afterwards. METHODS: The 19 fellowship program directors from the Society for the Study of Male Reproduction were asked to share a list of fellows from 2004 to 2019. Publications from 87 fellows at 12 programs were analyzed. PubMed® was utilized to search for peer-reviewed publications for each fellow during their fellowship and in the first 5 years afterwards. Each publication was classified by publication type (original research, review article, editorial comment, or case report), topic (fertility, testosterone, or other), and author type (sole, first, middle, or last author). RESULTS: Some 87 male infertility fellows were analyzed, and a total of 1608 peer-reviewed publications were identified. Some 662 total publications (41.2%) were written on the topic of fertility during fellowship and in the first 5 years afterwards. Some 554 (34.5%) publications were completed during fellowship, 178 (11.1%) in year 1, 164 (10.2%) in year 2, 220 (13.7%) in year 3, 269 (16.7%) in year 4, and 223 (13.9%) in year 5. The mean number of publications during fellowship was 6.37 (range 0-57). Means for years 1-5 after fellowship were 2.12, 1.95, 2.65, 3.36, and 2.97, respectively. After fellowship, 25.3% of the fellows did not publish again. A significant difference was detected between the group mean number of publications (analysis of variance, ANOVA - p = 0.0001) during fellowship and the 5 years afterwards. There was no significant difference between the group mean number of publications between the 1st and 5th years post-fellowship (ANOVA - p = 0.5919). CONCLUSIONS: As anticipated, male infertility fellows were most productive during fellowship, with relatively stable research production thereafter. Thus, early career support and mentorship remain important to the future academic success of fellows. Future investigation of the relationship between male infertility fellow characteristics and the pursuit of an academic career is warranted.

Buerger's Disease in the Testicle: A Case of Testicular Thromboangiitis Obliterans.

Thromboangiitis obliterans (TAO), otherwise known as Buerger's disease, is a rare, non-atherosclerotic inflammatory vasculopathy that typically affects small and medium-sized arteries of the distal extremities. Smoking is believed to be integral to the pathogenesis, as TAO primarily affects young male smokers. The disease is characterized by extremity pain secondary to ischemia that may progress to ulceration, gangrene, and amputation. Involvement of the reproductive system is uncommon. Here, we offer a case of TAO presenting as a testicular mass lesion.

Online Health Information for Penile Prosthesis Implants Lacks Quality and Is Unreadable to the Average US Patient.

BACKGROUND: Online health information (OHI) has become widely accessible and affects patient decisions regarding their healthcare. The purpose of this study was to assess the readability, quality, and accuracy of information available to patients online about penile prosthesis implants (PPIs). METHODS: We performed a Google search using the keywords "penile implant" and "penile prosthesis." The first 30 search results for both terms were analyzed, and advertisements, news articles, duplicates, and videos were excluded. Websites were categorized as institutional, commercial, and personal/patient support. Readability of each website was determined using the Flesch-Kincaid grade level (FKGL) readability formula within the readable tool. Quality was measured by Health On the Net (HON) certification status and the DISCERN scoring method. For website accuracy, a score of 1-4 (1=0-25%, 2=25-50%, 3=50-75%, and 4=75-100%) was assigned. RESULTS: Forty-four websites met the criteria (23 institutional, 12 commercial, and 9 personal/patient support). The mean total FKGL score was 9.55. No statistical difference was detected between mean FKGL for each website category (p=0.69). Only eight websites (18%) scored ≤8th-grade reading level (average US adult level), while 36 (82%) were >8th-grade level. Mean total DISCERN sum score was 39.74/75, with no statistical difference in mean DISCERN score between website types (p=0.08). Over half (55%) of the websites were defined as "very poor" or "poor" quality by DISCERN scoring. Mean total overall quality rating was 2.67/5. HON certification was verified for only nine websites (20%). Twenty-five percent of websites were classified as 0-25% accurate, 23% were 25-50% accurate, 30% were 50-75% accurate, and 23% were 75-100% accurate. CONCLUSION: Most information on the Internet about PPIs is reasonably accurate; however, the majority of websites are deficient in quality and unreadable to the average patient, irrespective of website type.

New Artificial Intelligence ChatGPT Performs Poorly on the 2022 Self-assessment Study Program for Urology.

INTRODUCTION: Large language models have demonstrated impressive capabilities, but application to medicine remains unclear. We seek to evaluate the use of ChatGPT on the American Urological Association Self-assessment Study Program as an educational adjunct for urology trainees and practicing physicians. METHODS: One hundred fifty questions from the 2022 Self-assessment Study Program exam were screened, and those containing visual assets (n=15) were removed. The remaining items were encoded as open ended or multiple choice. ChatGPT's output was coded as correct, incorrect, or indeterminate; if indeterminate, responses were regenerated up to 2 times. Concordance, quality, and accuracy were ascertained by 3 independent researchers and reviewed by 2 physician adjudicators. A new session was started for each entry to avoid crossover learning. RESULTS: ChatGPT was correct on 36/135 (26.7%) open-ended and 38/135 (28.2%) multiple-choice questions. Indeterminate responses were generated in 40 (29.6%) and 4 (3.0%), respectively. Of the correct responses, 24/36 (66.7%) and 36/38 (94.7%) were on initial output, 8 (22.2%) and 1 (2.6%) on second output, and 4 (11.1%) and 1 (2.6%) on final output, respectively. Although regeneration decreased indeterminate responses, proportion of correct responses did not increase. For open-ended and multiple-choice questions, ChatGPT provided consistent justifications for incorrect answers and remained concordant between correct and incorrect answers. CONCLUSIONS: ChatGPT previously demonstrated promise on medical licensing exams; however, application to the 2022 Self-assessment Study Program was not demonstrated. Performance improved with multiple-choice over open-ended questions. More importantly were the persistent justifications for incorrect responses-left unchecked, utilization of ChatGPT in medicine may facilitate medical misinformation.

Management of urethral stricture in women.

PURPOSE: We describe the diagnosis and treatment of urethral strictures in women. MATERIALS AND METHODS: We retrospectively identified female urethral strictures from 1998 to 2010. Study inclusion criteria were 1) clinical diagnosis of stricture, 2) stricture seen on cystoscopy, 3) urethral obstruction on videourodynamics according to the Blaivas-Groutz nomogram and/or 4) urethral caliber less than 17Fr. Postoperative recurrence was defined by the preoperative criteria. RESULTS: We identified 17 women with a mean age of 62 years (range 32 to 91) with stricture. Stricture was idiopathic in 8 patients, iatrogenic in 6, traumatic in 2 and associated with a urethral diverticulum in 1. Videourodynamics could not be done in 3 women due to complete obliteration of the urethra. Ten of 14 patients satisfied videourodynamic criteria for obstruction and 4 had impaired detrusor contractility. Nine women underwent vaginal flap urethroplasty, including 5 who also had a pubovaginal sling and 1 who had a Martius flap. One patient received a buccal mucosal graft as primary treatment after initial dilation. There was no recurrence at a minimum 1-year followup but 2 strictures recurred 5½ and 6 years postoperatively, respectively. These 2 women received a buccal mucosal graft and were stricture free 12 to 15 months postoperatively. Of 17 patients initially treated with urethral dilation recurrence developed in 16, requiring repeat dilations until urethroplasty was performed. CONCLUSIONS: In select women vaginal flap urethroplasty and buccal mucosal graft have high success rates, including 100% at 1 year and 78% at 5 years. Urethral dilation has a 6% success rate. Long-term followup is mandatory. Treatment should be individualized.

Partial nephrectomy online: a preliminary evaluation of the quality of health information on the Internet.

UNLABELLED: What's known on the subject? and What does the study add? Patients are highly likely to access the Internet for health information, and studies have reported that inaccurate or low-quality information may alter patients' expectations and negatively impact informed decision-making. In a unique collaboration with the Health On the Internet (HON) Foundation, we evaluated the top 20 search results for the urology search term 'partial nephrectomy,' and identified the highest and lowest scoring criteria to increase awareness of areas of concern and improvement. OBJECTIVE: To further evaluate the quality of information available on the Internet with regard to the management of localized renal cancer, we evaluated websites providing information on 'partial nephrectomy' in conjunction with the Health On the Internet (HON) Foundation. Many patients now utilize the Internet as a resource to provide further information on disease, treatments and outcomes, and health information on the Internet is largely unregulated. Inaccurate information may contribute to unrealistic expectations and dissatisfied patients. PATIENTS AND METHODS: A google.com search identified the top 30 websites for the search term 'partial nephrectomy'. The HON Foundation evaluated each website according to the eight principles for Health on the Internet code of conduct (HONcode) certification and reported the overall frequency of certification, as well as individual website compliance with each of the principles. RESULTS: Overall, seven (23.3%) of 30 websites met the requirements of HONcode certification and an additional two (6.7%) websites were under review to maintain their certification based on updating their resources. The remaining 21 (70%) websites did not meet the standards for certification. The lowest performing criteria included proper citation of medical information and a clear distinction of advertising from editorial content. CONCLUSIONS: The low rate of HONcode compliance for these websites illustrates the poor quality of information that patients may encounter when researching options for nephron-sparing surgery, which may have a significant impact on patient decision-making and treatment choices. Physicians should be aware of the quality of Internet resources and how to best use these tools to help guide patients to websites with valid information.

The Impact of Visiting Rotations on the Urology Residency Match: Insights and Perspectives From the 2021-2022 Applicants.

OBJECTIVE: To survey 2022 Urology Residency Match applicants on their away rotation experiences to better understand the impact of pandemic changes, including the one in-person away rotation limit, on interviews and match outcomes. METHODS: An anonymous post-match online survey was distributed to applicants of study-participating institutions. Data was prospectively collected regarding respondent demographics, away rotation experiences, interviews, utilization of preference signaling, and overall match outcomes. RESULTS: In total, 230 applicants completed the survey. Respondents prioritized geography (28.1%), program reputation (26.1%), and early notification (25.6%) as the top factors in determining whether to accept a rotation offer. The majority (93%) participated in a single away rotation, with nearly all respondents being offered a virtual interview from the program where they completed a visiting clerkship. Of those who declined away rotation offers, 56% were not offered an interview at the program they declined an offer from. The majority matched at either their home institution (20.8%), a program where they submitted a preference signal (22.2%), or a program where they completed an in-person away rotation (13%). Despite 46.3% of respondents reporting that their match outcome was negatively affected by the ability to rotate at only one away rotation, the majority were satisfied (70%) with their rotation selection based on match results. CONCLUSIONS: For applicants, participation in visiting rotations plays a significant role in the match process. Further research regarding mechanisms to optimize the away rotation application process is needed as the capacity to do visiting electives expands in the post-pandemic environment.

The association between operative repair of bladder injury and improved survival: results from the National Trauma Data Bank.

PURPOSE: The bladder is the most commonly injured genitourinary organ from blunt pelvic trauma. In this study we describe traumatic bladder injuries in the United States, their management and association with mortality. MATERIALS AND METHODS: We queried the 2002 to 2006 National Trauma Data Bank for all subjects with bladder injury. Demographics, mechanism of injury, coexisting injuries, type of bladder injury, and operative interventions for bladder and other abdominal trauma are described. Multivariate logistic regression analysis was used to examine the relationship between bladder injury and in-hospital mortality. RESULTS: Of 8,565 subjects with bladder trauma 46% had pelvic fracture and 15% had 2 or more intra-abdominal injuries. Of these subjects 54% underwent bladder surgery, including 76% with intraperitoneal injury and 51% with surgical repair of other abdominal organs. On multivariate analysis operative bladder repair reduced the likelihood of in-hospital mortality by 59%. Greater likelihood of death was seen in African-American and Native American patients, and those with pelvic injuries, triage to higher acuity care, penetrating trauma and multiple abdominal injuries. CONCLUSIONS: We demonstrated that surgical repair provides a significant survival advantage for subjects with bladder trauma. With 76% of intraperitoneal bladder injuries being repaired, there appears to be underuse of a lifesaving procedure. Additional studies to refine indications for bladder repair are warranted.

Genetic causes and management of male infertility.

Infertility affects approximately 15% of couples. With infertility such a common problem in a generally healthy age group, complete evaluation is needed of both men and women. Infertility work up for men includes a semen analysis, the results of which suggest various supplemental studies, including karyotype. Karyotype is indicated when a patient has findings on history or physical exam concerning for chromosomal abnormalities, azoospermia, or severe oligospermia (count <5 million/mL). The most common chromosomal numerical abnormality found on karyotype is Klinefelter syndrome which is classified as redundant sex chromosomes, with the most common chromosomal arrangement being 47, XXY. If a patient is found to have a chromosomal abnormality such as Klinefelter's, there is still a chance of fertility using testicular sperm extraction and in-vitro fertilization.