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BACKGROUND: The 3-piece inflatable penile prosthesis (IPP) is the most widely used device for erectile dysfunction refractory to medications, containing a reservoir inserted into the retropubic space (RPS) or an alternative/ectopic space (AES). Indications for removal of the reservoir include malfunction, malposition, or infection. In revision cases without infection, reservoir removal is sometimes optional. AIM: We reviewed outcomes and complications related to reservoir removal from a large multi-institutional series. METHODS: We retrospectively reviewed databases at 6 institutions over 7 years. Patients with artificial urethral sphincter, urethral sling, or mini-jupette were excluded. OUTCOMES: Outcomes and complications related to IPP reservoir removal were analyzed. Data were collected, but only reservoir-related complications at surgery were included. Data were compared between the RPS and AES cohorts to evaluate differences with a χ2 test, with significance at P < .05. RESULTS: Of 215 cases, there were 172 RPS and 43 AES reservoirs. The mean patient age was 65.3 years. An overall 131 procedures were due to malfunction and 49 to malposition of an IPP component; 35 were secondary to infection. Among those retained (n = 44), reasons included reuse, avoiding surrounding structure damage, and difficult dissection. Among those removed (n = 171), 15 required a counterincision. To determine the statistical difference between those removed from the RPS and an AES, the χ2 test result was P = .00059, indicating a significant difference in the need for a counterincision between the groups. Complications included bladder perforation (n = 1) in the RPS group and an avulsion of the epigastric vessels requiring abdominal exploration (n = 1) in the AES group. To determine the statistical difference between RPS and AES complications, the χ2 test result was P = .365, indicating no significant difference between the groups. STRENGTHS AND LIMITATIONS: Strengths include being a multi-institutional study with high-volume skilled implanters. Limitations include being a retrospective review, with implanters exclusively performing penoscrotal incisions and not utilizing an infrapubic approach. Last, there was a lack of long-term follow-up with these patients. CONCLUSIONS: Removal of an IPP reservoir remains safe, with few intraoperative complications. Surgeons should be aware of the inferior epigastric vessels during removal in an AES or be willing to perform a counterincision to avoid injury to surrounding structures. Surgeons should also obtain preoperative imaging to identify the specific location of the reservoir and adjacent anatomy. This is the first multi-institutional study reviewing outcomes related to reservoir removal during IPP revision or removal surgery.
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Due to the historic lack of transparency in healthcare pricing in the United States, the degree of price variation for vasectomy is largely unknown. Our study aims to assess characteristics of hospitals reporting prices for vasectomy as well as price variation associated with hospital factors and insurance status. A cross-sectional analysis was performed in October, 2022 using the Turquoise Database which compiles publicly available hospital pricing data. The database was queried for vasectomy prices to identify the cash (paid by patients not using insurance), commercial (negotiated by private insurers) and Medicare and Medicaid prices for vasectomies. Hospital characteristics of those that reported a price for vasectomy and those that did not were compared and pricing differences based on hospital ownership and reimbursement source were determined using multivariable linear regression analysis. Overall, only 24.7% (1657/6700) of hospitals reported a price for vasectomy. Those that reported a price had more beds (median 117 vs 80, p < 0.001), more physicians (median 1745 vs 1275, p < 0.001). They were also more likely to be nonprofit hospitals (77% vs 14%, p < 0.001) and to be in well-resourced areas (ADI 91.7 vs 94.4, p < 0.001). Both commercial prices and cash prices for vasectomy were lower at nonprofit hospitals than at for-profit hospitals (commercial: $1959.47 vs $2861.56, p < 0.001; cash: $1429.74 vs $3185.37, p < 0.001). Our study highlights the current state of pricing transparency for vasectomy in the United States. Patients may be counseled to consider seeking vasectomy at a nonprofit hospital to reduce their costs, especially when paying with cash. These findings also suggest a need for new policies to target areas with decreased price transparency to reduce price disparities.
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OBJECTIVE: Current literature demonstrates low rates of compliance with postvasectomy semen analysis (PVSA). This study sought to determine factors that correlate with noncompliance with PVSA. METHODS: A retrospective chart review was conducted for patients who underwent vasectomy within our institution. ArcGIS was used to securely calculate the shortest driving time from each patient's home to the single PVSA drop-off site. Kruskal-Wallis and chi-square tests analyzed characteristics of patients who did and did not submit PVSA samples, and odds ratios were calculated via multivariable logistic regression. RESULTS: Overall, 515 of 850 patients met inclusion criteria and 219 (42.5%) of these had no recorded PVSA. Of those with a PVSA, 59% were completed within 16 weeks. Compliance with PVSA was associated with a shorter median driving time (30.6 minutes vs 34.2 minutes), more vasectomy in the operating room (19% vs 10%), and attending a follow-up appointment (40% vs 17%) (P < .005 for all). Age at vasectomy, race, ethnicity, BMI, paternity, and location of preoperative consultation did not significantly differ between the groups. Each 30 minutes of driving time was associated with a 48% reduction in the odds of a patient submitting PVSA at any time (OR 0.52 [0.37, 0.73]). CONCLUSION: As driving time to a drop-off center appears to be a significant barrier to PVSA compliance, providers should consider alternative collection methods such as at-home or in-office semen analysis.
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Líquidos Corporais , Análise do Sêmen , Humanos , Estudos Retrospectivos , Sêmen , EtnicidadeRESUMO
The American Urological Association and Endocrine Society published guidelines for the management of testosterone deficiency in 2018. Testosterone prescription patterns have varied widely recently, owing to increased public interest and emerging data on the safety of testosterone therapy. The effect of guideline publication on testosterone prescribing is unknown. Thus, we aimed to assess testosterone prescription trends using Medicare prescriber data. Specialties with over 100 testosterone prescribers from 2016-2019 were analyzed. Nine specialties were included (in order of descending prescription frequency): family practice, internal medicine, urology, endocrinology, nurse practitioners, physician assistants, general practice, infectious disease, and emergency medicine. The number of prescribers grew by a mean of 8.8% annually. There was a significant increase in average claims per provider from 2016 to 2019 (26.4 to 28.7, p < 0.0001), with the steepest increase occurring between 2017 and 2018 when the guidelines were released (27.2 to 28.1, p = 0.015). The largest increase in claims per provider was among urologists. Advanced practice providers comprised 7.5% of Medicare testosterone claims in 2016 and 11.6% in 2019. While no causation can be established, these results suggest that professional society guidelines are associated with increasing numbers of testosterone claims per provider, especially among urologists. The changing demographics of prescribers justifies targeted education and further research.
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With the budding interest in testosterone therapy (TTh), online health information plays a significant role in patients' health care decisions. Therefore, we evaluated the source and readability of web-based information available to patients regarding TTh on Google. From Google search terms "Testosterone Therapy" and "Testosterone Replacement", 77 unique sources were identified. Sources were categorized as Academic, Commercial, Institutional, or Patient Support, then evaluated using validated readability and English language text assessment tools: the Flesch Reading Ease score, Flesch Kincade, Gunning Fog, Simple Measure of Gobbledygook (SMOG), Coleman-Liau Index and Automated Readability index. The average grade level for understanding academic sources was 16 (college senior); commercial, institutional, and patient support sources were 13 (college freshman); 8 and 5 grade levels, respectively, above the average U.S. adult. Patient support sources were most prevalent, while commercial sources were the least at 35 and 14%, respectively. The average reading ease score was 36.8, indicative of difficult-to-read material overall. These results indicate that the most immediate online sources for TTh information exceed the average reading level of most adults within the U.S., hence more effort should be taken to publish accessible and readable material to improve patient health literacy.
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Testosterone Therapy (TTh) trends have changed as a result of clinical research and market forces over the past several years. Understanding the trends or preferences regarding testosterone prescriptions remains unknown. Our objective was to assess both regional and national trends in TTh prescriptions amongst medical specialties within the United States between 2013 and 2017. Publicly available data from the Center for Medicare and Medicaid Services (CMS) Part D Prescriber database with regards to TTh prescriptions across a 5-year span (January 1, 2013-December 31, 2017) were analyzed. TTh therapies were consolidated into four categories: Topical, Oral, Injection and Pellet. Statistical analysis utilizing R 4.0.2 was performed on the resulting data. Trends in prescription modality claim count and cost were plotted over the study period while statistical analysis evaluated associations between TTh modality and medical specialist. We found that Endocrinologists and Urologists prescribed topical testosterone more than all other specialties (60.4% and 53.5%, respectively), while Family and Internal medicine physicians were more likely to prescribe injections (59.82% and 50.69%, respectively). Oral and pellet testosterone were rarely prescribed across all specialties. In conclusion, the wide variation in modalities of testosterone prescriptions illustrates an opportunity for treatment guidelines to be streamlined across all specialists to improve patient outcomes.
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Medicina , Testosterona , Idoso , Humanos , Estados Unidos , Testosterona/uso terapêutico , Medicare , Centers for Medicare and Medicaid Services, U.S. , PrescriçõesRESUMO
Patients may turn to social media websites, such as Reddit, for information on erectile dysfunction prior to seeking care from a physician. We sought to identify, characterize, and assess the quality of the erectile dysfunction treatments discussed on the highly influential Reddit website. We assessed 2634 comments from two subreddits, r/AskMen and r/ErectileDysfunction, for positive and negative statements regarding treatments for erectile dysfunction. A total of 45 unique treatments were discussed and consisted of changes in sexual behavior (30%), lifestyle changes (29%), medical interventions (23%), talking with a partner about ED (10%), and use of supplements (8%). Only 24.4% of all treatments discussed are in line with current American Urological Association guidelines. Only 43.8% of all positive statements made endorsed a guidelines-based treatment, indicating a high rate of self-proclaimed success with alternative therapies. Our results indicate that there is active discussion of erectile dysfunction treatment on Reddit with a wide range of therapies recommended, however, the majority of the recommendations are not supported by strong clinical evidence.
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Disfunção Erétil , Mídias Sociais , Masculino , Humanos , Disfunção Erétil/tratamento farmacológico , Comportamento SexualAssuntos
Aborto Induzido , Vasectomia , Vasovasostomia , Masculino , Humanos , Feminino , Gravidez , Aborto LegalRESUMO
Purpose of Review: Direct-to-consumer telemedicine has vastly expanded in recent years, and urologic conditions are a common target for these companies. We aim to identify the urologic conditions being treated by direct-to-consumer telemedicine platforms and review the feasibility of adherence to evidence-based practice guidelines via this relatively new healthcare model. Recent Findings: Erectile dysfunction, premature ejaculation, testosterone deficiency, and male infertility are being treated with direct-to-consumer telemedicine. Such platforms treating erectile dysfunction perform modestly in practice guideline adherence. Guidelines-based treatment of other urologic conditions via telemedicine is feasible, however, the treatment of these conditions through popular direct-to-consumer telemedicine platforms is largely unstudied. Summary: The impact of direct-to-consumer telemedicine on the field of urology is vast and likely to continue to grow. Future studies should inspect direct-to-consumer telemedicine companies' practice patterns and treatment outcomes to ensure the field's standards of care are being met. Guidelines specific to the treatment of various urologic conditions via telemedicine are needed.
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BACKGROUND: Direct-to-consumer telemedicine platforms have expanded their reach to include services for the evaluation and treatment of testosterone deficiency. AIM: We aim to (i) evaluate the treatment practices and costs associated with receiving testosterone therapy through direct-to-consumer telemedicine platforms; (ii) compare these practices to the American Urological Association guidelines; and (iii) compare the cost of receiving similar care at a tertiary center. METHODS: Google was queried to identify telemedicine platforms offing testosterone therapy. Websites were analyzed for information regarding the initial consultation, initial laboratory evaluation, follow up, treatment monitoring regimen, and associated costs of receiving testosterone therapy. The costs for similar services at a tertiary care center were estimated using a single institution's online cost estimator for a patient with no insurance, private insurance, or Medicare. OUTCOMES: Evaluation and treatment practices of each platform were compared to the American Urological Association guidelines, and a cost analysis was completed for the cost of (i) undergoing an initial evaluation, and (ii) receiving 12 months of treatment through each platform and at a tertiary center. RESULTS: Three online platforms met inclusion criteria: Hone, Regenex Health, and TRT Nation. The initial evaluation and follow up of patients on TTh were similar between the online platforms and practice guidelines. The costs of the initial consultation were lowest for the patient with Medicare at a tertiary center and via the telemedicine platforms. Conversely, the cost of 12 months of intramuscular testosterone treatment was highest via the telemedicine platforms, ranging from $1,586 to $4,200, as compared to the tertiary center, which ranged from $134.01 to $1,333.04 with varying insurance models. Costs of ongoing treatment with transdermal testosterone are similarly higher via DTC platforms. CLINICAL IMPLICATIONS: Patients with private insurance or Medicare should be counseled that ongoing treatment through telemedicine platforms will likely incur a greater cost than receiving such care at a tertiary center that can utilize insurance coverage. STRENGTHS & LIMITATIONS: Practice and cost comparisons include accurate, up-to-date information based on each platform's website. Limitations include the analysis of only three telemedicine platforms, and the ability to describe only the information provided on each website. In addition, cost estimates for the tertiary center only include a single type of private and public insurance, limiting generalizability. CONCLUSION: This observational study indicates that direct-to-consumer telemedicine platforms are largely following practice guidelines in the evaluation and treatment of testosterone, however, there is a high cost associated with ongoing treatment. Jesse E, Sellke N, Rivero M-J, et al. Practice Comparison and Cost Analysis of Direct-to-Consumer Telemedicine Platforms Offering Testosterone Therapy. J Sex Med 2022;19:1608-1615.
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Telemedicina , Testosterona , Idoso , Humanos , Estados Unidos , Testosterona/uso terapêutico , Medicare , Custos e Análise de Custo , Encaminhamento e ConsultaRESUMO
Testosterone deficiency is known to affect men with increasing incidence throughout their lifespan. The clinical manifestations of testosterone deficiency, in turn, negatively impact men's quality of life and perception of overall health. The interaction of chronic systemic disease and androgen deficiency represent an area for potential intervention. Here, we explore the topic of testosterone deficiency amongst men with end-stage organ failure requiring transplantation in order to elucidate the underlying pathophysiology of androgen deficiency of chronic disease and discuss whether intervention, including testosterone replacement and organ transplantation, improve patients' outcomes and quality of life.
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Androgênios , Transplante de Órgãos , Humanos , Masculino , Qualidade de Vida , Testosterona , Transplante de Órgãos/efeitos adversosRESUMO
INTRODUCTION: The management of chronic scrotal pain is long and varied, with historical treatment algorithms typically ending with orchiectomy. Microsurgical denervation of the spermatic cord (MDSC) is a testicle-sparing option for patients who have failed conservative treatment options and over its forty-year history has seen many technical refinements. OBJECTIVES: To review the history and development of MDSC and discuss the outcomes of different surgical techniques. METHODS: A literature review using PubMed and Google Scholar was conducted to identify studies pertaining to surgical treatment of CSP, MDSC, and outcomes. Search terms included "chronic," "scrotal pain," "orchialgia," "spermatic cord," "denervation," and "microsurgery." RESULTS: We included 21 case reports and series since the first seminal paper describing MDSC technique in 1978. Additional studies that challenged existing conventions or described novel techniques are also discussed. The current standard procedure utilizes a subinguinal incision and a surgical microscope. Open, robotic, and laparoscopic approaches to MDSC have been described, but access to minimally invasive instruments may be limited outside of developed nations. Pain reduction following preoperative spermatic cord predicts success of MDSC. Methods for identifying and preserving the testicular and deferential arteries vary depending on surgeon preference but appear to have comparable outcomes. Future developments in MDSC involve targeted denervation, minimizing collateral thermal injury, and alternative techniques to visualize arterial supply. CONCLUSION: For patients suffering from CSP, MDSC is a well-studied technique that may offer appropriately selected patients' relief. Future investigation comparing targeted vs full MDSC as well as in vivo study of new techniques are needed to continue to improve outcomes. Sun HH, Tay KS, Jesse E, et al. Microsurgical Denervation of the Spermatic Cord: A Historical Perspective and Recent Developments. Sex Med Rev 2022;10:791-799.
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Doenças dos Genitais Masculinos , Cordão Espermático , Doenças Testiculares , Denervação/métodos , Humanos , Masculino , Microcirurgia/métodos , Dor Pélvica , Cordão Espermático/cirurgia , Doenças Testiculares/cirurgiaRESUMO
INTRODUCTION: Procedural specialties are at higher risk for malpractice claims than non-procedural specialties. Previous studies have examined common damages and malpractice lawsuits resulting from specific procedures. Our goal was to analyze urological interventions that led to sexual dysfunction (SD) claims. METHODS: The Casetext legal research platform was queried using search terms for medical malpractice and common men's health procedures between 1993 and 2020. In total, 236 cases were found, and 21 cases met the inclusion criteria: malpractice cases against a urologist or urology group, clearly stated legal outcome, and allegation of sexual dysfunction from an intervention that directly caused damages. RESULTS: A total of 42 damages were cited in 21 lawsuits. The top three damages claimed were erectile dysfunction (ED) (14/42, 33.3%), genital pain syndrome (7/42, 16.7%), and urinary incontinence (5/42, 11.9%). The most commonly cited treatments were urinary catheter placement or removal (3/21, 14.3%), robotic-assisted laparoscopic radical prostatectomy (RALP) (3/21, 14.3%), circumcision (3/21, 14.3%), and penile implant (3/21, 14.3%). In 19 of 21 suits (90.4%), the outcome favored the defendant. Two cases favored the plaintiff: penile implant (failure to prove the patient was permanently, organically impotent prior to the procedure; missed urethral injury at time of surgery, $300 000) and vasectomy (damage to vasculature resulting in loss of testicle, $300 000). CONCLUSIONS: Most suspected malpractice cases resulting in SD favored the defendant urologist. Interestingly, urinary catheter placement is as likely to result in litigation as other operative interventions, such as RALP, inflatable penile prosthesis, and circumcision. It is possible that thorough preoperative counselling and increased responsiveness to patients' postoperative concerns may have avoided litigation in several cases.
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INTRODUCTION: The management of chronic scrotal pain is long and varied, with historical treatment algorithms typically ending with orchiectomy. Microsurgical denervation of the spermatic cord (MDSC) is a testicle-sparing option for patients who have failed conservative treatment options and over its forty-year history has seen many technical refinements. OBJECTIVES: To review the history and development of MDSC and discuss the outcomes of different surgical techniques. METHODS: A literature review using PubMed and Google Scholar was conducted to identify studies pertaining to surgical treatment of CSP, MDSC, and outcomes. Search terms included "chronic," "scrotal pain," "orchialgia," "spermatic cord," "denervation," and "microsurgery." RESULTS: We included 21 case reports and series since the first seminal paper describing MDSC technique in 1978. Additional studies that challenged existing conventions or described novel techniques are also discussed. The current standard procedure utilizes a subinguinal incision and a surgical microscope. Open, robotic, and laparoscopic approaches to MDSC have been described, but access to minimally invasive instruments may be limited outside of developed nations. Pain reduction following preoperative spermatic cord predicts success of MDSC. Methods for identifying and preserving the testicular and deferential arteries vary depending on surgeon preference but appear to have comparable outcomes. Future developments in MDSC involve targeted denervation, minimizing collateral thermal injury, and alternative techniques to visualize arterial supply. CONCLUSION: For patients suffering from CSP, MDSC is a well-studied technique that may offer appropriately selected patients' relief. Future investigation comparing targeted vs full MDSC as well as in vivo study of new techniques are needed to continue to improve outcomes.
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Doenças dos Genitais Masculinos , Cordão Espermático , Doenças Testiculares , Masculino , Humanos , Denervação/métodos , Cordão Espermático/cirurgia , Doenças Testiculares/cirurgia , Dor PélvicaRESUMO
PURPOSE: Ejaculatory dysfunction (EjD) and erectile dysfunction after cancer treatment are clinically important complications, but their exact prevalence by various kinds of cancer site and type of treatment is unknown. The aim of this systematic review and meta-analysis was to examine the available evidence and provide pooled estimates for prevalence of EjD and erectile dysfunction in relation to all cancer sites and identify characteristics associated with EjD in cancer patients. MATERIALS AND METHODS: We performed a systematic review and meta-analysis of cross-sectional and case-control studies. We searched 4 electronic databases (Medline®, CINAHL, PsychInfo and Embase®) until July 22, 2020. All retrospective or prospective studies reporting the prevalence of EjD in male patients with cancer were included in this review. A random effects meta-analysis was conducted calculating prevalence proportions with 95% confidence intervals. Prevalence proportions were calculated for the incidences of EjD by cancer site and type of treatment. RESULTS: A total of 64 studies (a total of 10,057 participants) were included for analysis. The most common cancer sites were bladder, colon, testis and rectum. The prevalence rates of EjD after surgical intervention ranged from 14.5% (95% CI 2.2-56.3) in colon cancer to 53.0% (95% CI 23.3-80.7) in bladder cancer. The prevalence rates of erectile dysfunction ranged from 6.8% (95% CI 0.8-39.1) in bladder cancer to 68.7% (95% CI 55.2-79.6) in cancer of the rectum. CONCLUSIONS: In a large study-level meta-analysis, we looked at a high prevalence of EjD and erectile dysfunction at various cancer sites and across different treatment types. Prospective studies of EjD and erectile dysfunction after various kinds of cancer treatments are warranted.
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Ejaculação , Disfunção Erétil/epidemiologia , Disfunção Erétil/etiologia , Neoplasias/complicações , Disfunções Sexuais Fisiológicas/epidemiologia , Disfunções Sexuais Fisiológicas/etiologia , Humanos , Masculino , PrevalênciaRESUMO
INTRODUCTION: We aimed to evaluate opioid prescribing patterns of urologists across the United States (U.S.) and the District of Columbia (D.C.) using publicly available data from Medicare Part D. Our secondary analysis was to identify any loco-regional trends that may exist within the U.S. METHODS: We queried publicly reported information from the Part D prescriber database, which is compiled from beneficiaries enrolled within the Medicare Part D prescription drug program. Only providers with the specialty description of urologist were included in this study. RESULTS: Between 2013 and 2017, a five-year average of 452 901 opioid claims by 9640 urologists - amounting to $5 357 114 USD and comprising 3.78% of all claims made - were identified. The state of Maine featured the highest percentage of opioid claims in relation to all claims (5.81%). West Virginia had the greatest average total opioid claims per provider (90), while Michigan featured the highest average proportion of opioid claims per provider (10.63%). The fewest opioid claims were processed within the Mid-Atlantic and New England regions. CONCLUSIONS: A multitude of factors likely contributes to variability between states. Urologists should be increasingly aware of their individual prescription tendencies and use available drug monitoring programs to reduce unnecessary prescriptions, all while providing more targeted and appropriate pain management.