Economic Impact of Urological Conditions in Men and Women in Belize.

INTRODUCTION: Urological disease is prevalent in low- and middle-income countries. Concurrently, the inability to maintain employment or provide family care contributes to poverty. We assessed the microeconomic impacts of urological disease in Belize. METHODS: We conducted a prospective survey-based assessment of patients evaluated during surgical trips by the charity Global Surgical Expedition. Patients completed a survey focusing on impact of urological disease on work and caretaker responsibilities, as well as its economic impact. The primary study outcome was income loss resulting from work impairment or work time missed related to urological disease. Income loss was calculated using the validated Work Productivity and Activity Impairment Questionnaire. RESULTS: A total of 114 patients completed surveys. Overall, 87.7% and 37.2% of respondents reported a negative impact of urological disease on job and caretaking responsibilities, respectively. Nine (7.9%) patients were unemployed secondary to their urological disease. Sixty-one (53.5%) patients provided financial data sufficient for analysis. In this cohort, median weekly income was $250 Belize dollars (approximately $125 United States Dollars), while median weekly cost for urological disease treatment was $25 Belize dollars. Among the 21 (34.5%) patients who missed work due to urological disease, median weekly income loss was $35.6 Belize dollars, representing 55% of their total income. A vast majority (88.6%) of patients reported that cure of urological disease would increase ability to work and/or care for family. CONCLUSIONS: In Belize, urological disease results in significant impairment of work and caretaking responsibilities, as well as income loss. Efforts are necessary to provide urological surgeries in low- and middle-income countries as urological disease impacts not only quality of life, but also financial health.

Prevalence of Cognitive Impairment and Sphincter Misuse Among Men With Artificial Urinary Sphincters.

OBJECTIVES: To define the prevalence of cognitive impairment and sphincter misuse among men who had undergone AUS placement. METHODS: Men who had previously undergone AUS placement from 2004 to 2019 were assessed through comprehensive telephone surveys. The primary survey outcome was cognitive function, assessed via validated Telephone Mini-Mental State Examination. Secondary survey outcomes included rate of AUS misuse, surgical outcomes, and overall device satisfaction. Statistical analysis was performed to assess for differences between patients with and without cognitive impairment. RESULTS: A total of 74 patients participated, with a mean age and follow-up of 75 and 7.8 years, respectively. Telephone Mini-Mental State Examination assessment revealed cognitive impairment in 18 (24%) patients, 13 (18%) with mild-moderate and 5 (7%) with severe impairment. Overall, 23 (31%) and 11 (15%) patients reported inconsistent use (not cycling AUS with every void) and device neglect, respectively. Patients with impaired cognition were more likely to report difficulty with AUS use compared to those with normal cognition (39% vs 9%, P= .01). There was no difference seen in rates of revision, rates of retention, or urinary tract infections between cognitive groups. CONCLUSIONS: Our study revealed significant rates of cognitive impairment and sphincter misuse among men with AUS. These data suggest a role for long-term follow-up and monitoring for cognitive changes. Prospective study of cognitive decline and surgical outcomes in patients undergoing AUS is warranted.

Analysis of Online Urologist Ratings: Are Rating Differences Associated With Subspecialty?

Patients are increasingly using online rating websites to obtain information about physicians and to provide feedback. We performed an analysis of urologist online ratings, with specific focus on the relationship between overall rating and urologist subspecialty. We conducted an analysis of urologist ratings on Healthgrades.com. Ratings were sampled across 4 US geographical regions, with focus across 3 practice types (large and small private practice, academic) and 7 urologic subspecialties. Statistical analysis was performed to assess for differences among subgroup ratings. Data were analyzed for 954 urologists with a mean age of 53 (±10) years. The median overall urologist rating was 4.0 [3.4-4.7]. Providers in an academic practice type or robotics/oncology subspecialty had statistically significantly higher ratings when compared to other practice settings or subspecialties (P < 0.001). All other comparisons between practice types, specialties, regions, and sexes failed to demonstrate statistically significant differences. In our study of online urologist ratings, robotics/oncology subspecialty and academic practice setting were associated with higher overall ratings. Further study is needed to assess reasons underlying this difference.

Identifying and addressing training deficiencies in the examination of cryptorchidism-a quality improvement study.

BACKGROUND: Accurate and timely diagnosis of cryptorchidism by primary care providers (PCPs) is critical to oncologic and fertility outcomes. Physical exam is the mainstay of diagnosis, but little is known about PCPs' skills in examining cryptorchid patients. Patients referred to surgeons for cryptorchidism often have normal or retractile testes on exam, and delayed or missed diagnosis of cryptorchidism may contribute to advanced age at surgical intervention. Previous studies on cryptorchidism have not investigated the baseline training, confidence, and/or exam skills of providers. OBJECTIVE: The authors aimed to define baseline training and provider confidence in the exam of cryptorchid patients and to improve examiner confidence using bedside teaching with a pediatric urologist. Secondarily, baseline training and confidence were correlated to skill. STUDY DESIGN: Medical students, family medicine, pediatrics, and urology residents, and pediatric attendings completed surveys on baseline training and self-reported confidence in the examination of cryptorchid patients at an academic institution from 2017 to 2018. N.G.K. (pediatric urologist) proctored examinations of cryptorchid patients and provided standardized grades and individualized feedback. Surveys were readministered after 3 months. Non-parametric comparison tests were performed to determine intervention effect and compare subgroups. RESULTS: Ninety-two respondents participated. 62% reported little to no formal training on the scrotal exam, 50% were self-taught, and 20% defined undescended testis incorrectly. Confidence increased with level of training, comparing attendings to residents to students (P < 0.001). Those who learned from a mentor had higher baseline confidence than those who did not (P < 0.01). Baseline confidence and amount of formal training positively correlated with exam skill as graded during proctored sessions (n = 59, P < 0.01). Provider confidence was higher after proctored exams (Fig. 2, n = 32, P < 0.0001). DISCUSSION: Significant training deficiencies exist in the examination of cryptorchid patients. A single proctored exam with a pediatric urologist can improve provider confidence and may improve exam skills. A rotation with pediatric urology, including proctored exams of cryptorchid patients, has become standard practice for pediatric trainees at the authors institution as a result of this study. CONCLUSIONS: While further studies are required to assess the effectiveness of bedside teaching and its impact on accurate and timely diagnosis of cryptorchidism, implementation of the authors quality improvement recommendations at other teaching institutions would help address training deficiencies in the examination of cryptorchid patients.

Long-Term Safety and Efficacy of Clomiphene Citrate for the Treatment of Hypogonadism.

PURPOSE: Clomiphene citrate may be used as an off label treatment of hypogonadism. There are few long-term data on clomiphene citrate efficacy and safety when administered for more than 3 years. We assessed improvements in testosterone and hypogonadal symptoms while on clomiphene citrate for extended periods. MATERIALS AND METHODS: We performed a retrospective review to identify patients treated with clomiphene citrate for hypogonadism (baseline testosterone less than 300 ng/dl) at a total of 2 institutions from 2010 to 2018. We assessed the duration of clomiphene citrate therapy, serum testosterone levels, symptom improvement and clomiphene citrate side effects. RESULTS: A total of 400 patients underwent clomiphene citrate treatment for a mean ± SD of 25.5 ± 20.48 months (range 0 to 84). Of the patients 280 received clomiphene citrate for 3 years or less (mean 12.75 ± 9.52 months) and 120 received it for more than 3 years (mean 51.93 ± 10.52 months). Of men on clomiphene citrate for more than 3 years 88% achieved eugonadism, 77% reported improved symptoms and 8% reported side effects. Estradiol was significantly increased following clomiphene citrate treatment. Results did not significantly differ between patients treated for more than 3, or 3 or fewer years. The most common side effects reported by patients treated more than 3 years included changes in mood in 5, blurred vision in 3 and breast tenderness in 2. There was no significant adverse event in any patient treated with clomiphene citrate. CONCLUSIONS: Clomiphene citrate is not typically offered as primary treatment of hypogonadism in men who do not desire fertility preservation. These data demonstrate that clomiphene citrate is safe and effective with few side effects when used as long-term treatment of hypogonadism.

Improvements in semen parameters in men treated with clomiphene citrate-A retrospective analysis.

Clomiphene citrate (CC) is commonly used off-label for the treatment of male infertility, yet there is limited data to guide patient selection. To identify a subset of patients more likely to benefit from CC, we aimed to define predictors of improvement in semen parameters among men receiving CC. We retrospectively analysed 151 men treated with at least 25 mg CC daily for male infertility and/or hypogonadism at two institutions between 2004 and 2014. Men previously on testosterone were excluded. The primary outcome was change in semen parameters. Variables included baseline patient characteristics, pre-treatment hormone profiles and pre-treatment semen analyses. A total of 77 men met inclusion criteria. Median length of therapy was 2.8 months. There was significant improvement in sperm concentration (14-21 million/ml; p = 0.002) and total motile count (TMC; 13-28 million; p = 0.04). One third of patients who began with fewer than 5 million motile spermatozoon improved to a TMC > 5 million, increasing reproductive options to include intrauterine insemination. Patient characteristics, pre-treatment hormone profile and degree of oligozoospermia did not predict treatment response. While no predictors of improvement were identified, clinically useful response rates are described for use in shared decision-making.

Clomiphene Citrate for the Treatment of Hypogonadism.

INTRODUCTION: Clomiphene citrate (CC) is a selective estrogen receptor modulator that has been used for the treatment of hypogonadism in men since the 1970s. It acts centrally to increase secretion of luteinizing hormone and follicle-stimulating hormone, thereby increasing testosterone production and serum levels. Unlike testosterone replacement therapy, CC does not suppress the hypothalamic-pituitary-gonadal axis, preserving intratesticular testosterone production and spermatogenesis. This is especially useful in treating hypogonadal men who are interested in fertility. AIM: To review the literature regarding the use of CC in the setting of hypogonadism. METHODS: A review of the relevant literature through September 2018 was performed via PubMed. MAIN OUTCOME MEASURE: The data regarding the efficacy and safety of CC when used in the setting of hypogonadism is summarized. RESULTS: Although results are mixed, many studies show CC reduces symptoms in hypogonadal men. Studies have also shown improvement in erectile function and bone mineral density, as well as a reduction in body mass index. There have been few studies investigating fertility rates in hypogonadal men treated with CC, but a metaanalysis of these shows significant improvement in fertility rates. Several studies show improvement in semen parameters. Few studies have investigated adverse effects of the drug. Reports include headache, dizziness, gynecomastia, and exacerbation of psychiatric illnesses. Despite these reports, CC is generally considered to be safe and well tolerated. CONCLUSION: CC is safe and effective and should remain in the armament of urologists treating hypogonadal men, especially men interested in preservation of fertility. Wheeler KM, Sharma D, Kavoussi PK, et al. Clomiphene citrate for the treatment of hypogonadism. Sex Med Rev 2019;7:272-276.

Troubleshooting intraoperative complications of penile prosthesis placement.

Placement of a penile prosthesis is an excellent option for well-selected patients, offering high patient satisfaction and a low rate of complications. Most urologists who perform the procedure are not high volume implanters and may have limited experience with troubleshooting intraoperative issues. In this review, the authors use current literature to provide recommendations for the management of various intraoperative issues such as difficultly with dilation, incongruent measurement, perforation, urethral injury, crossover, complications of reservoir placement, penile curvature, glans mobility, and hemostasis are all discussed. Preparedness for the management of intraoperative issues can help improve patient outcomes and limit morbidity.

The natural history of nonobstructing asymptomatic renal stones managed with active surveillance.

PURPOSE: We documented the natural history of asymptomatic nonobstructing renal calculi managed with active surveillance and explored factors predicting stone related events to better inform shared decision making. MATERIALS AND METHODS: Patients with asymptomatic nonobstructing renal calculi electing active surveillance of their stone(s) were retrospectively reviewed. Stone characteristics, patient characteristics, and stone related events were collected. We evaluated the effects of stone size and location on development of symptoms, spontaneous passage, requirement for surgical intervention, and stone growth. RESULTS: We identified 160 stones with an average size of 7.0 ± 4.2 mm among 110 patients with average followup of 41 ± 19 months. Forty-five (28% of total) stones caused symptoms during followup. Notably 3 stones (3% of asymptomatic subgroup, 2% of total stones) caused painless silent obstruction necessitating intervention after an average of 37 ± 17 months. The only significant predictor of spontaneous passage or symptom development was location. Upper pole/mid renal stones were more likely than lower pole stones to become symptomatic (40.6% vs 24.3%, p = 0.047) and to pass spontaneously (14.5% vs 2.9%, p = 0.016). CONCLUSIONS: Among asymptomatic nonobstructing renal calculi managed with active surveillance, most remained asymptomatic through an average followup of more than 3 years. Less than 30% caused renal colic, less than 20% were operated on for pain and 7% spontaneously passed. Lower poles stones were significantly less likely to cause symptoms or pass spontaneously. Despite 3 stones causing silent hydronephrosis suggestive of obstruction, regular followup imaging facilitated interventions that prevented renal loss.

Survival of Salmonella Typhi and Shigella dysenteriae in dehydrated infant formula.

UNLABELLED: Powdered infant formula has previously been linked to the transmission of various bacterial pathogens in infants resulting in life-threatening disease and death. Survival studies of 2 common foodborne pathogens, Salmonella enterica serovar Typhi and Shigella dysenteriae, in powdered infant formula have not been previously studied despite the potentially devastating consequences from ingestion of these organisms, particularly by newborns, in case of a natural or deliberate contamination event. Therefore, to better predict the risk of S. Typhi and S. dysenteriae infection from consumption of infant formula, the present study was undertaken to determine survival of these microorganisms in dry infant formula under varying atmospheric conditions. A 2-strain cocktail of S. Typhi and a 3-strain cocktail of S. dysenteriae were stored for up to 12 wk in dehydrated infant formula in an ambient air or nitrogen atmosphere. Viable counts of S. Typhi at 12 wk in infant formula revealed a 2.9- and 1.69-log decrease in ambient air and nitrogen atmosphere, respectively. Viable counts of S. dysenteriae at 12 wk in infant formula revealed a 0.81- and 0.42-log decrease in ambient air and nitrogen atmosphere, respectively. These results show that S. Typhi and S. dysenteriae can remain viable for prolonged periods of time in powdered infant formula, and the presence of nitrogen enhances survival. PRACTICAL APPLICATION: Our goal in this work was to study the survival of S. Typhi and S. dysenteriae in dehydrated storage conditions in infant formula. This interest is partially generated by the possibility of using these 2 microorganisms to deliberately contaminate the food supply. The outcome of this study will help us to have a better idea how to respond and react to the risk of deliberate food contamination.

Detection of Yersinia enterocolitica in alfalfa, mung bean, cilantro, and mamey sapote (Pouteria sapota) food matrices using DNA microarray chip hybridization.

Four different food matrices (alfalfa, cilantro, mamey sapote, and mung bean) were contaminated with three different dilutions 10(6), 10(4), and 10(3) cfu/g of Yersinia enterocolitica. DNA was isolated from each food mix and used in chromosomal amplifications. The amplified DNA was used as templates in single PCR reactions of the four genes (virF, ail, yst, and blaA) followed by mixing the four reactions for one PCR primer extension reaction. The presence and the limit of detection of four genes in four food matrices were established by microarray hybridization. Data revealed the diversity of signal intensities. Neither the microarray chip hybridization nor the single PCR amplification could detect virF's presence located on a plasmid. Ail was detected in 10(3) cfu/g, whereas blaA and yst were detected from 10(5) to 10(6) cfu/g in all food matrices. Therefore, the ail gene could be the gene of choice in identifying Y. enterocolitica in alfalfa, cilantro, mamey, and mung bean. Other genes--blaA, yst, virF--exhibited wide variability in hybridization signals, highlighting the need of a better DNA purification step prior to DNA microarray hybridization.