Challenges in completing a successful vasectomy reversal.

Although a wide array of interventions exist for men seeking fertility after vasectomy, up to 6% of them will elect for a vasectomy reversal. While the widespread adoption of telemedicine promises convenience and improved access, lack of ability to do a physical examination may hinder appropriate counselling. Although vasectomy reversal is successfully completed in most of the men either with a vasovasostomy or a vasoepididymostomy, there could be various reasons for the inability to successfully complete the operation. Our commentary outlines the reasons why a vasectomy reversal is not possible or successful. We also discuss a pre-operative management algorithm in men seeking vasectomy reversal to ensure appropriate counselling with a thorough pre-operative history, physical examination and on occasion, hormonal evaluation.

Twelve tips for the integration of medical students into telemedicine visits.

The use of telemedicine in clinical care has grown significantly in the last few years and has only increased during the COVID-19 pandemic. Given that many physicians will be expected to deliver virtual care moving forward, it is important for medical students to gain exposure via this modality during their clinical training. Many medical schools are actively working to integrate students into telemedicine. This article aims to provide guidance for readers incorporating medical students in telemedicine visits at an institutional or departmental level. This article covers essential topics such as coordinating key stakeholders, conducting needs assessments, addressing technological or software considerations, and creating appropriate workflows for students and physicians.

What is the impact of a clinically related readmission measure on the assessment of hospital performance?

BACKGROUND: The Hospital Readmission Reduction Program (HRRP) penalizes hospitals for high all-cause unplanned readmission rates. Many have expressed concern that hospitals serving patient populations with more comorbidities, lower incomes, and worse self-reported health status may be disproportionately penalized by readmissions that are not clinically related to the index admission. The impact of including clinically unrelated readmissions on hospital performance is largely unknown. We sought to determine if a clinically related readmission measure would significantly alter the assessment of hospital performance. METHODS: We analyzed Medicare claims for beneficiaries in Michigan admitted for pneumonia and joint replacement from 2011 to 2013. We compared each hospital's 30-day readmission rate using specifications from the HRRP's all-cause unplanned readmission measure to values calculated using a clinically related readmission measure. RESULTS: We found that the mean 30-day readmission rates were lower when calculated using the clinically related readmission measure (joint replacement: all-cause 5.8%, clinically related 4.9%, p < 0.001; pneumonia: all cause 12.5%, clinically related 11.3%, p < 0.001)). The correlation of hospital ranks using both methods was strong (joint replacement: 0.95 (p < 0.001), pneumonia: 0.90 (p < 0.001)). CONCLUSIONS: Our findings suggest that, while greater specificity may be achieved with a clinically related measure, clinically unrelated readmissions may not impact hospital performance in the HRRP.

Analyzing the Current State and Visibility of Diversity, Equity, and Inclusion Initiatives at Urology Residency Programs.

OBJECTIVE: To analyze AUA urology residency program websites to determine visibility of diversity, equity, and inclusion (DEI) initiatives. There is growing interest in DEI initiatives by urology applicants, and in recent years, urology programs have invested in efforts to promote DEI. METHODS: All ACGME-accredited urology residency program with a website were assessed. Military programs were excluded. A DEI Score Card was developed using published pillars of DEI, including five domains: departmental inclusion, pipeline growth, departmental education, community engagement, and faculty demographics. Program Doximity rank, address, and surrounding demographics were collected to determine predictors of investing in DEI. RESULTS: One hundred forty-one urology residency websites were included for analysis. Only 40.7% of programs referenced DEI on their webpage, and 21.4% offered funded mentorship opportunities. Department education and community engagement were the least popular initiatives. The Western, Northeastern, and North Central sections had the highest DEI total score with wide variation across domains. Mention of DEI was not associated with program's county-level social vulnerability or percent minority but was associated with being a top 50 program (OR=4.0; 95% CI 1.8, 8.9; P = .0007). CONCLUSION: Less than half of academic urology programs' websites referenced DEI initiatives. Using a DEI score card, our study shows that investment in DEI varies widely by AUA section, and greater investment is positively correlated with program rank. Our DEI score card serves as a tool that programs can use to assess their current DEI investment, identify areas for improvement, and ensure existing initiatives are visible to applicants.

Collagenase Clostridium histolyticum for Peyronie's disease: a contemporary atlas of complications and their management.

INTRODUCTION: Collagenase Clostridium histolyticum (CCH) remains the only Food and Drug Administration-approved medical treatment for Peyronie's disease (PD). The initial IMPRESS I and II trials (Investigation for Maximal Peyronie's Reduction Efficacy and Safety), which led to Food and Drug Administration approval, revealed a rate of treatment-related adverse events as high as 84%. Studies fail to provide clear definitions of complications. OBJECTIVES: To review complications, provide a CCH complication atlas, and propose management strategies for commonly encountered complications. METHODS: We performed a literature review using PubMed. A photographic atlas was provided regarding complications in patients in a high-volume CCH center for PD. RESULTS: Complications were identified and classified by nature and severity. We followed a standardized previously published grading system for hematomas. Complications include bruising, swelling, hematoma formation, back pain, and, rarely, corporal rupture. Complications were discussed, and hematomas were graded by penile surface area. Complication photographs were graded and displayed. Treatment-related adverse effects do not affect overall results. CONCLUSION: Recognizing and grading complications associated with CCH therapy for PD is crucial for effective patient management and informed decision making. A standardized grading system allows for consistency in reporting and comparing hematoma complication rates across studies and patient populations. Herein we provide images that will help clinicians identify and confidently manage common complications that may occur in any CCH program.

Epididymectomy Is an Effective Treatment for Chronic Epididymal Pain.

INTRODUCTION: Chronic scrotal pain is difficult to manage, and epididymectomy is a treatment option for a subset of men with pain localized to the epididymis. We sought to evaluate the efficacy of epididymectomy at our institution. METHODS: Between 2000 and 2020, 225 men underwent epididymectomy at our institution for pain localized to the epididymis and not part of a greater constellation of pelvic pain or urinary symptoms. Our primary outcome measure was change in pain after epididymectomy, categorized as cured/improved or no change/worsened. Multivariable logistic regression compared the impact of pain duration, and surgical and psychiatric histories on postoperative pain. RESULTS: Patients in both outcome categories-cured/improved and no change/worsened-were similar in age and BMI. Overall, 162 patients (72%) reported cured/improved pain at the last documented follow-up visit. Median follow-up time was 12 (IQR 1-364) weeks. About half of the cohort (n = 117, 52%) had a prior vasectomy, and there was no difference in outcome based on vasectomy history on multivariate analysis (OR 0.625, P = .3). Men with pain duration > 1 year (OR 0.46, P = .03), diagnosed psychiatric conditions (OR 0.44, P = .04), or prior scrotal/inguinal/abdominal surgeries other than vasectomy (OR 0.47, P = .03) had decreased odds of pain relief after epididymectomy. CONCLUSIONS: This 20-year analysis is the largest review of postepididymectomy outcomes reported. Among carefully screened men, 72% had resolution or improvement of scrotal pain. Epididymectomy is most effective for men with < 1 year of focal epididymal pain, with no history of psychiatric conditions or scrotal/inguinal/abdominal surgery other than vasectomy.

Patient-Directed Vasectomy Information: How Readable Is It?

PURPOSE: To assess the quality and readability of online health information on vasectomy using validated readability and quality assessment tools. MATERIALS AND METHODS: The top 50 search results for "vasectomy" on Google, Bing, and Yahoo were selected. Duplicate links, advertisements, blog posts, paid webpages, and information intended for healthcare providers were excluded. Flesch Reading Ease score, Flesch-Kincaid Grade level, Gunning Fog Index, and Simple Measure of Gobbledygook (SMOG) index were used to assess readability, with optimal readability level for online health information established as being at sixth grade reading level. DISCERN Instrument and JAMA Benchmark were used to assess the quality of selected webpages. Inter-assessment score correlation and results by webpage type were analyzed. RESULTS: We analyzed 44 webpages, including 16 academic, 5 hospital-affiliated, 6 commercial, 13 non-profit health advocacy, and 4 uncategorized sources. The average readability of the evaluated webpages was at a 10th grade reading level as measured by the Flesch Kincaid Assessment tool, and an undergraduate reading level per the SMOG and Gunning Fog indices. Non-profit health advocacy webpages had the best reading level but still was not at the recommended level of grade 6 to 7. The overall DISCERN quality of the webpages was "fair", with non-profit health advocacy pages performing best. CONCLUSIONS: The assessed webpages offer education on vasectomy in a language that is too complex for the general population to understand. Furthermore, several sources for online health information, such as non-profits, outperformed webpages by academic institutions. Increased healthcare collaboration and dedication to producing quality online patient resources is necessary to address these shortcomings and build trust among patients to increase utilization of vasectomy and decrease decisional regret.

Short-Term Changes in Vasectomy Consults and Procedures Following Dobbs v Jackson Women's Health Organization.

INTRODUCTION: On June 24, 2022, the US Supreme Court issued its decision on Dobbs v Jackson Women's Health Organization (Dobbs). This decision had major implications on female reproductive choices, but also had potential implications on their male counterparts. We sought to determine the association of Dobbs with the number and characteristics of men seeking vasectomy. METHODS: A retrospective review was performed to determine the number of vasectomy consults and procedures completed at a single Michigan health system in the 6 months following Dobbs (June 24, 2022-December 24, 2022) vs the same 6-month time frame between 2019 and 2021. Another retrospective review was conducted in the 3 months following Dobbs (June 24, 2022-September 24, 2022) vs the same days in 2021 to determine the number of vasectomy consults completed and to evaluate for differences in the characteristics of these men. RESULTS: In the 6 months after Dobbs, there was a 150% and 160% increase in vasectomy consults and procedures completed, respectively, compared to a similar time frame in 2019 to 2021. In the 3 months after Dobbs, there was a 225% increase in new vasectomy consults compared to a similar time frame in 2021. There were no differences in the age, race, religion, median household income, or insurance type of men seeking vasectomy consult pre- vs post-Dobbs. Partnerless men (odds ratio 3.66) and those without children (odds ratio 2.85) were more likely than married men and those with 3 or more children, respectively, to seek vasectomy consult post-Dobbs. CONCLUSIONS: Dobbs was associated with a marked increase in vasectomy consultations and procedures at our institution in the state of Michigan. Future studies are needed to determine the long-term implications of Dobbs on vasectomy practices and determine if vasectomy practices differ by states and their respective abortion laws.

Overview of telehealth in the United States since the COVID-19 public health emergency: a narrative review.

Background and Objective: The coronavirus disease 2019 (COVID-19) public health emergency (PHE) resulted in rapid expansion and use of telehealth services. Regulatory and reimbursement flexibilities were put in place to ensure patients had continued access to care while the health system was overwhelmed by COVID-19 cases. These changes have allowed clinicians to use and researchers to evaluate telehealth in new ways. Methods: This narrative review focuses on highlighting telehealth research and evaluation that took place from March 2020 to February 2023 in the outpatient setting of the United States healthcare system. Key Content and Findings: The research conducted during the COVID-19 PHE shows that telehealth was primarily used as a substitute for in-person care, to maintain continuity of care for established patients, and has not had a negative impact on clinical outcomes or resulted in increasing healthcare costs. Conclusions: Studies show high patient and physician satisfaction, similar clinical outcomes and suggest that telehealth is used as a substitute for in-person care. The findings of this narrative review have direct implications for key stakeholders using telehealth now and beyond the COVID-19 pandemic. Patients, physicians and providers, healthcare leaders and administrators, as well as policymakers should consider how telehealth should continue to be reimbursed and regulated even as the COVID-19 PHE expired in May 2023.

Potential primary prevention of Peyronie's disease post prostatectomy?-retrospective analysis of peri-operative multi-modal penile rehabilitation.

The surgical management of prostate cancer through radical prostatectomy has the potential to impact patients' sexual function, including erectile dysfunction and Peyronie's disease (PD). Historical data suggests the incidence of PD in post-prostatectomy patients is higher than in the general population at 15.9%. Our study objective was to measure the rate of the development of PD among patients that receive penile rehabilitation (PR) regimen prior to and immediately after radical prostatectomy. In this study, we retrospectively reviewed the charts of 581 patients who were diagnosed with prostate cancer, treated with radical prostatectomy, and engaged in a PR program. Patients with the diagnosis of PD prior to prostatectomy were excluded from this study. The PR program consists of daily tadalafil, L-citrulline, and weekly vacuum erectile device with the option of intracavernosal injections if patients fail to respond to the regular regimen. We found the incidence of PD to be 2.9%, suggesting that PR regimens programs may be associated with a reduced incidence of PD in post-prostatectomy patients. Ten (out of 17) patients were diagnosed with PD after 2 years of follow up. The return of erections was not statistically different among patients who developed PD and the rest of the patients. Prospective, multi-institutional trials will be required to elucidate whether PR can prevent the development of PD in this patient population.

Deafening Silence of Male Infertility.

Think about 6 loved ones of reproductive age in your life. Now imagine that 1 of these 6 individuals is suffering from infertility. Perhaps they feel alone and isolated, unable to discuss their heartbreak with their closest friends, family, and support network. Suffering in silence. In this editorial, we discuss the infertility journey through the lens of the patients, the providers, and the scientists who struggle with infertility each and every day. Our goal is to open a dialogue surrounding infertility, with an emphasis on dismantling the longstanding societal barriers to acknowledging male infertility as a disease. Through education, communication, compassion, and advocacy, together we can all begin to break the deafening silence of male infertility.

Interstate Telehealth Use By Medicare Beneficiaries Before And After COVID-19 Licensure Waivers, 2017-20.

During the COVID-19 pandemic, all fifty states and Washington, D.C., passed licensure waivers that allowed patients to participate in telehealth visits with out-of-state clinicians (that is, interstate telehealth). Because many of these temporary flexibilities have expired or are set to expire, we analyzed trends in interstate telehealth use by Medicare beneficiaries during 2017-20, which covers the period both directly before and during the first year of the pandemic. Although the volume of interstate telehealth use increased in 2020, out-of-state telehealth made up a small share of all outpatient visits (0.8 percent) and of all telehealth visits (5 percent) overall. For individual states, out-of-state telehealth made up between 0.2 percent and 9.3 percent of all outpatient visits. We found that most out-of-state telehealth use was for established patient care and that a higher percentage of out-of-state telehealth users lived in rural areas compared with beneficiaries who did not receive care outside of their state (28 percent versus 23 percent). Our collective findings suggest that the elimination of pandemic licensure flexibilities will affect different states to varying degrees and will also affect the delivery of care for both established patients and rural patients.

The Lack of a Physical Exam During New Patient Telehealth Visits Does Not Impact Plans for Office and Operating Room Procedures.

OBJECTIVE: To understand how the lack of a physical examination during new patient video visits can impact urological surgery planning during the COVID-19 pandemic. METHODS: We retrospectively reviewed 590 consecutive urology patients who underwent new patient video visits from March through May 2020 at a single academic center. Our primary outcome was procedural plan concordance, the proportion of video visit surgical plans that remained the same after the patient was seen in-person, either in clinic or on day of surgery. Median days between video and in-person visits were compared between concordant and discordant cases using the Mann-Whitney U test; P < .05 was significant. RESULTS: Overall, 195 (33%) were evaluated by new patient video visits and had a procedure scheduled, of which, 186 (95%) had concordant plans after in-person evaluation. Further, 99% of plans for in-office procedures and 91% for operating room procedures were unchanged. Four patients (2.1%) had surgical plans altered after changes in clinical course, two (1%) due to additional imaging, and three (1.5%) based on genitourinary examination findings. Days between video visit and in-person evaluation did not differ significantly in concordant cases (median 37.5 [IQR, 16 - 80.5]) as compared to discordant cases (median 58.0 [IQR, 20 - 224]; P = .12). CONCLUSIONS: Most surgical plans developed during new patient video visits remain unchanged after in-person examination. However, changes in clinical course or updated imaging can alter operative plans. Likewise, certain urologic conditions (eg, penile cancer) rely on the genitourinary examination to dictate surgical approach.

Patient Preferences for Receiving Gender-Affirming Hormone Therapy.

Purpose: To characterize patient preferences regarding gender-affirming hormone therapy (HT) providers and telemedicine use. Methods: Between May and October 2019, a survey was administered to adult patients attending a tertiary medical center's HT clinic. The survey included questions on demographics, barriers to care, and preferences for HT follow-up care. Interest in telemedicine was measured using a Likert scale. Multivariable logistic regression was used to identify patient factors associated with interest in telemedicine. Results: Among 111 patients, 63.1% (n=70) preferred an in-person visit with a specialist and 21.6% (n=24) preferred a video visit with their specialist. While only 15.3% (n=17) preferred follow-up with a primary care provider (PCP), 71.0% (n=80) felt comfortable transitioning future care to a PCP. Notably, 52.3% (n=58) of patients were interested in a telemedicine visit. Factors associated with interest in telemedicine included identifying as a transgender man (aOR 3.94, 95% CI [1.24-12.53], p=0.02), minority race/ethnicity (aOR 6.71, 95% CI [1.79-25.17], p=0.005), no need to travel (aOR 3.34, 95% CI [1.14-9.85], p=0.03), no concerns about video visits (aOR 14.66, 95% CI [4.34-49.56], p<0.0001), and concern about their PCP offering a broad range of gender services (aOR 8.63, 95% CI [2.41-29.67], p=0.0006). Conclusions: Patients presenting for HT follow-up prefer continued care with a specialist. However, patients were willing to transition care to PCPs and were interested in telemedicine before the COVID-19 pandemic.

Virtual "Matchmaking": Stakeholder Perspectives on the Future of the Urology Residency Match.

OBJECTIVE: To examine stakeholder perspectives regarding the lack of in-person externships and transition to a virtual urology residency interview format. The unprecedented disruption from the COVID-19 pandemic forced an abrupt pivot to a "virtual" Urology Match for the 2021 cycle. We aim for our study to inform ongoing deliberations on the future of the Urology Match. MATERIALS AND METHODS: Following Urology Match day in February 2021, two surveys were distributed by the Society of Academic Urologists to all applicants and program directors (PDs) who participated in the 2021 Urology Match. RESULTS: Overall, 192 of 481 applicants (40%) and 63 of 160 PDs (39%) responded. Most applicants (67%) were satisfied with their match outcomes, although unmatched applicants were significantly more likely to be unsatisfied than matched applicants (98% vs 9%, P <.0001). Most PDs were equally (79%) or more satisfied (13%) with their match outcomes compared with prior years. Nearly all applicants (93%) and PDs (94%) recommended retaining an in-person externship option. Most applicants (61%) and PDs (71%) felt their outcomes would not have changed with in-person interviews. Applicants and PDs were evenly split as to whether interviews should be conducted in-person or virtually in the future. CONCLUSION: The vast majority of applicants and PDs recommended retaining in-person externships for future match cycles despite high costs. In contrast, there was ambivalence amongst both groups of stakeholders regarding the format of interviews for future match cycles. We recommend virtual interviews moving forward to help alleviate the financial burden placed on applicants and increase equity.

THE IMPACT OF VIDEO VISITS ON MEASURES OF CLINICAL EFFICIENCY AND REIMBURSEMENT.

INTRODUCTION: Telehealth is gaining more attention in multiple specialties, including urology. Video visits in particular have shown high satisfaction and cost-saving for patients. However, there has been little investigation into how video visits compare to traditional clinic visits on measures of clinical efficiency and reimbursement. METHODS: Our dataset included 250 video visits of established patients at Michigan Medicine Department of Urology and 250 in-person clinic visits with the same providers completed between July 2016 and July 2017. Information on visit completion and cancellation rates; cycle time (time from check in to check out); reimbursement; and patient out-of-pocket expenses was collected using the electronic medical record and billing data. RESULTS: Completion rates were similar between video and clinic visits (58% versus 61%, respectively; p=0.24). Average cycle time for video visits was significantly shorter compared to clinic visits (24 min vs 80 min, respectively; p<0.01). Neither average commercial payer reimbursement (p=0.21) nor average out-of-pocket expense (p=0.22) was statistically different between video and traditional visits. More video visits than clinic visits were billed as level 3 encounters (85% and 63%, respectively, p=0.002). CONCLUSIONS: Our study demonstrates that video visits have the potential to reduce the time patients spend on follow-up care without negatively impacting reimbursement rates. However, these visits could reduce average billing levels. These findings suggest that the incorporation of video visits into practice may be more efficient for patients but may also reduce billing levels.

Understanding the Barriers to Neoadjuvant Chemotherapy in Patients with Muscle Invasive Bladder Cancer: A Quality Improvement Initiative.

PURPOSE: Utilization of neoadjuvant chemotherapy (NAC) for the management of muscle-invasive bladder cancer remains low. We sought to understand our practice of NAC use in order to design a quality improvement initiative geared towards optimizing medical oncology referral. MATERIALS AND METHODS: We identified 339 patients with ≥cT2 bladder cancer treated with radical cystectomy between 2012-2017 at our institution. We assessed the rate of referral to medical oncology, rate of NAC administration, as well as medical, patient and provider variables associated with NAC use. Bayesian logistic regression modeling identified variables associated with NAC use and chart review provided granular patient-level data. RESULTS: 85% (n=289) of patients were referred to medical oncology and 62.5% (n=212) received NAC. Renal insufficiency, hearing loss, and treating urologist were conclusively associated with lower odds of NAC use. 46 patients were not referred to medical oncology and 50% of these had medical contraindications to cisplatin cited as the reason for no referral. 38 patients met with medical oncology but did not receive NAC. 30 (79%) had comorbidities that impacted this decision with 15 (39%) ineligible based on impaired renal function. CONCLUSIONS: Despite the relatively high rates of medical oncology referral and NAC use in this cohort, there are still opportunities to improve the efficiency of this practice. Quality improvement initiatives could optimize the referral of patients with ≥T2 bladder cancer for consideration of cisplatin-based NAC and establish an important quality metric in the management of these patients.

Video Visits as a Substitute for Urological Clinic Visits.

OBJECTIVE: To evaluate whether video visits were being used as substitutes to clinic visits prior to COVID-19 at our institution's outpatient urology centers. METHODS: We reviewed 600 established patient video visits completed by 13 urology providers at a tertiary academic center in southeast Michigan. We compared these visits to a random, stratified sample of established patient clinic visits. We assessed baseline demographics and visit characteristics for both groups. We defined our primary outcome ("revisit rate") as the proportion of additional healthcare evaluation (ie, office, emergency room, hospitalization) by a urology provider within 30 days of the initial encounter. RESULTS: Patients seen by video visit tended to be younger (51 vs 61 years, P <.001), would have to travel further for a clinic appointment (82 vs 68 miles, P <.001), and were more likely to be female (36 vs 28%, P = .001). The most common diagnostic groups evaluated through video visits were nephrolithiasis (40%), oncology (18%) and andrology (14.3%). While the 30-day revisit rates were higher for clinic visits (4.3% vs 7.5%, P = .01) primarily due to previously scheduled appointments, revisits due to medical concerns were similar across both groups (0.5% vs 0.67%; P = .60). CONCLUSIONS: Video visits can be used to deliver care across a broad range of urologic diagnoses and can serve as a substitute for clinic visits.

Is There a Urologist in the House? Trends in the Management of Consults Based on Shift, Location and Resident Organization.

INTRODUCTION: Consultations represent a significant workload for inpatient urology providers, yet consult patterns are poorly described. We report trends in billable urology consult activity by location, time and organization of consult residents at a single institution. METHODS: Using a secure database urology consults between 2011 and 2018 at an academic center were recorded. Consult time, location and management were documented. Consults were considered eligible for billing if seen by faculty at time of consult in the emergency room or within 24 hours in the inpatient or operating room settings. Furthermore, in 2016 consult responsibilities overnight were given to an in-house resident. An interrupted time series was used to evaluate trends in consultations. RESULTS: Ultimately 18,431 consults were seen, 40.8% in the inpatient setting and 55.2% in the emergency room setting. The overall number of consults increased annually. The majority of consults (64.8%) were made during the day. Around 88.7% of inpatient and 88.2% of operating room consults were eligible for billing, yet only half (54.43%) of emergency room consults were eligible. After the addition of an in-house consult resident there was a significant (12%) increase in the number of billable consults. CONCLUSIONS: Ultimately, nearly half of emergency room consults were not eligible for billing. Initiation of an in-house overnight consult resident significantly increased the fraction of total billable consults. Understanding patterns in consult data offers insight into quality improvement measures that maximize departmental labor efficiency.