Testosterone levels increase following bariatric surgery - validation of preceding literature in a large-scale population analysis.

BACKGROUND: The effects of bariatric surgery on testosterone levels in men with obesity and hypogonadism have not been thoroughly explored yet. OBJECTIVES: To investigate the possible effects of bariatric surgery on T levels in obese hypogonadal men by comparing T levels before and after surgery using a comprehensive claims database. MATERIALS AND METHODS: The TriNetX US Collaborative Network database was used to identify men ages 18-80 who underwent a bariatric procedure and had a serum T value of < 350 ng/dL prior to surgery. Men who received testosterone therapy before/or after surgery were excluded. We conducted a retrospective self-matched cohort analysis to examine the difference in serum T levels before and after bariatric surgery. A sub-analysis was carried out to explore differences between men who reached eugonadal status or maintained low T levels following surgery. Descriptive statistics detailed sociodemographic and clinical characteristics, with continuous and categorical data compared using unpaired t-tests and chi-square analysis, respectively. Changes in T levels and body mass index (BMI) before and after surgery were compared using an unpaired t-test with a < 0.05 set for significance. All analyses were conducted using the TriNetX platform which utilizes both Python and R software. RESULTS: The study analyzed 69 hypogonadal men who underwent bariatric surgery and had T levels assessed before and after the procedure. The mean (standard deviation) pre-surgery serum T level was 208 ± 79 ng/dL, which post-surgery increased to 371 ± 164 ng/dL, marking an average increase of 163 ± 164 ng/dL. Likewise, the mean (standard deviation) body mass index decreased from 42.9 ± 9.0 to 38.8 ± 5.7 kg/m2. Post-surgery, 45% (31 men) achieved eugonadal status, while 55% (38 men) continued to have low T levels. A comparison between the post-surgery eugonadal cohort and the persistent low T cohort revealed that the former had higher pre-surgery serum T levels (235 ± 71 ng/dL vs. 184 ± 80.4 ng/dL, p = 0.007), a higher pre-surgery body mass index (45.5 ± 4.5 kg/m2 vs. 41.1 ± 11.5 kg/m2, p = 0.041), and a significantly greater reduction in body mass index post-surgery (7.3 ± 7.2 kg/m2 vs. 2.0 ± 12.8 kg/m2, p = 0.04). Notably, the increase in T was significantly higher in the eugonadal cohort compared to the persistent low testosterone cohort (257 ± 143 ng/dL vs. 95 ± 178 ng/dL, p < 0.0001). CONCLUSION: This study provides evidence of bariatric surgery's positive effect on serum T levels in obese men with baseline low T. Almost one out of two men with low T reached normal T levels after bariatric surgery. As the most comprehensive study to date, it validates and substantiates previous work suggesting that weight loss can improve T levels physiologically.

Testosterone therapy in females is not associated with increased cardiovascular or breast cancer risk: a claims database analysis.

BACKGROUND: Testosterone therapy (TTh) has been shown to improve libido in women with sexual dysfunction, but its utilization has been limited due to concern for cardiovascular events and past studies reporting highly variable results. AIM: To assess the association of TTh in women with major adverse cardiac events (MACEs), including heart attack, stroke, or death, using a large database. METHODS: The TriNetX Diamond Network was queried from 2009 to 2022. Our study cohort included adult females with ≥3 systemic testosterone prescriptions within a year. Our control cohort excluded females with any testosterone prescriptions, polycystic ovary syndrome, or androgen excess. Both cohorts excluded females with prior heart failure, unstable angina, intersex surgery (female to male), personal history of sex reassignment, or gender identity disorders. Propensity matching between the cohorts was performed. A subanalysis by age was conducted (18-55 and >55 years). OUTCOMES: We evaluated the association of TTh to the following: MACE, upper or lower emboli or deep vein thrombosis (DVT), pulmonary embolism (PE), breast neoplasm, and hirsutism within 3 years of TTh. RESULTS: When compared with propensity-matched controls, adult females with TTh had a lower risk of MACE (risk ratio [RR], 0.64; 95% CI, 0.51-0.81), DVT (RR, 0.61; 95% CI, 0.42-0.90), PE (RR, 0.48; 95% CI, 0.28-0.82), and malignant breast neoplasm (RR, 0.48; 95% CI, 0.37-0.62). Similarly, females aged 18 to 55 years with TTh had a lower risk of MACE (RR, 0.49; 95% CI, 0.28-0.85) and DVT (RR, 0.48; 95% CI, 0.25-0.93) and a similar risk of malignant breast neoplasm (RR, 0.62; 95% CI, 0.34-1.12). Females aged ≥56 years with TTh had a similar risk of MACE (RR, 0.84; 95% CI, 0.64-1.10), DVT (RR, 0.82; 95% CI, 0.50-1.36), and PE (RR, 0.52; 95% CI, 0.26-1.05) and a significantly lower risk of malignant breast neoplasm (RR, 0.51; 95% CI, 0.38-0.68). Risk of hirsutism was consistently higher in those with TTh as compared with propensity-matched controls. CLINICAL IMPLICATIONS: Our results contribute to safety data on TTh, a therapy for sexual dysfunction in women. STRENGTHS AND LIMITATIONS: The TriNetX Diamond Network allows for significant generalizability but has insufficient information for some factors. CONCLUSIONS: We found a decreased risk of MACE among women with TTh as compared with matched controls and a similar risk of MACE in postmenopausal women while demonstrating a similar or significantly lower risk of breast cancer on age-based subanalysis.

Ileal Conduit versus Cutaneous Ureterostomy after Open Radical Cystectomy: Comparison of 90-Day Morbidity and Tube Dependence at Intermediate Term Follow-Up.

Background: This study aims to compare perioperative morbidity and drainage tube dependence following open radical cystectomy (ORC) with ileal conduit (IC) or cutaneous ureterostomy (CU) for bladder cancer. Methods: A single-center, retrospective cohort study of patients undergoing ORC with IC or CU urinary diversion between 2020 and 2023 was carried out. The 90-day perioperative morbidity, as per Clavien-Dindo (C.D.) complication rates (Minor C.D. I-II, Major C.D. III-V), and urinary drainage tube dependence (ureteral stent or nephrostomy tube) after tube-free trial were assessed. Results: The study included 56 patients (IC: 26, CU: 30) with a 14-month median follow-up. At 90 days after IC or CU, the frequencies of any, minor, and major C.D. complications were similar (any-69% vs. 77%; minor-61% vs. 73%; major-46% vs. 30%, respectively, p > 0.2). Tube-free trial was performed in 86% of patients with similar rates of tube replacement (19% IC vs. 32% CU, p = 0.34) and tube-free survival at 12 months was assessed (76% IC vs. 70% CU, p = 0.31). Conclusions: Compared to the ORC+IC, ORC+CU has similar rates of both 90-day perioperative complications and 12-month tube-free dependence. CU should be offered to select patients as an alternative to IC urinary diversion after RC.

National Postoperative Opioid Prescribing Rates Following Pediatric Urology Procedures Before and After the 2018 American Academy of Pediatrics Challenge to Reduce Opioid Prescribing: A Claims Database Analysis.

OBJECTIVE: To evaluate trends in opioid prescribing rates following pediatric urologic surgery. METHODS: We queried the TriNetX Research database for patients under age 18 who underwent one of seven common pediatric urology procedures. We identified the proportion of patients that received an oral opioid prescription within 5days of surgery. The primary analysis evaluated the trend in postoperative opioid prescriptions using 3-month intervals from January 2010 to December 2022. We performed an interrupted time series analysis assessing trends in opioid prescribing patterns both before and after the American Academy of Pediatrics challenge. RESULTS: Of the 81,644 pediatric urology procedures, 29,595 (36.2%) received a postoperative opioid prescription, including 29.8% of circumcisions, 25.8% of hydrocelectomies, 39.6% of hypospadias repairs, 42.7% of pyeloplasties, 42.8% of ureteral reimplants. For all procedures we observed rising rates of opioid prescribing, increasing by 0.9% per 3-month interval prior to the challenge statement release from 2010 to 2018. We observed an overall significant decrease in opioid prescribing by 2.2% per 3-month interval following the challenge statement release. Additionally, since 2018, there was a significant decrease in opioid prescribing in all of the race, ethnicity, and age cohorts. CONCLUSION: Opioid prescribing following pediatric urology procedures has sharply decreased following the 2018 American Academy of Pediatrics challenge statement which underscores the value of cross-specialty quality improvement initiatives. Nonetheless, opioid prescribing remains high with potential racial or age disparities that warrant further investigation.

Erectile dysfunction and Peyronie's disease diagnosis rates after penile fracture-a retrospective claims database cohort analysis.

Our objective was to analyze the rates of erectile dysfunction and Peyronie's disease following a penile fracture using a large, multi-institutional claims database. Inclusion criteria included men ages 15 or older with a diagnosis of penile fracture and any office visit within 5 years of the penile fracture. Exclusion criteria included prior erectile dysfunction, prescription of erectile aids, or penile prosthesis placement. Our primary outcome was the diagnosis of erectile dysfunction or prescription of phosphodiesterase-5 inhibitors within 5 years. A secondary analysis assessed rates of Peyronie's disease following penile fracture. 1242 men were identified with penile fracture and subsequently matched to men without penile fracture, resulting in equal cohorts of 1227 men. Men with a history of penile fracture were more likely to receive a diagnosis of erectile dysfunction or require phosphodiesterase-5 inhibitors (RR 3.18, 95% CI: 2.30-4.40). Men who did not undergo immediate repair had higher rates of erectile dysfunction or treatment (RR: 1.84, 95% CI: 1.22-2.78). Men over the age of 45 years who had a penile fracture were more likely to develop erectile dysfunction or treatment compared to men under 45 years (RR: 1.65, 95% CI: 1.14-2.39). Rates of Peyronie's disease were higher in men with a history of penile fracture (5.8% vs 0%, p < 0.0001). Rates of Peyronie's disease were lower if immediate repair of the fracture was performed (RR: 0.20, 95% CI: 0.10-0.41). Men over the age of 45 years with penile fracture were more likely to develop Peyronie's Disease within 5 years compared to men under the age of 45 years penile fracture (RR: 3.72, 95% CI: 1.94-7.16). Penile fracture increases the risk of both erectile dysfunction and Peyronie's disease, especially those treated with conservative measures or over the age of 45 years compared to patients under 45 years with a penile fracture.

Postoperative Opioid Prescribing in Adolescents and Young Adults After Urologic Procedures Is Associated With New Persistent Opioid Use Disorder: A Large Claims Database Analysis.

OBJECTIVE: To assess the risk of persistent opioid use following various urologic procedures in adolescents and young adults. MATERIALS AND METHODS: The TriNetX LLC Diamond Network was queried for patients aged 13-21years who underwent pyeloplasty, hypospadias repair, inguinal hernia repair, inguinal orchiopexy, hydrocelectomy, or circumcision. Cohorts of patients prescribed and not prescribed postoperative opioids were created and propensity-matched for age, race/ethnicity, psychiatric diagnoses, and preoperative pain diagnoses. The primary outcome was new persistent opioid use, defined as new opioid use 3-9months after index procedure without another surgery requiring anesthesia during the postoperative timeframe. RESULTS: Of 32,789 patients identified, 66.0% received a postoperative opioid prescription. After propensity score matching for each procedure, 18,416 patients were included: 197 for pyeloplasty, 469 for hypospadias repair, 1818 for inguinal hernia repair, 2664 for inguinal orchiopexy, 534 for hydrocelectomy, and 3526 for circumcision. Overall, 0.41% of patients who did not receive postoperative opioids developed new persistent opioid use, whereas 1.69% of patients who received postoperative opioids developed new persistent opioid use (P < .05). Patients prescribed postoperative opioids had statistically higher odds of developing new persistent opioid use for hypospadias repair (RR: 17.0; 95% CI: 2.27-127.2), inguinal orchiopexy (RR: 3.46; 95% CI: 1.87-6.4), inguinal hernia repair (RR: 2.18; 95% CI: 1.07-4.44), and circumcision (RR: 4.83; 95% CI: 2.60-8.98). CONCLUSION: The use of postoperative opioids after urological procedures in adolescents and young adults is associated with a significant risk of developing new persistent opioid use.

Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer.

OBJECTIVE: To assess the risk of recurrence of breast cancer associated with vaginal estrogen therapy in women diagnosed with genitourinary syndrome of menopause with a history of breast cancer using a large U.S. claims database. METHODS: A U.S. health research network (TriNetX Diamond Network) was queried from January 2009 to June 2022. Our cohort consisted of women diagnosed with breast cancer within 5 years before the initial genitourinary syndrome of menopause diagnosis. Patients with active disease , defined as those undergoing mastectomy, radiation treatment, or chemotherapy within 3 months before diagnosis of genitourinary syndrome of menopause, were excluded. Recurrence was defined as mastectomy, radiation, chemotherapy, or secondary malignancy within 3 months to 5 years after the initiation of vaginal estrogen therapy for genitourinary syndrome of menopause. The study cohort included those with three or more vaginal estrogen prescriptions. The control cohort included women with breast cancer without any vaginal estrogen prescriptions after genitourinary syndrome of menopause diagnosis. Propensity matching was performed. A subanalysis by positive estrogen receptor status, when available, was performed. RESULTS: We identified 42,113 women with a diagnosis of genitourinary syndrome of menopause after breast cancer diagnosis with any estrogen receptor status, 5.0% of whom received vaginal estrogen. Of the initial cohort, 10,584 patients had a history of positive estrogen receptor breast cancer, and 3.9% of this group received vaginal estrogen. Risk of breast cancer recurrence was comparable between those who received vaginal estrogen and those who did not in both the any estrogen receptor (risk ratio 1.03, 95% CI 0.91-1.18) and positive estrogen receptor (risk ratio 0.94, 95% CI 0.77-1.15) status analyses. CONCLUSION: In a large, claims-based analysis, we did not find an increased risk of breast cancer recurrence within 5 years in women with a personal history of breast cancer who were using vaginal estrogen for genitourinary syndrome of menopause.

Stent-free rates in cutaneous ureterostomy urinary diversion after radical cystectomy.

PURPOSE: Cutaneous ureterostomy (CU) urinary diversion after radical cystectomy has been relegated to highly comorbid patients due to presumed rates of stenosis and drainage tube dependence. Rates of stricture as high as 70% have been reported. Though a variety of techniques have been developed to obviate the need for prolonged stenting, CU remains uncommonly performed. Herein, we present our experience with CU diversion after radical cystectomy and stent-free rates post-operatively. MATERIALS AND METHODS: We retrospectively reviewed the records of consecutive patients undergoing radical cystectomy with single-stoma cutaneous ureterostomy from June 2020 to December 2022 at our institution. Demographic and clinical data were summarized. We recorded the presence of ureteral stent, nephrostomy, or nephroureteral catheter at the last follow-up. The primary outcome was "stent-free survival" incorporating all modalities of tube-dependent urinary drainage. Kaplan-Meier analysis was performed to determine stent-free survival at 12 months. RESULTS AND CONCLUSIONS: We identified 28 patients meeting inclusion criteria with median age of 73 years (IQR: 66-78) and median body mass index of 25 (IQR: 22-28). Of patients that underwent stent-free trial (N = 23), the stent-free survival at 12 months was 74%. Five of 28 patients had continued tube dependence due to locally advanced disease with hydronephrosis rather than CU stenosis. These results suggest that single-stoma CU should be considered a viable option for patients undergoing radical cystectomy. Longer follow-up is needed to assess durability of stent-free rates.

Perioperative opioid prescribing after male fertility procedures is associated with new persistent opioid use: retrospective analysis of a large claims database.

OBJECTIVE: To assess the risk of new persistent opioid use in opioid-naïve men who underwent male fertility procedures. DESIGN: Retrospective cohort study using a claims database. SETTING: A database linking electronic medical record data and claims-assessing men who underwent fertility procedures between 2010 and 2021. PATIENT(S): Opioid-naïve men who underwent fertility procedures (open or laparoscopic varicocelectomy, spermatocele excision, and testicular excisional or incisional biopsy) without further surgical intervention requiring anesthesia in the 2 years after the index procedure. Those with and without perioperative opioid prescriptions were propensity score matched on age, race/ethnicity, smoking status, mental health diagnoses, and preoperative pain diagnoses. INTERVENTION(S): Perioperative opioid prescription. MAIN OUTCOME MEASURE(S): The primary outcome was the incidence of new persistent opioid use (opioid prescription 3-9 months after the index fertility procedure). The secondary outcome was prolonged opioid use (opioid prescription 9-24 months after the index fertility procedure). RESULT(S): A total of 387,565 men who underwent fertility procedures were identified, of whom 25.1% received an opioid prescription. After propensity score matching, 97,215 men were included; 4.7% of men who received a perioperative opioid prescription developed new persistent opioid use compared with 2.2% of those without a perioperative opioid prescription (risk ratio, 2.16; 95% confidence interval, 2.05-2.27; number needed to harm, 39). When assessing each unique fertility procedure independently, men who received perioperative opioids had statistically higher odds of developing new persistent opioid use for all procedure types. Men with new persistent opioid use were much more likely to go on and develop prolonged opioid use than men without new persistent opioid use. CONCLUSION(S): Opioid prescription after male fertility procedures is associated with a significant risk of new persistent opioid use, emphasizing the importance of judicious opioid prescribing for male fertility procedures.

Sleep disorders are associated with testosterone deficiency and erectile dysfunction-a U.S. claims database analysis.

The relationship between male genitourinary conditions and sleep disorders has previously only been reported in single-institution studies with small cohorts. Our objective was to assess the association of erectile dysfunction (ED) and testosterone deficiency with various sleep disorders using a large claims database. The TriNetX Diamond database was queried in June 2022. In men aged 40-70 years, insomnia, sleep apnea, and circadian rhythm sleep disorder were each independently assessed to determine the association with ED and testosterone deficiency and then followed by propensity score matching performed for age, hypertension, hyperlipidemia, diabetes mellitus, ischemic heart disease, tobacco usage, and obesity. Testosterone deficiency was more likely to be found in men diagnosed with sleep apnea (odds ratio (OR) 1.66 [95% confidence interval (CI) 1.65-1.67]), insomnia (OR 1.74 [95% CI 1.73-1.76]), and circadian rhythm dysfunction (OR 2.63 [95% CI 2.54-2.73]) compared to matched controls. ED was more likely to be found in men diagnosed with sleep apnea (OR 1.02 [95% CI 1.01-1.03]), insomnia (OR 1.30 [95% CI 1.30-1.31]), and circadian rhythm dysfunction (OR 1.54 [95% CI 1.49-1.59]) compared to matched controls. Our results emphasize the negative impact of poor sleep on diseases of the male genitourinary system by identifying these relationships in the largest cohort in the U.S. reported to date.

Unilateral orchiectomy of a testicular adrenal rest tumor: Case report and review of management options.

Testicular adrenal rest tumors are a rare development of patients with congenital adrenal hyperplasia. It is difficult to diagnose due to similarities with Leydig cell tumors. Treatment can be conservative or surgical. We describe the case of a 56 year old male presenting with bilateral testicular pain and irregular growth that was managed with a unilateral orchiectomy. We analyzed the distinguishing factors of testicular adrenal rest tumors compared to Leydig cell tumors, as well as the diagnostic and treatment methods.

Robotic management of a large mullerian duct cyst: a case report and review of surgical options.

Introduction: Mullerian duct cysts (MDCs) are a rare diagnosis in adulthood, primarily found in men aged 20 to 40 due to reproductive or urinary symptoms. Asymptomatic patients are generally observed. Treatment of symptomatic patients varies widely based on the presentation. Small cysts can be treated with transurethral and percutaneous methods due to a lower risk of damage to surrounding structures. However, larger and more complicated cysts are often treated using open or laparoscopic approaches. Case Description: Our case presents a 38-year-old male with worsening obstructive lower urinary tract symptoms and recurrent episodes of acute urinary retention. Preliminary diagnosis of a MDC was made using CT and MRI. After failing initial minimally invasive therapy, the patient was treated with definitive robotic-assisted laparoscopic surgical excision of the cyst. At the one-month follow-up, the patient reported no complications and resolution of symptoms. As shown by this case, robotic surgical methods may be used as a more precise approach, reducing the risk of damage to vessels, nerves, and structures within the abdomen and pelvis. Conclusions: Asymptomatic patients can be observed. Treatment of symptomatic patients varies widely based on the presentation. Small cysts can be treated with transurethral and percutaneous methods due to a lower risk of damage to surrounding structures. Larger, more complicated cysts are often treated using open, laparoscopic, or robotic surgical methods. More precise approaches, including robotic methods, can reduce the risk of damage to vessels, nerves, and structures within the abdomen and pelvis.