Does climate impact inflatable penile prosthesis infection (IPP) risk? Assessment of temperature and dew point on IPP infections.

BACKGROUND: Variations in climate have been associated with a greater risk of surgical site infections, urinary tract infections, and changes in the skin microbiome; however, limited data exist on the impact of climate on inflatable penile prosthesis (IPP) infections. AIM: We sought to evaluate the impact of climate on the risk of IPP infections in a large international, multicenter cohort. METHODS: We performed a multi-institutional, retrospective study of patients undergoing IPP surgery. We then evaluated whether the month or season, during which surgery was performed, affected device infections. Implant infections were defined as infections requiring device explantation. A univariate logistic regression analysis was undertaken. OUTCOMES: Our primary outcome was implant infection. RESULTS: A total of 5289 patients with a mean age of 62.2 ± 10.8 years received IPP placement. There was a fairly even distribution of implants performed in each season. A total of 103 (1.9%) infections were recorded. There were 32 (31.1%) IPP infections in patients who underwent surgery in the summer, followed by 28 (27.2%) in the winter, 26 (25.2%) in the spring, and 17 (16.5%) in the fall. No statistically significant differences were recorded in terms of season (P = .19) and month (P = .29). The mean daily temperature (P = .43), dew point (P = .43), and humidity (P = .92) at the time of IPP placement was not associated with infection. CLINICAL IMPLICATIONS: These findings provide reassurance to prosthetic urologists that infection reduction strategies do not need to be tailored to local climate. STRENGTHS AND LIMITATIONS: Climate data were not directly recorded for each hospital, but rather based on the monthly averages in the city where the surgery was performed. CONCLUSION: The climate at time of IPP placement and time of year of surgery is not associated with IPP infection risk.

5qSMA: standardised retrospective natural history assessment in 268 patients with four copies of SMN2.

Newborn screening for 5qSMA offers the potential for early, ideally pre-symptomatic, therapeutic intervention. However, limited data exist on the outcomes of individuals with 4 copies of SMN2, and there is no consensus within the SMA treatment community regarding early treatment initiation in this subgroup. To provide evidence-based insights into disease progression, we performed a retrospective analysis of 268 patients with 4 copies of SMN2 from the SMArtCARE registry in Germany, Austria and Switzerland. Inclusion criteria required comprehensive baseline data and diagnosis outside of newborn screening. Only data prior to initiation of disease-modifying treatment were included. The median age at disease onset was 3.0 years, with a mean of 6.4 years. Significantly, 55% of patients experienced symptoms before the age of 36 months. 3% never learned to sit unaided, a further 13% never gained the ability to walk independently and 33% of ambulatory patients lost this ability during the course of the disease. 43% developed scoliosis, 6.3% required non-invasive ventilation and 1.1% required tube feeding. In conclusion, our study, in line with previous observations, highlights the substantial phenotypic heterogeneity in SMA. Importantly, this study provides novel insights: the median age of disease onset in patients with 4 SMN2 copies typically occurs before school age, and in half of the patients even before the age of three years. These findings support a proactive approach, particularly early treatment initiation, in this subset of SMA patients diagnosed pre-symptomatically. However, it is important to recognize that the register will not include asymptomatic individuals.

Defining the incidence and management of postoperative scrotal hematoma after primary and complex three-piece inflatable penile prosthesis surgery.

Scrotal hematoma is a challenging complication of penile prosthesis surgery. We characterize the risk of hematoma formation with implementation of standardized techniques to mitigate hematomas and assess for any associated factors in a large multi-institutional penile implant cohort. This was a retrospective review from February 2018 to December 2020 of all patients who underwent inflatable penile prosthesis implantation at 2 high volume implant centers. Cases were defined as "complex" if they involved revision, salvage with removal/replacement, or were performed with concurrent penile, scrotal or intra-abdominal surgeries. The incidence of scrotal hematoma among primary and complex IPP recipients was measured and modifiable and innate risk factors associated with hematoma formation within the two cohorts were tracked. Of 246 men who underwent penile prosthesis surgery, 194 (78.9%) patients underwent primary implantation and 52 (21.1%) were complex. Although hematoma formers in the complex group had comparable drain outputs to primary patients on postoperative day 0 (66.8cc ± 32.5 vs 48.4 ± 27.7, p = 0.470) and postoperative day 1 (40.3cc ± 20.8vs 21.8 ± 11.3 p = 0.125), hematomas in the complex group had a higher propensity for OR evacuation (p = 0.03). Difference in duration of temporary device inflation between 2 (64, 26%) and 4 weeks (182, 74%) did not contribute to hematoma formation (p = 0.562). The incidence of postoperative hematoma formation in complex cases was 9.6% (5/52) and 3.6% in primary cases (7/194) (HR = 2.61, p = 0.072). Complex IPP surgery performed for revision or with ancillary procedures are more likely to result in clinically significant hematomas that require surgical management, suggesting a need for heightened caution in managing these individuals.

Differences in Healthcare Expenditures, Visits, and Prescriptions by Race for Common Benign Urologic Conditions.

OBJECTIVE: To identify differences in healthcare expenditures and utilization by race in patients treated for common benign urologic conditions. MATERIALS AND METHODS: A retrospective secondary data analysis was conducted of patients with common benign urologic conditions using 2016-2018 Medical Expenditure Panel Survey data. Benign conditions included urolithiasis, cystitis, erectile dysfunction (ED), pelvic organ prolapse (POP), urinary incontinence (UI), and benign prostatic hyperplasia (BPH). Generalized linear models were used to evaluate the relationship between total healthcare expenditures and utilization and race for each condition. Adjusted analyses accounted for age, sex, number of chronic conditions, poverty status, self-reported health status, marital status, highest degree of educational attainment, and insurance status. RESULTS: The weighted analysis sample consisted of 27,110,416 patients, of whom 80.9% were Non-Hispanic white, 6.9% Non-Hispanic black, and 12.2% other minority races. After adjustment, total healthcare expenditures were significantly lower for Non-Hispanic blacks (incidence rate ratio [IRR] = 0.19, 95% confidence interval [CI]: 0.06-0.61) and other minority races (IRR = 0.30, 95% CI: 0.10-0.88) compared to Non-Hispanic whites treated for ED. Similarly, compared to Non-Hispanic whites, healthcare expenditures were significantly lower for Non-Hispanic blacks treated for UI (IRR = 0.56, 95% CI: 0.35-0.90). CONCLUSION: Healthcare expenditures are significantly lower for Non-Hispanic black patients treated for ED and UI in the US Future research is needed to determine if these differences represent an inequality in the delivery of urologic care for patients with these conditions.

An assessment of current penile prosthesis reimbursement guidelines for insurance plans nationwide.

A lack of uniformity exists for insurance payer coverage for all categories of penile prostheses (PP). We sought to determine common insurance coverage criteria and barriers to implantation across common insurance plans from healthcare referral regions (HRR) nationwide. Coverage criteria and stipulations were reviewed regarding erectile dysfunction (ED) etiology, ED duration, contributing comorbid conditions, medications, drug use, diagnostic tests, use of procedures and prior interventions. Seventy of 100 plans included coverage criteria. 36.1% provided coverage only in cases of gender dysphoria. 27.7% required documentation of trial, contraindication or intolerance to pharmacologic therapy, with varying descriptors of what this entailed. 13.8% required at least consideration of prior pharmacologic therapy. 4.2% required trial or contraindication to classic second-line therapies. 25.0% stated that ED must be organic. Psychogenic ED was covered by 12.5% of plans. Eleven plans required at least 6 or 12 months of symptoms. Laboratory evaluation to rule out hypogonadism or hyperprolactinemia was required by five plans. Insurance coverage criteria for PP placement were highly variable by state and plan. Coverage is provided for PP implantation in most cases for ED of organic etiology following failure of pharmacologic therapy when contributing comorbidities are optimally managed.

Radiation protection modelling for 2.5 Petawatt-laser production of ultrashort x-ray, proton and ion bunches: Monte Carlo model of the Munich CALA facility.

The 'Centre for Advanced Laser Applications' (CALA) is a new research institute for laser-based acceleration of electron beams for brilliant x-ray generation, laser-driven sub-nanosecond bunches of protons and heavy ions for biomedical applications like imaging and tumour therapy as well as for nuclear and high-field physics.The radiation sources emerging from experiments using the up to 2.5 petawatt laser pulses with 25 femtosecond duration will be mixed particle-species of high intensity, high energy and pulsed, thus posing new challenges compared to conventional radiation protection. Such worldwide pioneering laser experiments result in source characteristics that require careful a-priori radiation safety simulations.The FLUKA Monte-Carlo code was used to model the five CALA experimental caves, including the corridors, halls and air spaces surrounding the caves. Beams of electrons (<5 GeV), protons (<200 MeV),12C (<400MeV/u) and197Au (<10MeV/u) ions were simulated using spectra, divergences and bunch-charges based on expectations from recent scientific progress.Simulated dose rates locally can exceed 1.5 kSv h-1inside beam dumps. Vacuum pipes in the cave walls for laser transport and extraction channels for the generated x-rays result in small dose leakage to neighboring areas. Secondary neutrons contribute to most of the prompt dose rate outside caves into which the beam is delivered. This secondary radiation component causes non-negligible dose rates to occur behind walls to which large fluences of secondary particles are directed.By employing adequate beam dumps matched to beam-divergence, magnets, passive shielding and laser pulse repetition limits, average dose rates in- and outside the experimental building stay below design specifications (<0.5µSv h-1) for unclassified areas,<2.5µSv h-1for supervised areas,<7.5µSv h-1maximum local dose rate) and regulatory limits (<1mSv a-1for unclassified areas).

Regional Variation in Penile Prosthesis Utilization among Medicare Patients with Erectile Dysfunction.

OBJECTIVE: To characterize penile prosthesis surgery utilization and assess for regional differences in the use of this procedure across the United States. MATERIALS & METHODS: We examined penile prosthesis surgeries (inflatable and semirigid implants) in Medicare beneficiaries with erectile dysfunction (ED) for the years 2006 through 2014. Adjusted utilization rates were calculated per 1000 beneficiaries accounting for age and race. Utilization rates were examined nationally and by hospital referral region (HRR). RESULTS: The national adjusted rate of penile prosthesis surgery declined from 5.41 per 1000 beneficiaries in 2006 to 3.74 per 1000 beneficiaries in 2014. The number of beneficiaries diagnosed with ED outpaced the number of patients undergoing surgery. Regional variation was observed; a 12-fold difference in 2014 (1.9/1000 in Norfolk, VA to 24.2/1000 in Miami, FL). Adjustment of 2014 data by urology provider density reduced variation between HRRs, and as a result a 3.5-fold difference was observed. Over 60% of HRRs performed 0 to <11 surgeries. CONCLUSION: The rate of penile prosthesis surgery is declining amongst Medicare beneficiaries with ED. Significant regional variation exists in the utilization of penile prosthesis surgery. This variation may be explained by a series of urologist and patient-specific factors, including provider density. Penile prosthesis surgery in Medicare beneficiaries is likely highly dependent on where these patients seek care.

A Review of Economic Evaluations of Erectile Dysfunction Therapies.

INTRODUCTION: Erectile dysfunction (ED) is a common and costly urologic condition with increasing prevalence as men age. Cost-effectiveness of ED therapies and whether cost-effectiveness varies for different populations of men remains underexplored. AIM: To review and summarize available published data on the economic evaluation of ED therapies and to identify gaps in the literature that still need to be addressed. METHODS: All relevant peer-reviewed publications and conference abstracts were reviewed and incorporated. RESULTS: There are a number of medical and surgical treatment options available for ED. The economic evaluation of phosphodiesterase-5 inhibitors, particularly sildenafil, has been well described. However, minimal research has been conducted to assess the cost-effectiveness of intracavernosal injections, intraurethral suppositories, penile prosthesis surgery, vacuum erection devices, and other emerging therapies in men with different causes of ED. CONCLUSION: Available economic evaluations of ED therapies are dated, do not reflect present-day physician, pharmaceutical, and device costs, fail to account for patient comorbidities, and may not be generalizable to today's ED patients. Substantial research is needed to evaluate the cost-effectiveness of ED treatments across different patient populations, countries, and reimbursement systems. Rezaee ME, Ward CE, Brandes ER, et al. A Review of Economic Evaluations of Erectile Dysfunction Therapies. Sex Med Rev 2019;8:497-503.

Epidemiology of genitourinary foreign bodies in the united states emergency room setting and its association with mental health disorders.

The epidemiology of genitourinary foreign bodies (GUFB) has been mainly described through case reports and small series. The aim of this study is to investigate the epidemiologic, medical, and socioeconomic factors associated with GUFB, along with the resultant costs of care in emergency departments (EDs) nationwide. ED visits with the primary diagnosis of a GUFB between 2010 and 2014 were abstracted from the Nationwide Emergency Department Sample database. Between 2010 and 2014, a weighted estimate of 102,333 visits to the ED with GUFB were recorded in the US, representing a national incidence of 7.6 ED visits per 100,000 persons. Of these visits, 4.7% resulted in admission and males were more likely to be admitted (24.8% vs. 2.1%, p < 0.01). A third of patients had low income, 30% had no medical insurance, and a third of patients had Medicaid. Urethra/bladder and penile foreign bodies had a significant association with mental health disorders (35.6%). Vulvar/vaginal foreign bodies had a lower prevalence of mental health disorders (6.1%). Costs of managing patients in the ED averaged $3769. More importantly, penile or urethra/bladder foreign bodies incurred a higher cost ($30,071). This is the largest population-based study investigating the epidemiology of GUFB. GUFB are more common in young women and the majority of them are vulvar/vaginal. Urethral and bladder foreign bodies occurred in older male patients and are associated with longer hospital stays and costs. Over one third of male patients with urethra/bladder had significant mental health disorders.

A Multi-institutional Assessment of Multimodal Analgesia in Penile Implant Recipients Demonstrates Dramatic Reduction in Pain Scores and Narcotic Usage.

INTRODUCTION: Despite the pain associated with inflatable penile prosthesis (IPP) implantation, there has been a lack of standardized, nonopioid pain control regimens described to date. AIM: To assess the effectiveness of a multimodal analgesic regimen in patients undergoing implantation of an IPP compared with patients treated with an opioid-only regimen. METHODS: A large, multicenter patient cohort undergoing IPP implantation whose pain was managed using a multimodal analgesia (MMA) protocol (preoperative and postoperative acetaminophen, meloxicam orcelecoxib, and gabapentin and intraoperative dorsal and pudendal nerve blocks) was compared with a matched cohort of patients managed via an opioid-only protocol. Both groups were compared with respect to visual analog score (VAS) and opioid usage (total morphine equivalents [TME]) in the post-anesthesia care unit (PACU), postoperative day 0 (POD0) and postoperative day 1 (POD1), and in the immediate postdischarge period. Narcotic usage on discharge and follow-up were assessed and compared. MAIN OUTCOME MEASURE: Postoperative pain scores and narcotic usage are the main outcome measures. RESULTS: 203 patients were eligible for final analysis: 103 (50.7%) patients receiving MMA medication and 100 (49.3%) patients receiving opioids only. The VAS was significantly lower in the multimodal group in PACU (median 0.0 vs 2.0, P = .001), POD0 (median 3.0 vs 4.0, P = .001), and POD1 (median 3.0 vs 4.3, P = .04). Patients in the multimodal group also used fewer narcotics in PACU (median 0.0 vs 4.0 TME, P = .001), POD0 (median 7.5 vs 12.5 TME, P < .001), and POD1 (median 7.5 vs 13.5 TME, P = .01). Despite being discharged with fewer narcotics (median 20.0 vs 30.0 tablets, P < .001), a smaller proportion of patients in the MMA cohort required narcotic refills (10.7% vs 28.0%, P = .001). There were no narcotic- or MMA medication-related side effects in the entire cohort. CLINICAL IMPLICATIONS: MMA confers significant improvement in pain management while also providing a significant reduction in narcotic usage in patients undergoing implantation of IPP. STRENGTH & LIMITATIONS: This is the 1st large multi-institutional assessment of a multimodal analgesic regimen in urologic prosthetic surgery. The analgesic regimen targets several pain pathways that provide excellent pain control throughout the recovery process. Limitations include retrospective design and lack of standardization of the nonsteroidal anti-inflammatory drug type within the multimodal analgesic regimen. CONCLUSION: The use of a MMA protocol significantly reduces postoperative pain measures in penile implant recipients and further reduces both inpatient and outpatient narcotic usage without any discernable side effects. Lucas J, Gross M, Yafi F, et al. A Multi-institutional Assessment of Multimodal Analgesia in Penile Implant Recipients Demonstrates Dramatic Reduction in Pain Scores and Narcotic Usage. J Sex Med 2020;17:518-525.