Revisiting the penoscrotal approach to artificial urinary sphincter surgery: how does it compare to a perineal incision for initial implantation?

PURPOSE: Artificial urinary sphincters (AUS) remain the gold standard to treat male stress urinary incontinence. AUS implantation can be performed through a penoscrotal or perineal incision depending on surgeon preference. METHODS: The present study compares initial AUS implantation through two surgical approaches focusing on outcomes of continence and revision. All AUS implanted at an academic medical center between 2000 and 2018 were retrospectively reviewed. RESULTS: A total of 225 AUS implantations were identified, of which, 114 patients who underwent virgin AUS placement were included in the study with a mean follow-up of 28.5 months. A total of 68 patients (59.6%) had AUS placement through penoscrotal incision; while, 46 (40.4%) had a perineal incision. While operative time was significantly shorter for penoscrotal placement (98.6 min vs. 136.3 min, p = 0.001), there were no significant differences in continence rates between either surgical approach with 76.5% socially continent defined as using zero to less than 1 pad per day (safety pad). The overall rate of device erosion or infection was not significantly different between groups. However, the rate of revision or replacement was significantly higher in the perineal group (26.1% v. 8.8%; p = 0.01). On multivariate analysis, the penoscrotal incision predicted a lower rate of device revision (p = 0.01). CONCLUSIONS: The penoscrotal approach of AUS placement is associated with shorter operative time. While we observed a lower revision rate compared to the perineal approach, there were equivalent continence outcomes.

Antibiotic prophylaxis after urethroplasty may offer no benefit.

PURPOSE: Patients often receive antibiotic prophylaxis after urethroplasty to minimize the risk of urinary tract infection (UTI). The aim of this study was to determine the frequency of UTIs after urethroplasty and its impact on urethral and incisional healing. METHODS: Patients undergoing urethroplasty by a single surgeon from 2000 to 2012 were retrospectively reviewed. All patients received preoperative antibiotic prophylaxis and postoperative prophylaxis for 30 days or until catheter removal. We reviewed urine cultures obtained within 30 days after urethroplasty in symptomatic patients, and rates of stricture recurrence and wound complications. A positive culture was defined as > 1000 cfu/mL of an organism. RESULTS: 398 patients were included with a mean age of 43.5 years at time of surgery. We identified 102 positive urine cultures (25.6%) within 30 days of urethroplasty. 78 stricture recurrences (19.6%) occurred at an average of 3 years after surgery and 18 (4.5%) experienced a wound complication, with a 52 month mean follow-up. There were no significant differences in stricture recurrence (p = 0.36) or wound complications (p = 0.42) between patients who had a positive and negative urine culture. On multivariate analysis, positive urine cultures (HR 1.0, 95% CI 0.6-1.8, p = 0.88) were not associated with stricture recurrence, while lichen sclerosis (HR 3.2, 95% CI 1.1-9.2, p = 0.03) and previous urethroplasty (HR 2.3, 95% CI 1.1-4.6, p = 0.03) were. CONCLUSION: Bacterial colonization and UTIs despite antimicrobial prophylaxis are common in urethroplasty patients. This, however, does not appear to impair urethral healing or influence wound healing, suggesting that postoperative prophylaxis may in fact offer no benefit.

Diagnostic value of biopsy sampling in predicting histology in patients with diffuse malignant pleural mesothelioma.

BACKGROUND: The classification of diffuse malignant mesothelioma into epithelioid, biphasic, and sarcomatoid types is based on histologic patterns. The diagnosis is made on biopsies, and because of intratumoral heterogeneity, they may not be representative of the entire tumor. The number and volume of biopsies needed to reach diagnostic accuracy in diffuse malignant mesothelioma and their prognostic value remain unclear. METHODS: This study examined 759 consecutive patients with pleural diffuse malignant mesothelioma treated by pleurectomy/decortication or extrapleural pneumonectomy for the presence of epithelioid and/or sarcomatoid histology and classified both the presurgery biopsies (core-needle or thoracoscopic) and surgical resection specimens. The number and volume of biopsies were correlated with pre- and postsurgery histologies and overall survival. RESULTS: Diffuse malignant mesothelioma was classified as epithelioid (76%), biphasic (18%), sarcomatoid (5%), or indeterminate (1%) in biopsies and as epithelioid (64%), biphasic (32%), and sarcomatoid (4%) in surgical resection specimens (overall concordance, 80.6%). The positive likelihood ratios were 2.4, 13.6, and 90.1 for biopsies with epithelioid, biphasic, and sarcomatoid histologies, respectively. Concordant histologies between biopsies and resections were associated with a higher number of biopsies (median tissue blocks for concordant histologies vs discordant histologies, 3 vs 2; P < .002) but were less associated with a higher volume (median, 1.2 vs 1.1 cm3 ; P = .06). In a multivariate analysis, overall survival was independently predicted by histology in the resection specimen (P < .0001) but not in the biopsy (P = .09). CONCLUSIONS: In contrast to epithelioid histology, sarcomatoid histology in biopsies is highly accurate. Despite intratumoral heterogeneity, the accuracy of histologic classification increases with the number of tissue blocks examined, emphasizing the diagnostic value of extensive sampling by presurgery biopsies.

Prostate cancer risk regions at 8q24 and 17q24 are differentially associated with somatic TMPRSS2:ERG fusion status.

Molecular and epidemiological differences have been described between TMPRSS2:ERG fusion-positive and fusion-negative prostate cancer (PrCa). Assuming two molecularly distinct subtypes, we have examined 27 common PrCa risk variants, previously identified in genome-wide association studies, for subtype specific associations in a total of 1221 TMPRSS2:ERG phenotyped PrCa cases. In meta-analyses of a discovery set of 552 cases with TMPRSS2:ERG data and 7650 unaffected men from five centers we have found support for the hypothesis that several common risk variants are associated with one particular subtype rather than with PrCa in general. Risk variants were analyzed in case-case comparisons (296 TMPRSS2:ERG fusion-positive versus 256 fusion-negative cases) and an independent set of 669 cases with TMPRSS2:ERG data was established to replicate the top five candidates. Significant differences (P < 0.00185) between the two subtypes were observed for rs16901979 (8q24) and rs1859962 (17q24), which were enriched in TMPRSS2:ERG fusion-negative (OR = 0.53, P = 0.0007) and TMPRSS2:ERG fusion-positive PrCa (OR = 1.30, P = 0.0016), respectively. Expression quantitative trait locus analysis was performed to investigate mechanistic links between risk variants, fusion status and target gene mRNA levels. For rs1859962 at 17q24, genotype dependent expression was observed for the candidate target gene SOX9 in TMPRSS2:ERG fusion-positive PrCa, which was not evident in TMPRSS2:ERG negative tumors. The present study established evidence for the first two common PrCa risk variants differentially associated with TMPRSS2:ERG fusion status. TMPRSS2:ERG phenotyping of larger studies is required to determine comprehensive sets of variants with subtype-specific roles in PrCa.

Surgical Approaches and Long-Term Outcomes in Adults with Complex Reoperative Hypospadias Repair.

PURPOSE: Patients with failed hypospadias repair are a challenging population for pediatric and reconstructive urologists. We describe our long-term outcomes and factors associated with complications of repeat hypospadias repair. MATERIALS AND METHODS: We retrospectively reviewed the records of 32 adult patients with a history of hypospadias repair who required subsequent urethroplasty between 2002 and 2012. Data on the presenting complaint, past medical and surgical history, demographic data, surgical approach, intraoperative findings and complications were collected and analyzed. RESULTS: Median patient age at urethroplasty was 32 years. Stricture of the penile urethra was the most common presentation. Urethroplasty was done in 30 patients as stricture treatment, 1 underwent perineal urethrostomy and 1 underwent diverticulectomy. Two-stage repair was performed in 90% of the men who underwent urethroplasty. The initial success rate was 83% in patients who underwent 1 or 2-stage urethroplasty. At a median followup of 9.5 years complications included 4 recurrent strictures and 1 fistula. Patient age, previous interventions, stricture length, hair present at the time of repair, the need to excise the urethral plate and the number of stages were not associated with complications or recurrence. If a graft was required, skin grafts were significantly associated with recurrence compared to buccal mucosa grafts. CONCLUSIONS: Excellent outcomes can be achieved using a 2-stage approach with replacement or augmentation of the urethral plate in adults with failed hypospadias repair. In our experience buccal mucosa appears to be associated with fewer complications and less stricture recurrence than skin grafts.

Synchronous Ipsilateral High Submuscular Placement of Prosthetic Balloons and Reservoirs.

INTRODUCTION: Synchronous ipsilateral high submuscular placement of artificial urinary sphincter (AUS) pressure-regulating balloons (PRBs) and inflatable penile prosthesis (IPP) reservoirs in a single submuscular tunnel is a novel strategy that could be advantageous for patients who have had major pelvic surgery. AIM: To report our initial experience with synchronous ipsilateral vs bilateral placement of AUS PRBs and IPP reservoirs in men undergoing implant surgery. METHODS: We retrospectively reviewed all patients undergoing synchronous AUS and IPP placement from 2007 through 2015 by a single surgeon at our tertiary center. Patients were stratified according to ipsilateral vs bilateral placement of the AUS PRB and IPP reservoir. MAIN OUTCOME MEASURES: Reoperation rates because of infectious or erosive complications and mechanical failure were assessed. RESULTS: Of the 968 implant surgeries during the study period, 47 men had synchronous device placement, of whom 17 (36%) underwent ipsilateral placement of the PRB and reservoir. During a median follow-up of 19 months (range = 1-84 months), reoperations were necessary in 12 of 47 (26%) and were similar between groups (ipsilateral, 5 of 17, 29%; bilateral, 7 of 30, 23%; P = .73). Most reoperations were due to AUS-related complications (10 of 12, 83%) and nearly all patients with reoperation (10 of 12, 83%) had compromised urethras (ie, prior urethral surgery, radiation, or prior AUS implantation). The most common indication for reintervention was cuff erosion (4 of 47, 9%), with no difference between groups (ipsilateral, 3 of 17, 18%; bilateral, 1 of 30, 3%; P = .13). CONCLUSION: Synchronous ipsilateral high submuscular placement of urologic prosthetic balloons could safely facilitate prosthetic surgery in patients with a history of major pelvic and inguinal surgery.

Preoperative Urine Culture Results Correlate Poorly With Bacteriology of Urologic Prosthetic Device Infections.

INTRODUCTION: Although preoperative negative urine culture results and treatment of urinary tract infections are generally advised before artificial urinary sphincter (AUS) and penile prosthesis (PP) surgery to prevent device infection, limited evidence exists to support this practice. AIM: To evaluate the relation between preoperative urine culture results and the bacteriology of prosthetic device infections. METHODS: Men undergoing AUS and/or PP placement at a tertiary referral center from 2007 through 2015 were analyzed. A total of 713 devices were implanted in 681 patients (337 AUSs in 314 patients and 376 PPs in 367 patients), of whom 259 (36%) did not have preoperative urine culture and were excluded. The remaining 454 patients received standard broad-spectrum perioperative antibiotics. Two patient groups were identified based on preoperative urine cultures: group 1 had negative urine culture results and group 2 had untreated asymptomatic positive urine culture results identified postoperatively. MAIN OUTCOME MEASURES: Device infection was diagnosed clinically and cultures obtained from the explanted device and tissue spaces were compared with preoperative urine culture results. RESULTS: Although multivariate analysis showed that patients undergoing AUS placement had a 4.5-fold greater risk of positive urine culture results (114 of 250, 45%) compared with those undergoing PP placement (36 of 204, 18%; P < .001), infection rates between device types were similar (8 of 250 for AUSs [3%] and 7 of 204 for PPs [3%]; P = .89). At a median follow-up of 15 months, device infection occurred in 15 of 454 devices (3%) implanted and no differences in infection rates were noted between urine culture groups (10 of 337 in group 1 [3.3%] and 5 of 117 in group 2 [4.3%]; P = .28). Remarkably, only 1 of 15 device infections (7%) had the same organism present at preoperative urine culture. CONCLUSIONS: Despite the finding that patients with AUS placement had a 4.5 times higher rate of positive urine culture results than patients with PP placement, preoperative urine culture results appeared to show little correlation with the bacteriology of prosthetic device infections.

Prolapse repair with and without apical resuspension-Practice patterns among certifying American urologists.

AIMS: To examine surgeon characteristics in certifying urologists performing prolapse surgeries. Anterior compartment prolapse is often associated with apical prolapse, with high rates of recurrence when anterior repair is performed without apical resuspension. METHODS: Six-month case log data of certifying urologists between 2003 and 2013 was obtained from the American Board of Urology (ABU). Cases with a CPT code for common prolapse repairs in females ≥18 years were analyzed. RESULTS: Among 2,588 urologists logging at least one prolapse surgery and a total of 30,983 surgeries, 320 (1.0% of all cases) uterosacral ligament suspension, 3,673 (11.9%) sacrospinous ligament suspension, and 2,618 (8.4%) abdominal sacrocolpopexy were identified. The remaining 14,585 cases were logged as anterior repair. 54.7% of anterior repairs did not include apical suspension. The proportion of anterior repairs without apical suspension has decreased from 77.7% in 2004 to 41.4% in 2012 (P < 0.001). Female subspecialists before 2011 performed anterior repair without apical suspension in 58.5%, versus 70.3% by all others. Since 2011 there has been a decrease in number of anterior repairs without apical suspension, notably in those applying for Female Pelvic Medicine and Reconstructive Surgery (FPMRS) certification (17.1% vs. 30.7% by all other urologists, P < 0.001); nonacademically affiliated urologists are 2.1 times more likely to report anterior repair without apical suspension than academically affiliated colleagues (P < 0.001). CONCLUSIONS: The proportion of prolapse repairs reported as anterior repairs without apical suspension is decreasing, although it remains a substantial portion. Recent log year, FPMRS, and academic affiliation were associated with prolapse repairs addressing apical support. Neurourol. Urodynam. 36:344-348, 2017. © 2015 Wiley Periodicals, Inc.

Disparities in female urologic case distribution with new subspecialty certification and surgeon gender.

AIMS: To examine surgical case volume characteristics in certifying urologists associated with common female urologic procedures to evaluate the practice patterns, given the recent establishment of subspecialty certification in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) and changes in urologist gender composition. METHODS: Six-month case log data of certifying urologists (2003-2013) was obtained from the American Board of Urology (ABU). We examined case logs for 26 CPT codes for common female urologic procedures focused on four procedure groups: incontinence, prolapse, vesicovaginal fistula (VVF), and revision/removal of vaginal mesh/graft. RESULTS: Among 4802 urologists logging at least one female urology case, 43,949 (55.6% of all cases) incontinence, 30,983 (39.2%) prolapse, 451 (0.6%) VVF, and 3643 (4.6%) revision of mesh/graft surgeries were identified. While 90.8% logging at least one female CPT code were men, women surgeons (9.2%) accounted for a disproportionate volume (22.6%) of cases. With initiation of the FPMRS subspecialty certification in 2011, 225 FPMRS candidates (out of 1716 certifying urologists) were identified, compared to 367 (out of 3828 certifying urologists) female subspecialists prior to 2011. FPMRS accounted for 56.7% of prolapse, 62.9% VVF, 59.0% mesh/graft revisions, and 41.9% of incontinence surgeries, compared to female specialists before 2011 (39.1%, 42.4%, 41.5%, and 21.6% respectively (all P < 0.001)). CONCLUSIONS: A growing proportion of female urologic cases are performed by female subspecialists, with a significant increase since initiation of FPMRS subspecialty certification. Women surgeons account for a disproportionate volume of these cases despite remaining a minority of certifying urologists and female subspecialists. Neurourol. Urodynam. 36:399-403, 2017. © 2015 Wiley Periodicals, Inc.

Is Risk of Artificial Urethral Sphincter Cuff Erosion Higher in Patients with Penile Prosthesis?

INTRODUCTION: Frequently encountered morbidities after prostatectomy include stress urinary incontinence and erectile dysfunction. Patients with severe disease may undergo placement of both a penile prosthesis (PP) and an artificial urethral sphincter (AUS). AIM: We hypothesized that concomitant PP may promote AUS cuff erosion by impaired corporal blood flow and/or direct pressure on the cuff. The aim of this study was to compare the rate of AUS cuff erosion in patients with and without a PP. METHODS: We reviewed 366 AUS operations at our tertiary center between 2007 and 2015 with a mean follow-up of 41 months (range 6-104). Included in the analysis were first-time AUS cuff erosions. Patients with recurrent erosions, AUS revisions, and iatrogenic erosions were excluded. In a separate analysis, we analyzed AUS explantations for all causes. Cohorts were compared by demographic information, preoperative characteristics, and rates of erosion and explantation. MAIN OUTCOME MEASURES: Erosion confirmed by cystourethroscopy and explantation of the AUS for all causes. RESULTS: Among 366 AUS surgeries at a mean follow-up of 41 months, there were 248 (67.8%) AUS alone cases compared to 118 (32.2%) AUS and PP cases (AUS/PP). Sixty-two patients met exclusion criteria for first-time cuff erosion. Among 304 evaluable AUS patients, we found a significantly higher rate of erosion in the AUS/PP group (11/95, 11.6%) compared to the AUS alone group (9/209, 4.3%, P = .037). When examining explantations for all causes in the entire cohort (n = 366), we observed a significantly higher rate of device removal, (20/118, 17%) in the AUS/PP group compared to the AUS group (23/248, 9.2%, P = .044). CONCLUSION: AUS/PP patients appear to have a higher risk of AUS cuff erosion and explantation compared to men with AUS alone.

National practice patterns of treatment of erectile dysfunction with penile prosthesis implantation.

PURPOSE: The increase in medical options to manage erectile dysfunction has changed how urologists approach erectile dysfunction. We reviewed contemporary trends in penile prosthesis implantation in the United States with an emphasis on practice patterns, demographics and temporal changes. MATERIALS AND METHODS: Annualized case log data of penile prosthesis surgeries from certifying and recertifying urologists from 2003 to 2012 were obtained from the American Board of Urology. CPT code 54400 was used to identify malleable prosthesis surgeries and CPT codes 54401 and 54405 were used to identify inflatable prosthesis surgeries. To evaluate the association between surgeon characteristics and practice patterns we used the chi-square test. RESULTS: The surgical cohort included 6,615 urologists who placed a total of 9,558 penile prostheses during the study period. Only 23.9% of urologists reported performing a penile prosthesis operation. Of the prostheses 75% were placed by surgeons who completed 4 or fewer such operations per year. Of urologists who recorded logs 1.5% considered themselves to be specialists in andrology and yet they were responsible for a disproportionate 10% of all prostheses implanted (OR 5.9, p <0.0001). The proportion of inflatable penile prostheses compared to malleable prostheses increased twelvefold in 10 years. The number of logged prosthesis surgeries was skewed toward more implants placed by the most experienced urologists than by new urologists (OR 1.92, p <0.0001). CONCLUSIONS: Although specialists and high volume surgeons perform a disproportionate number of implant surgeries, low volume surgeons place most penile prostheses in the United States. Additional research is needed to determine best practices to achieve optimal patient outcomes in penile prosthesis surgery.

Risk of urethral stricture recurrence increases over time after urethroplasty.

OBJECTIVE: To report a single institutional experience with urethroplasty outcomes and success rates at long-term follow up. METHODS: A retrospective review was carried out of all urethroplasties performed by a single surgeon from 2000 to 2010. A total of 347 patients underwent urethroplasty during this time period, of which 227 had minimum 1-year follow-up data available. Demographic, clinical, pathological and outcome data were reviewed. Recurrence was defined by patient reported urinary symptoms or need for subsequent intervention. Statistical analyses were carried out using SPSS statistical software. RESULTS: A total of 26% of all patients had a recurrence at a mean follow up of 62 months (range 13-147 months). The recurrence rate after anastomotic urethroplasty was 18%, as compared with 31% after substitution urethroplasty. Mean time to recurrence was 34 months (range 5-87). On univariate analysis, use of abdominal skin graft, history of prior urethroplasty, lichen sclerosus and length of follow up were statistically significant predictors of recurrence. On multivariate analysis, only history of prior urethroplasty and length of follow-up time exceeding 48 months were statistically significant predictors of recurrence. CONCLUSIONS: Urethroplasty for urethral stricture is the most durable treatment modality, regardless of surgical approach. However, there is an ongoing risk of recurrence with the passage of time. Patients should be counseled appropriately on the potential for late recurrence of stricture disease after urethroplasty.

Lichen sclerosus and isolated bulbar urethral stricture disease.

PURPOSE: Lichen sclerosus is a chronic inflammatory genital skin condition that can cause destructive urethral scarring. To our knowledge no prior study has described lichen sclerosus in isolated bulbar urethral stricture segments without progressive disease originating from the penile urethra. We report the incidence of lichen sclerosus in isolated bulbar urethral stricture segments. MATERIALS AND METHODS: We retrospectively reviewed the records of 70 patients after urethroplasty for isolated bulbar stricture disease was performed from 2007 to 2013. Stricture specimens were re-reviewed by a single uropathologist. Cases were evaluated using common histological features of lichen sclerosus, including hyperkeratosis or epithelial atrophy, basal cell vacuolar degeneration, lichenoid lymphocytic infiltrate and superepithelial sclerosis. RESULTS: Average patient age was 46.5 years (range 19 to 77) and average stricture length was 3.5 cm (range 1 to 7). Of the patients 51 (73.0%) underwent excision and primary anastomosis, and 19 (27.1%) underwent buccal mucosal onlay. In 6 patients (8.6%) stricture recurred during a median followup of 22 months (IQR 14, 44). Three of those patients had lichen sclerosus. Initial pathology assessment revealed lichen sclerosus in 5 patients (7.1%, 95% CI 1.0-13.3). On re-review of specimens using pathology criteria specific to lichen sclerosus 31 patients (44.3%, 95% CI 32.4-56.2) showed pathology findings highly suggestive of (13) or diagnostic for (18) lichen sclerosus (p = 0.0001). On pathological re-review lichen sclerosus was associated with recurrent stricture. CONCLUSIONS: On re-review of surgical specimens we noted a significant incidence of lichen sclerosus in isolated bulbar strictures in men undergoing urethroplasty. The incidence of lichen sclerosus may be higher than reported in isolated bulbar urethral segments without evidence of distal to proximal progressive urethral disease.

Outcomes after urethroplasty for radiotherapy induced bulbomembranous urethral stricture disease.

PURPOSE: We recently demonstrated that radiotherapy induced urethral strictures can be successfully managed with urethroplasty. We increased size and followup in our multi-institutional cohort, and evaluated excision and primary anastomosis as treatment for radiotherapy induced urethral strictures. MATERIALS AND METHODS: A retrospective review was performed of 72 patients from 3 academic institutions treated for radiotherapy induced bulbomembranous strictures. Outcome parameters of successful repair included recurrence, incontinence and erectile dysfunction. RESULTS: Among the 72 men treated for radiotherapy induced strictures 66 (91.7%) underwent excision and primary anastomosis. Mean followup was 3.5 years (median 3.1, range 0.8 to 11.2). Prostate cancer was the most common reason for radiotherapy (in 64 of 66, 96.9%). External beam radiotherapy and brachytherapy were performed in 28 of 66 men (42.4%) each, and a combination of both was performed in 9 (13.6%). Mean time from radiation to excision and primary anastomosis was 6.4 years (range 1 to 20) and mean stricture length was 2.3 cm (range 1 to 6). Successful reconstruction was achieved in 46 men (69.7%). Mean time to recurrence was 10.2 months (range 1 to 64) with new onset of incontinence observed in 12 men (18.5%). This was associated with stricture length greater than 2 cm (p = 0.013) and treatment center (p <0.001). The rate of erectile dysfunction remained stable (preoperative 45.6%, postoperative 50.9%, p = 0.71). Radiotherapy type did not affect stricture length (p = 0.41), recurrence risk (p = 0.91), postoperative incontinence (p = 0.88) or erectile dysfunction (p = 0.53). CONCLUSIONS: Radiotherapy induced bulbomembranous urethral strictures can be successfully managed with excision and primary anastomosis. Substitution urethroplasty with graft or flap is needed infrequently. Patients should be counseled on the potential risks of urinary incontinence and erectile dysfunction.

Lichen sclerosus in men is associated with elevated body mass index, diabetes mellitus, coronary artery disease and smoking.

PURPOSE: To elucidate disease associations and possible etiology of lichen sclerosus (LS), we identified comorbidities present in men with LS. LS is a chronic inflammatory disease of unknown etiology affecting genitals and urethra of men commonly resulting in strictures. METHODS: Men with LS of the urethra, penis, prepuce and scrotum were identified. A control population was generated from men seen in the Department of Urology matched by age and race in a 5:1 ratio. A case-control study was performed and comorbidities identified by ICD9, CPT codes and medication use via systematic electronic medical record review. Subgroup analysis of men with urethral strictures was performed based on their LS status. RESULTS: Men with LS had a significantly higher mean body mass index [31.0 (range 18.9-52.6)] compared to controls [28.1 (16.8-64.1), p = 0.001], significantly increased rate of coronary artery disease (CAD) (15.3 vs. 8.9%, p = 0.05) as well as a twofold higher rate of diabetes mellitus (15.5 vs. 8.3%, p = 0.02). Of men with LS and stricture disease, 11/19 (58%) were current or former smokers, compared to 28% of men with strictures without LS (p = 0.006). No association of LS with other morbidities like hyperlipidemia, hypertension, cerebrovascular disease, peripheral vascular disease or dermatologic disorders was found. CONCLUSIONS: Men suffering from LS have an increased BMI and a higher prevalence of concomitant CAD, diabetes mellitus and tobacco use. Development and chronicity of LS may not be a purely dermatologic condition, but be associated or confounded by systemic or vascular compromise from disorders of CAD, DM and smoking.

Rapid adoption of penoscrotal decompression for ischemic priapism in private practice.

Refractory ischemic priapism is a difficult to treat clinical entity for which there are a host of shunt procedures identified, but no singular agreed upon technique for surgical therapy. Recent literature describes success using a penoscrotal decompression technique that uses a similar dissection of a penoscrotal penile prosthesis placement. We demonstrate that this technique is easily applicable in the private practice setting as it uses a familiar setup to most general urologists in our case report.