Metacognitive control over the distribution of retrieval practice with and without feedback and the efficacy of learners' spacing choices.

In two experiments on self-regulated learning, participants studied word pairs, made judgments of learning (JOLs), and decided whether to continue practicing after a long or short spacing interval prior to a final cued-recall test. When practice involved restudying, learners preferred a long spacing interval. However, when retrieval practice was involved, learners preferred a short spacing interval for items with low and medium JOLs and a long interval for high-JOL items, regardless of whether retrieval practice was followed by feedback or not. Taking retrieval practice after a short rather than a long spacing interval was efficacious when no feedback followed practice tests, leading to superior recall. Given that retrieval practice was successful, a long spacing interval led to better recall than a short one, but learners were insufficiently accurate in determining which items should be given a long spacing interval for this strategy to be effective. Presenting feedback after retrieval practice did not alter learners' spacing strategy, and the frequent selection of short spacing intervals impaired subsequent recall.

Diagnostic yield of cystoscopy in the evaluation of recurrent urinary tract infection in women.

AIMS: Due to a paucity of evidence-based guidelines, anecdotal practice patterns often dictate clinical management of recurrent urinary tract infection (UTI) in women. Our aim was to identify pathologic findings of the urinary tract through cystoscopy and imaging in women with recurrent UTI, and to determine if specific risk factors are associated with a higher rate of abnormal findings. METHODS: In a single-institutional cohort, cystoscopy was performed for women with recurrent UTI between 1/2010 and 7/2014. All eligible patients were included in a maintained database and those with gross or microscopic hematuria were excluded. Abdominopelvic imaging was recommended and included in study data when completed. Associations between clinical risk factors (history of renal transplant, urogynecologic surgery, or urolithiasis) and abnormal findings were analyzed by Fisher's exact test. RESULTS: A total of 163 women (mean age 60.6 years) were included in final analysis. Abdominopelvic imaging was available in 133 (82%) cases. Cystoscopy identified 9 (5.5%) cases of significant clinical findings. Of these only 5 (3.8%) cases were uniquely identified on cystoscopy and missed on imaging modalities. When imaging was normal, cystoscopy was also normal in 94% of cases. The examined clinical risk factors were not associated with higher risk of abnormal cystoscopy (P = 0.49) or imaging (P = 0.42). CONCLUSIONS: Cystoscopy performed solely for recurrent UTI is low yield in patients with normal imaging studies, but a small number of abnormal findings may be missed by foregoing this element of the patient workup. No studied risk factor was predictive of an abnormal workup. Neurourol. Urodynam. 36:692-696, 2017. © 2016 Wiley Periodicals, Inc.

Predictors of biochemical recurrence in pT3b prostate cancer after radical prostatectomy without adjuvant radiotherapy.

BACKGROUND: Men with pathologic evidence of seminal vesicle invasion (SVI) at radical prostatectomy (RP) have higher rates of biochemical recurrence (BCR) and mortality. Adjuvant radiotherapy (XRT) has been shown to increase freedom from BCR, but its impact on overall survival is controversial and it may represent overtreatment for some. The present study, therefore, sought to identify men with SVI at higher risk for BCR after RP in the absence of adjuvant XRT. METHODS: We identified 180 patients in our institutional database who underwent RP from 1990 to 2011 who had pT3bN0-1 disease. The Kaplan-Meier method was used to estimate freedom from BCR for the overall cohort and substratified by Gleason score, PSA, surgical margin status, and lymph node positivity. Cox Proportional Hazards models were used to determine demographic and histopathological factors predictive of BCR. Time-dependent ROC curve analysis was conducted to assess the ability of the UCSF-CAPRA score to predict BCR. RESULTS: Median age was 64 years, and 52.8% of patients were preoperative D'Amico high risk. At RP, 41.4% had a positive surgical margin (PSM), and 12.2% had positive lymph nodes (LN). The most common sites of PSM were the peripheral zone (56.8%) and the apex (32.4%). Positive bladder neck margin (HR = 7.01, P = 0.035) and PSA 10-20 versus ≤10 (HR = 1.63, P = 0.047) predicted higher BCR in multivariable analyses. Median follow-up was 26 months, and 2-, 3-, and 5-year BCR-free rates were 56.1%, 49.0%, and 39.5%. Log rank tests showed that freedom from BCR was significantly less for Gleason 9-10, PSA >20, PSM, and N1 patients. The area under curve (AUC) for CAPRA in predicting BCR was 0.713 at 2 years, 0.692 at 3 years, and 0.641 at 5 years. Increasing CAPRA score was associated with an increased risk of BCR (HR = 1.33, P < 0.001). CONCLUSIONS: pT3b prostate cancer is a heterogeneous disease commonly associated with several high-risk features. Stratifying men with SVI by prognostic features (i.e., Gleason, PSA, node status, surgical margin status) and using these features to augment the CAPRA score will improve identification of those at higher risk for BCR that should be strongly considered for adjuvant XRT.

Sub-Coronal Inflatable Penile Prosthesis Placement With Modified No-Touch Technique: A Step-by-Step Approach With Outcomes.

INTRODUCTION: The surgical treatment of disorders of male sexual function requires specific exposure to correct the underlying problem safely and efficiently. Currently, sub-coronal exposure is used for treatment of phimosis, Peyronie's disease plaque (PDP), and semirigid penile prosthesis insertion. Infra-pubic and scrotal incisions are used for inflatable penile prosthesis (IPP) placement. However, men who present with several disorders might require multiple procedures and surgical incisions. AIM: To report a prospective review of our surgical experience and outcomes with a single sub-coronal incision for IPP placement with a modified no-touch technique. This approach allows for access to the entire corporal body for multiple reconstructive procedures. METHODS: Two hundred men had IPPs placed through a sub-coronal incision using our modified no-touch technique. The penis was degloved to the level of the penoscrotal junction and the dartos muscle was everted and secured to the drapes. This allowed exclusion of the scrotal and penile skin from the operative field. After artificial erection, the patient's corpora were inspected for PDP and other abnormalities. Penoscrotal IPP models were placed in all cases with insertion proximal to the penoscrotal junction. After placement of the IPP, the abnormalities were repaired. MAIN OUTCOME MEASURES: Feasibility of the procedure, operative times, complication rate, utilization of accessory, reconstructive procedures, and post-operative penile length. RESULTS: Of the 200 men who had IPP placement, 92 had PDP that was treated, 106 (53%) consented to circumcision, 24 (12%) had their reservoir placed ectopically, and 31 (16%) had a prosthesis exchanged through the sub-coronal technique. Mean operative time was 73 minutes (39-161 minutes). CONCLUSION: Specialists in the surgical treatment of disorders of male sexual function can perform multiple procedures safely and easily through a modified no-touch single sub-coronal incision. This approach allows access to the entire corporal body, providing excellent visibility and allowing the surgeon to perform multiple penile reconstructive surgeries through a single incision.

Variation in Penile Hemodynamics by Anatomic Location of Cavernosal Artery Imaging in Penile Duplex Doppler Ultrasound.

INTRODUCTION: Standard operating procedures (SOP) for penile duplex Doppler ultrasound (PDDU) were published in 2013 to promote uniform vascular assessment for erectile dysfunction (ED). However, SOPs do not specify a standard anatomic location for cavernosal artery (CA) imaging. AIM: The aim of this study was to determine the effects of CA imaging location on measured penile hemodynamics assessed by PDDU. METHODS: PDDU was performed in men with ED and/or Peyronie's disease. CA peak systolic velocity (PSV) and end diastolic velocity (EDV) were measured at three points: the origin of the CA within the penile crus, the proximal CA, and mid-CA. Differences in PSV and EDV were assessed by Friedman test and categorical vascular outcomes by Fisher's exact test. Data were analyzed for the main cohort, the subgroup with maximal smooth muscle relaxation (SMR) as defined by negative EDV, and the subgroup with valid-for-intromission erections. MAIN OUTCOME MEASURES: Mean PSV and EDV at three specified CA locations and the vascular diagnoses resulting from these measurements. RESULTS: One hundred four CAs were imaged in 52 men. Mean PSVs at the crus, proximal, and mid-CA were 52.9 ± 20.2, 29.5 ± 15.1, and 21.6 ± 10.6 cm/s, respectively (P < 0.0001); mean EDVs were 2.1 ± 8.9, 3.2 ± 5.4, and 3.3 ± 3.5 cm/s, respectively (P = 0.1225). The distribution of arteriogenic (P < 0.0001) and venogenic (P < 0.0001) diagnoses both differed significantly by location. Significant differences in vasculogenic diagnoses were also observed in the subgroup of CAs with definite maximal SMR (n = 38, arteriogenic P < 0.0001, venogenic P = 0.007) and in those with valid-for-intromission erections (n = 68, arteriogenic P < 0.0001, venogenic P = 0.0002). CONCLUSION: There is large variability in measured PSV and EDV on PDDU depending on the site of Doppler imaging, which can often sway clinical diagnosis. Future guidelines should attempt to incorporate standard locations of CA imaging, and new normative values may be necessary for each location.

Optimal treatment of non-muscle invasive urothelial carcinoma including perioperative management revisited.

Non-muscle invasive urothelial carcinoma is a heterogeneous disease that requires the practicing urologist to implement a variety of surgical and non-surgical treatment strategies. The disease course can range from recurrent low grade papillary disease to aggressive disease concerning for progression from initial presentation. Depending on the particular patient and goals of care, treatments similarly span the range from minimally invasive fulgurations to immediate radical cystectomy. For most patients some form of intravesical therapy will bridge the gap between transurethral resections (TUR) and radical surgery. Recent advances in the field continue to emphasize the importance of quality TUR and its strong impact on outcomes. In addition, continued research to optimize intravesical therapies has provided more information about how, when, and in whom these agents should be utilized to enhance their efficacy. This review covers the current state of NMIBC and the standards of care for the management of this disease.

Beyond Curvature: Prevalence and Characteristics of Penile Volume-Loss Deformities in Men With Peyronie's Disease.

INTRODUCTION: Non-curvature penile deformities associated with loss of erect penile volume are often overlooked and have not been thoroughly investigated. AIM: To describe the prevalence and functional impact of penile volume-loss deformities in our cohort of men with Peyronie's disease (PD). METHODS: We retrospectively examined medical records of patients with PD consecutively evaluated by a specialized urologist from December 2012 to June 2016. We excluded patients with prior surgical correction of PD, prior penile prosthesis, and inadequate erection during office examination. All patients underwent deformity assessment of the erect penis after intracavernosal injection. The assessment included measurement of penile curvature; evaluation for hourglass deformities, indentations, and distal tapering; and application of axial force to assess for penile buckling. Prior to the deformity assessment, each patient completed the Male Sexual Health Questionnaire and was asked if he experienced psychological distress and functional impairment related to his penile deformity. MAIN OUTCOME MEASURE: The primary clinical parameters that we evaluated were presence or absence of axial instability, functional impairment, psychological distress, penile pain, erectile dysfunction, ejaculatory dysfunction, sexual dissatisfaction, decreased sexual activity, and decreased sexual desire. RESULTS: 128 patients met criteria for inclusion. 83 patients (65%) had volume-loss deformities. Unilateral indentations, hourglass deformities, and distal tapering were present in 50 (39%), 30 (23%), and 16 (13%) patients, respectively. Penile curvature <10° degrees was present in 115 patients (90%). After controlling for angle of curvature, patients with volume-loss deformities had significantly higher rates of axial instability (odds ratio [OR] = 3.5, P = .01) and psychological distress (OR = 2.6, P = .03), as well as decreased sexual activity (OR = 2.7, P = .02), than patients with non-volume-loss deformities. CONCLUSION: Volume-loss penile deformities are highly prevalent in men with PD. These deformities are associated with penile axial instability and psychological distress, which may contribute to decreased frequency of sexual activity. Margolin EJ, Pagano MJ, Aisen CM, et al. Beyond curvature: prevalence and characteristics of penile volume-loss deformities in men with Peyronie's disease. Sex Med 2018;6:309-315.

Prevalence of Research Publication Misrepresentation Among Urology Residency Applicants and Its Effect on Match Success.

OBJECTIVE: To report the prevalence of research misrepresentation among urology residency applicants and assess its effect on match success. MATERIALS AND METHODS: All applications to the Columbia University urology residency program for the 2014-2015 match cycle were reviewed. "In-press," "accepted," and "submitted" manuscripts were verified using PubMed, Google Scholar, and journal websites. Misrepresentation for "in-press" and "accepted" manuscripts was defined as: (1) nonexistent manuscript, (2) nonauthorship of existent manuscript, (3) self-promotion to a higher author rank, and/or (4) existent manuscript in a nonpeer-reviewed publication. Logistic regression was performed to identify associated factors of misrepresentation and of match success. RESULTS: Of 257 applicants, 204 (79.4%) reported 1098 total manuscripts and 142 (55.3%) reported 371 unpublished manuscripts. About 5% (13 of 257) of applicants misrepresented 1 or more publications: 10 listed nonexistent manuscripts, 1 listed a publication for which he/she was listed a lower author rank than reported, 1 listed an accepted manuscript in a nonpeer-reviewed publication and for which he/she was not listed as an author, and 1 listed 4 in-press manuscripts in a nonpeer-reviewed publication. Only 55.8% (139 of 249) of "submitted" manuscripts were published within 12 months, with 41% (51 of 139) published in a journal of a lower impact factor than the reported journal of submission. Higher number of unpublished manuscripts was associated with misrepresentation. Higher Step 1 score, number of away sub-internships, and publication ratio were associated with match success. CONCLUSION: Research misrepresentation is a persistent issue in urology residency applications. However, misrepresentation in this cohort did not confer a significant advantage in match success.

Outcome Analysis of Factors Impacting the Urology Residency Match.

INTRODUCTION: Match outcome studies allow applicants and counselors to adequately prepare and make informed decisions. We sought to characterize predictors of success in URMP (Urology Residency Match Program) using standard application data. METHODS: All residency applications received at our department for the 2015 URMP, representing 56% of the national applicant pool, were prospectively entered in an applicant database. Data pertaining to applicant demographics and academic achievement were collected. Nationally published medical school and urology residency rankings were abstracted into tiers. The primary outcome was successful matching into urology and the secondary outcome was quality of the matched residency by ranking. Logistic and linear univariate and multiple regression modeling was performed to detect associations among all independent and outcome variables. RESULTS: The final analysis included 244 applicants, of whom 191 (78.3%) successfully matched. On multivariable analysis significant positive predictors included the number of honors grades (p = 0.047, OR 1.4), away subinternships (p = 0.013, OR 1.8) and USMLE (United States Medical Licensing Examination) Step 1 score (median 245 vs 232, p = 0.024). Negative predictors included noncurrent medical school senior status (p = 0.044, OR 0.24) and lower ranked medical school tier (p = 0.003, OR 0.78). Medical school tier (p <0.001), USMLE Step 1 score (p = 0.002) and number of published abstracts (p = 0.042) were predictive of entering a more highly ranked residency program. CONCLUSIONS: Based on an institutional sample of the national applicant cohort we identified multiple independent predictors of URMP outcome. This may be useful for applicant counseling in preparation for the match process, although findings may not be applicable to all candidates.

Age, Body Mass Index, and Frequency of Sexual Activity are Independent Predictors of Testosterone Deficiency in Men With Erectile Dysfunction.

OBJECTIVES: To identify clinical predictors of testosterone deficiency (TD) in men with erectile dysfunction (ED), thereby identifying subgroups that are most likely to benefit from targeted testosterone screening. METHODS: Retrospective review was conducted on 498 men evaluated for ED between January 2013 and July 2014. Testing for TD by early morning serum measurement was offered to all eligible men. Patients with history of prostate cancer or testosterone replacement were excluded. Univariable linear regression was conducted to analyze 19 clinical variables for associations with serum total testosterone (TT), calculated free testosterone (cFT), and TD (T <300 ng/dL or cFT <6.5 ng/dL). Variables significant on univariable analysis were included in multiple regression models. RESULTS: A total of 225 men met inclusion criteria. Lower TT levels were associated with greater body mass index (BMI), less frequent sexual activity, and absence of clinical depression on multiple regression analysis. TT decreased by 49.5 ng/dL for each 5-point increase in BMI. BMI and age were the only independent predictors of cFT levels on multivariable analysis. Overall, 62 subjects (27.6%) met criteria for TD. Older age, greater BMI, and less frequent sexual activity were the only independent predictors of TD on multiple regression. We observed a 2.2-fold increase in the odds of TD for every 5-point increase in BMI, and a 1.8-fold increase for every 10 year increase in age. CONCLUSIONS: Men with ED and elevated BMI, advanced age, or infrequent sexual activity appear to be at high risk of TD, and such patients represent excellent potential candidates for targeted testosterone screening.

Lengthening strategies for Peyronie's disease.

Loss of penile length is a common complaint of men with Peyronie's disease (PD), both before and after corrective intervention, which has a significant negative effect on patient quality of life. We sought to identify and describe the methods by which penile length can be preserved or increased. We conducted an extensive, systematic literature review, based on a search of the PUBMED database for articles published between 1990 and 2015. Articles with the key words "Peyronie's disease", "penile length" and/or "penile lengthening" were reviewed if they contained subjective or objective penile length outcomes. Only English-language articles that were related to PD and penile size were included. We found no evidence in the literature that medical therapy alone increases penile length. Classic inflatable penile prosthesis (IPP) placement, plication procedures, and the Nesbit procedure appear likely to maintain or decrease penile length. Plaque incision (PI) and grafting appears likely to maintain or increase penile length, but is complicated by risk of post-operative erectile dysfunction (ED). There are several surgical procedures performed concomitantly with IPP placement that may be suitable treatment options for men with comorbid ED, and consistently increase penile length with otherwise good outcomes concerning sexual function. These include the subcoronal penile prosthesis (scIPP), Egydio circumferential technique, the sliding technique, the modified sliding technique (MoST), and the multiple slice technique (MuST). In addition, adjuvant therapies such as penile traction therapy (PTT), post-operative inflation protocols, suspensory ligament relaxation, lipectomy, and adjuvant medical therapy for glans engorgement appear to increase subjective and/or objective penile length for men at high risk of decreased penile length after PD surgery. Considering the psychological burden of length loss in men with PD, providers with adequate volume and expertise should attempt, if possible, to maintain or increase penile length for men undergoing surgical intervention. There are several evidence-based, safe, and effective ways to increase penile length for these men and multiple emerging adjuvant therapies that may help ensure adequate length.

Laser ablation in the management of obstructive uropathy in neonates.

INTRODUCTION: Endoscopic management of posterior urethral valves and congenital ureteroceles is the current standard to relieve the obstruction. While the most commonly used techniques involve cystoscopic incision with cold knife or electrosurgery, an alternative is to ablate the obstructive tissue with laser energy. With increasing prenatal diagnoses, there has been an increasing shift in the timing of intervention toward earlier periods. The literature contains only two reports of laser ablation in neonates for these disease entities. MATERIALS AND METHODS: A case series was conducted by retrospectively reviewing our surgical database for all consecutive infants <28 days old (i.e., neonates) diagnosed in utero with obstructive uropathy and with postnatal imaging consistent with either urethral valves (anterior or posterior) or ureterocele. Holmium: yttrium aluminum-garnet (Ho:YAG) laser ablation was used as the exclusive modality of endoscopic management during the study period. All patients were followed with voiding cystourethrogram and renal/bladder ultrasounds postoperatively. RESULTS: Seventeen neonates underwent retrograde transurethral laser ablation procedures at a median age of 7 days (range 3-27). There were nine cases of urethral valve ablation (seven posterior, two anterior) and eight ureterocele ablations. Median operative time was 23 minutes (range 18-33). There were no intraoperative complications or reoperative procedures required for any case. All patients voided after postoperative catheter removal, and no patient had evidence of residual valve tissue or urethral stricture at mean follow-up of 10.1 months. All patients with ureterocele demonstrated partial or complete decompression of the ureterocele and improvement in hydroureteronephrosis at 3 months. CONCLUSIONS: Ho:YAG laser ablation appears safe, effective, and efficient for the management of urethral valves and ureteroceles in the neonatal period. With a continuing trend toward early definitive intervention for these conditions, laser ablation remains an important alternative to electrosurgery in this population.

Osteoporosis and Low Bone Mineral Density in Men with Testosterone Deficiency Syndrome.

INTRODUCTION: Testosterone deficiency syndrome (TDS) is a risk factor for low bone mineral density (BMD) and osteoporosis. Knowledge of the relationship between TDS and bone health, as well as the practical aspects of how to diagnose and treat low BMD, is therefore of practical importance to sexual medicine practitioners. AIM: The aim of this study was to review the physiologic basis and clinical evidence of the relationship between TDS and bone health; and to provide a practical, evidence-based algorithm for the diagnosis and management of low BMD in men with TDS. METHODS: Method used was a review of relevant publications in PubMed. MAIN OUTCOME MEASURES: Pathophysiology of low BMD in TDS, morbidity, and mortality of osteoporosis in men, association between TDS and osteoporosis, indications for dual X-ray absorptiometry (DXA) scanning in TDS, evidence for testosterone replacement therapy (TRT) in men with osteoporosis, treatment for osteoporosis in the setting of TDS. RESULTS: Sex hormones play a pleomorphic role in maintenance of BMD. TDS is associated with increased risk of osteoporosis and osteopenia, both of which contribute to morbidity and mortality in men. DXA scanning is indicated in men older than 50 years with TDS, and in younger men with longstanding TDS. Men with TDS and osteoporosis should be treated with anti-osteoporotic agents and TRT should be highly considered. Men with osteopenia should be stratified by fracture risk. Those at high risk should be treated with anti-osteoporotic agents with strong consideration of TRT; while those at low risk should be strongly considered for TRT, which has a beneficial effect on BMD. CONCLUSION: Low BMD is a prevalent and treatable cause of morbidity and mortality in men with TDS. Utilization of a practical, evidence-based approach to diagnosis and treatment of low BMD in men with TDS enables sexual medicine practitioners to make a meaningful impact on patient quality of life and longevity. Gaffney CD, Pagano MJ, Kuker AP, Stember DS, and Stahl PJ. Osteoporosis and low bone mineral density in men with testosterone deficiency syndrome.