Healthcare system contact following ureteroscopy: does discharge instruction readability matter?

INTRODUCTION: We aimed to assess the impact of discharge instruction (DCI) readability on 30-day postoperative contact with the healthcare system. MATERIALS AND METHODS: Utilizing a multidisciplinary team, DCI were modified for patients undergoing cystoscopy, retrograde pyelogram, ureteroscopy, laser lithotripsy, and stent placement (CRULLS) from a 13th grade to a 7th grade reading level. We retrospectively reviewed 100 patients including 50 consecutive patients with original DCI (oDCI) and 50 consecutive patients with improved readability DCI (irDCI). Clinical and demographic data collected including healthcare system contact (communications [phone or electronic message], emergency department [ED], and unplanned clinic visits) within 30 days of surgery. Uni/multivariate logistic regression analyses used to identify factors, including DCI-type, associated with increased healthcare system contact. Findings reported as odds ratios with 95% confidence intervals and p values (< 0.05 significant). RESULTS: There were 105 contacts to the healthcare system within 30 days of surgery: 78 communications, 14 ED visits and 13 clinic visits. There were no significant differences between cohorts in the proportion of patients with communications (p = 0.16), ED visits (p =1.0) or clinic visits (p = 0.37). On multivariable analysis, older age and psychiatric diagnosis were associated with significantly increased odds of overall healthcare contact (p = 0.03 and p = 0.04) and communications (p = 0.02 and p = 0.03). Prior psychiatric diagnosis was also associated with significantly increased odds of unplanned clinic visits (p = 0.003). Overall, irDCI were not significantly associated with the endpoints of interest. CONCLUSIONS: Increasing age and prior psychiatric diagnosis, but not irDCI, were significantly associated with an increased rate of healthcare system contact following CRULLS.

Assessing the Impact of Hospital Dismissal Summary Readability on Patient Outcomes Following Prostatectomy.

PURPOSE: To assess the impact of decreasing the reading level of hospital dismissal summary information on the number of unplanned patient contacts with providers following robot-assisted radical prostatectomy. METHODS: A multidisciplinary team revised the hospital dismissal summary given to patients following prostatectomy to decrease the reading level from a 13th grade to seventh grade level. We conducted a retrospective cohort study comparing 30-day outcome measures including: patient-initiated telephone calls and online messages, unplanned clinic visits, readmission rates, and emergency department visits pre- and post-intervention. Other perioperative practices remained unchanged between the cohorts. RESULTS: A total of 110 patients were included in the study (pre-intervention n=60, post-intervention n=50). Patient age (P =.72), race (P =.59), marital status (P =.39), and education level (P = 1.0) were similar between the groups. Pre-intervention, 11.7% of patients had a self-reported education lever lower than the 13th grade, compared to 2% of patients post-intervention with an education level at or below the seventh grade. Following revision of the dismissal information, the number of patient-initiated messages (per patient) significantly decreased (mean 2.3 vs 1.4; P =.02). Patients who received the new dismissal information were significantly less likely to have an emergency department visit (20% vs 4%;P = .02). There were no differences in 30-day unplanned office visits (P =.75) or readmissions (P = 1.0). CONCLUSION: Reducing grade level readability of hospital dismissal information was associated with significantly lower rates of patient-initiated messages and emergency department visits. This intervention represents a valuable opportunity for improving the quality of patient care and decreasing postoperative care burden on the healthcare system.

Comparing and Contrasting Peyronie's Disease Guidelines: Points of Consensus and Deviation.

BACKGROUND: Peyronie's disease (PD) is a challenging clinical entity. To assist clinicians with diagnosis and management, four separate organizations have published PD guidelines over the past five years, but there remains a lack of consensus and data-driven recommendations for many aspects of diagnosis and treatment. AIM: To compare and contrast PD guidelines, highlighting key similarities and differences among the guideline panel recommendations and identify areas for further research. METHODS: We performed an extensive review to compare and contrast diagnosis and treatment recommendations from publically available published PD guidelines from four different organizations: American Urological Association, European Association of Urology, Canadian Urologic Association, and the International Society of Sexual Medicine. OUTCOMES: Key similarities and differences with regards to definition, evaluation, nonsurgical and surgical treatments were compared. RESULTS: Points of general consensus among the guideline panels included: History is adequate for diagnosis of PD, and intracavernosal injection is a gold standard to evaluate penile deformity prior to invasive intervention. Careful counseling with shared decision-making is required prior to treatment. In general, plication and incision and/or grafting surgery is reserved for patients with preserved erectile function whereas penile prosthesis implantation is the only surgical option for PD patients with erectile dysfunction. Overall, nonsurgical treatments have inferior evidence of efficacy with these being the main area of controversy; however, all societies recognize that intralesional injections may be used. 0Further research into the pathophysiology of PD may direct novel treatments targeted towards early intervention and rigorous outcomes research may direct best practices for the surgical treatment of PD in the future. CLINICAL IMPLICATIONS: PD is a challenging clinical entity. Direct comparison of the published PD guidelines highlights clear standards of care as well as areas where more research is needed to promote higher levels of evidence-based practice. STRENGTHS & LIMITATIONS: To our knowledge this is the first report to directly compare and contrast published guidelines pertaining to the diagnosis and management of PD. Limitations include the lack of evidence-quality review pertaining to individual guideline recommendations, although this was not the aim of this review. CONCLUSION: We highlight consensus of major urologic societies on many aspects of work up and management of PD with notable exceptions which may guide further research. Manka MG, White LA, Yafi FA, et al. Comparing and Contrasting Peyronie's Disease Guidelines: Points of Consensus and Deviation. J Sex Med 2021;18:363-375.

Defining the Current Landscape of Women in Urology: An Analysis of Female Applicants, Residents, and Faculty at AUA-Accredited Residency Programs.

OBJECTIVE: To describe the current landscape of women in academic Urology and determine if there is a correlation between female applicant matches and the proportion of female faculty/residents at their home institution or matched program. METHODS: We obtained 2020 American Urological Association (AUA) Match applicant demographics through social media platforms and program inquiries. The gender of full-time faculty and residents at AUA accredited programs was obtained from program websites. Correlations between proportions of female matched applicants and female faculty and residents were analyzed using linear regression models. RESULTS: A total of 353 residency slots at all 142 non-military programs were filled in the 2020 AUA Match, with 105 filled by women (30%). Of all applicants, 221 of 286 (77%) males and 105 of 122 (86%) females matched. Regarding institutions with urology residencies, women made up 27% of residents and 16% of full-time faculty. A total of 23 (17%) did not have any female faculty and 8 (6%) had no female residents. We found a positive correlation between the proportion of female residents and female faculty (r2 = 0.12, P <.0001). There was no significant correlation between the proportion of female matched applicants and female faculty or female residents at their matched programs or home institutions. CONCLUSION: The proportion of female residents within a urology program is positively correlated with the number of female faculty in the department, although further studies are needed to examine contributing factors. The current distribution of female applicants may demonstrate further narrowing of the gender gap within residency programs.

Discrepancy between Post-Vasectomy Semen Analysis Recommendation and Practice Patterns in the Post-2012 American Urological Association Guideline Era.

PURPOSE: In 2012 the American Urological Association published vasectomy guidelines to promote best practices, including when to obtain post-vasectomy semen analyses. In this study we assessed practice patterns of post-vasectomy semen analysis since this guideline publication. MATERIALS AND METHODS: We retrospectively analyzed a database of men who underwent post-vasectomy semen analysis between 2013 and 2017. Vasectomies were performed by urologist and nonurologist providers in academic and community settings. RESULTS: A total of 4,827 men underwent post-vasectomy semen analysis with 22.3% undergoing 1 or more repeat analyses. On initial analysis 58.2% were azoospermic, 28.3% had less than 100,000/ml rare nonmotile sperm, 8.7% had greater than 100,000/ml nonmotile sperm and 4.8% had motile sperm. The rate of repeat post-vasectomy semen analysis decreased from 30.7% in 2013 to 18.6% in 2016. Overall 72% of repeat post-vasectomy semen analyses were performed for patients with azoospermia or rare nonmotile sperm on initial post-vasectomy semen analysis. Of the 421 men with greater than 100,000/ml nonmotile sperm, 61.3% did not obtain a repeat analysis. Among cases of repeat analysis after initially having greater than 100,000/ml nonmotile sperm, 67.5% were downgraded to rare nonmotile sperm or azoospermia, 32.5% had a persistent count greater than 100,000/ml nonmotile sperm and none developed motile sperm. CONCLUSIONS: The rate of repeat post-vasectomy semen analysis is decreasing, likely highlighting a decrease in unnecessary testing. However, there is ongoing discordance between vasectomy guidelines and practice patterns, with 72% of repeat post-vasectomy semen analyses obtained unnecessarily based on guideline recommendations. Interestingly, no men with greater than 100,000/ml nonmotile sperm went on to have motile sperm on repeat post-vasectomy semen analysis. Further provider education is warranted and subsequent studies may allow for guideline modification wherein all nonmotile sperm are characterized similarly.

Intraoperative Use of Betadine Irrigation is Associated With a 9-Fold Increased Likelihood of Penile Prosthesis Infection: Results From a Retrospective Case-Control Study.

INTRODUCTION: Infection remains a persistent complication of penile prosthesis (PP) surgery. Despite popularity of Mulcahy's PP washout protocol, Betadine has known tissue toxicity. AIM: We evaluated PP infection rate based on the type of intraoperative irrigation used, ½ strength Betadine vs vancomycin/gentamicin. METHODS: We reviewed a prospective database of men undergoing primary, revision, and salvage PPs. No other changes to operative or perioperative techniques occurred after the change in irrigation solution. Univariate and logistic regression analyses were used to evaluate differences in infection rate with use of Betadine vs vancomycin/gentamicin irrigation. Potential confounders were reviewed. MAIN OUTCOME MEASURE: The primary outcome was rate of PP infection before and after change of intraoperative irrigation. RESULTS: From 2014 to 2018, 217 patients underwent PP placement at our institution by a single surgeon; of whom, 21 (9.7%) experienced an infection (primary = 10 [7.1%], revision = 11 [17.19%], salvage = 0 [0%]). Overall, 152 (70%) received irrigation with Betadine and 65 (30%) with Vancomycin/Gentamicin. Univariate analysis demonstrated significantly increased infection rates with Betadine irrigation (odds ratio [OR]: 4.64, P = .006) and with revision surgery (OR: 2.68, P = .02). Significance of increased infection rate with Betadine was maintained (OR: 9.3; P = .025) after controlling for age, body mass index, Charlson comorbidity index, smoking, diabetes, primary vs revision/salvage, prior penile surgery, use of ectopic reservoir, and adjunctive glanulopexy. CONCLUSIONS: Changing from intraoperative Betadine to vancomycin/gentamicin solution dramatically reduced infection rates among men undergoing PP placement in both primary and revision cases. We hypothesize that differences in infection rate may relate to the relative toxicity or non-sterile nature of Betadine. Manka MG, Yang D, Andrews J, et al. Intraoperative Use of Betadine Irrigation is Associated With a 9-Fold Increased Likelihood of Penile Prosthesis Infection: Results From a Retrospective Case-Control Study. Sex Med 2020;8:422-427.

Causes of Artificial Urinary Sphincter Failure and Strategies for Surgical Revision: Implications of Device Component Survival.

BACKGROUND: Up to 50% of patients receiving an artificial urinary sphincter (AUS) require surgical revision after initial placement. However, the literature is heterogeneous regarding the leading causes of AUS failure and appropriate surgical management. OBJECTIVE: To inform a revision approach by tabulating the causes of AUS failure, assessing AUS component survival, and examining the single-component revision efficacy. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed 168 patients receiving AUS placements carried out by a single surgeon from 2008 to 2016 at a high-volume academic institution. The median follow-up from initial placement was 2.7 yr, with 37.5% experiencing recurrent incontinence. The cuff size ranged from 4.0 to 5.5cm, with median size of 4.5cm. INTERVENTION: Patients without infection or erosion underwent systematic device interrogation and revision, starting with the pressure-regulating balloon (PRB) and then, if necessary, the urethral cuff. Device revision involved either PRB-only correction or cuff and PRB revision. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We used bootstrapped intervals to estimate the mean time to failure for individual AUS components. Kaplan-Meier estimates were used to compare survival for individual components and for revised devices by revision technique. RESULTS AND LIMITATIONS: PRB malfunction most commonly caused device failure, while cuff or pump malfunction was rare. Among patients undergoing surgical revision, those with PRB-only correction had similar outcomes to those with more extensive device correction (cuff and PRB exchange; p=0.46). This study, while systematic and detailed, is limited by sample size, follow-up length, and its retrospective nature. CONCLUSIONS: PRB malfunction most commonly caused AUS failure in our cohort. PRB-only correction may satisfactorily restore AUS function in select patients. Consequently, initial interrogation of the PRB may avoid a second incision and urethral exposure for many patients requiring AUS revision. PATIENT SUMMARY: Artificial urinary sphincters remain prone to failure over time. In many instances, correcting only the pressure-regulating balloon may effectively restore device function, allowing for a less invasive revision.

Patient Decision-making and Predictors of Genital Satisfaction Associated With Testicular Prostheses After Radical Orchiectomy: A Questionnaire-based Study of Men With Germ Cell Tumors of the Testicle.

OBJECTIVE: To better understand patient decision-making and genital satisfaction associated with postorchiectomy testicular prosthesis (TP) implantation in patients with germ cell tumors of the testicle. MATERIALS AND METHODS: An electronic survey to assess TP decision-making and genital satisfaction was distributed to patients via an institutional database (n = 70) and social media outlets (n = 167). Statistical analyses were performed using chi-square tests for categorical variables, Wilcoxon-Mann-Whitney tests for continuous variables, and multivariate regression analyses to identify independent predictors of receiving a prosthesis, genital satisfaction, and prosthesis satisfaction. RESULTS: 24.9% of respondents elected to receive a TP, but 42% of men without a prosthesis reported never being offered one. Identifying as a heterosexual man (2.86) and receiving a TP (odds ratio = 3.29) were both positive predictors of overall genital satisfaction. Having the orchiectomy performed at an academic institution (odds ratio = 2.87) was a positive predictor of testicular prosthesis TP placement. 89.8% of TP recipients were satisfied with the look of their prosthetic, but only 59.3% of respondents were satisfied with prosthetic feel. CONCLUSION: There are high levels of genital satisfaction in those who elect to receive a TP postorchiectomy. Associations between TP placement, genital satisfaction, and sexuality merit further investigation. Our results also indicate that patients who pursue an orchiectomy at an academic institution are more likely to receive a TP. The use of social media to recruit study participants in urology should be explored further.

Impact of Adjuvant Radiation on Artificial Urinary Sphincter Durability in Postprostatectomy Patients.

OBJECTIVE: To further understand the implications of adjuvant radiation on artificial urinary sphincter (AUS) durability in postprostatectomy patients. METHODS: One hundred fifty-eight postprostatectomy patients, identified by retrospective chart review, underwent AUS placement by 1 surgeon from 2008 to 2016. Time-to-event analysis measured the effect of adjuvant radiation on all-cause failure, and competing-risks regression stratified failure by cause (infection or erosion, urethral atrophy, mechanical failure). RESULTS: Adjuvant radiation independently predicted all-cause failure over time (hazard ratio = 4.32, P <.01) When stratifying failure by cause, we find that adjuvant radiation patients have increased risk of infection or erosion complications (hazard ratio = 4.48, P = .03). However, there was no statistical increase in urethral atrophy or mechanical failure. Lastly, among patients who have urethral comorbidities (bladder neck contracture, prior urethral sling, or urethral stricture), those with radiation history have particularly poor outcomes (22.4% revision-free survival at 3 years). CONCLUSION: In our series of postprostatectomy patients, adjuvant radiation portends worse AUS device survival over time. Furthermore, this decrease in revision-free survival appears to be concentrated in an increase in infection or erosion complications. Patients with prior urethral injury or manipulation who have also undergone adjuvant radiation should be carefully selected when receiving an AUS as this subset of patients experiences low device survival.

Hidden Renal Artery Pseudoaneurysm: The Need for Repeat Angiographic Intervention in a Symptomatic Patient.

Renal artery pseudoaneurysm (RAP) is a well-known and life-threatening complication of partial nephrectomies. Angioembolization is the preferred intervention, allowing for visualization, diagnosis, and treatment in 96% of cases. We report a case of a pseudoaneurysm that was difficult to diagnose even with optimal technique, requiring repeat imaging and additional angiographic intervention. Our case shows that RAP after partial nephrectomies may be difficult to diagnose even with high suspicion and appropriate technique. Repeat angiography may be required. Urologists and interventional radiologists together must keep RAP high on the differential even after a negative angiogram to adequately diagnose and treat symptomatic patients.

Does Use of a Second Cuff Improve Artificial Urinary Sphincter Effectiveness? Evaluation Using a Comparative Cadaver Model.

PURPOSE: The artificial urinary sphincter is the gold standard long-term solution for male stress incontinence. Some urologists believe that including a second urethral cuff at the time of placement can improve efficacy but strong evidence is lacking. We compared the functionality of a single vs a tandem cuff in a cadaver model. MATERIALS AND METHODS: Artificial urinary sphincter reservoir pressure was confirmed at 61 to 70 cm H2O. The bulbar urethra was dissected through a perineal approach in each of 4 cadavers. Distal and proximal bulbar urethral circumference was measured. The membranous urethra was transected. Cuffs sized based on circumference measurements were placed distal and proximal, and connected to the reservoir and pump. Retrograde leak point pressure was measured sequentially across the distal, proximal and tandem cuffs. We used the Friedman test to compare retrograde leak point pressure among the 3 cuff positions, the paired t-test to compare distal and proximal urethral circumferences and the Spearman correlation to compare urethral circumference to retrograde leak point pressure. RESULTS: Mean retrograde leak point pressure across the distal, proximal and tandem cuffs was 73.5, 77.75 and 79.25 cm H2O, respectively (p=0.44). Mean urethral circumference of the distal and proximal bulbar urethra was 4.78 and 5.83 cm, respectively (p=0.019). There was a strong positive correlation between urethral circumference and retrograde leak point pressure (rs=0.5). CONCLUSIONS: The tandem cuff did not improve retrograde leak point pressure. Proximal bulbar urethral circumference was greater than distal circumference and increasing urethral circumference correlated with increasing retrograde leak point pressure. Therefore, the perceived benefit of tandem cuffs may reflect more proximal placement of one of the cuffs.

Tubular Adenoma in the Indiana Pouch of a Patient With a History of Bladder Exstrophy.

An increased risk of neoplasm has been noted when bowel segments are used for urinary diversion. Particularly true for ureterosigmoidostomy, colonic adenocarcinoma has rarely been reported following Indiana Pouch diversion. This report describes a 42-year-old woman with a history of bladder exstrophy who developed a polyp in her Indiana Pouch 24 years after its creation. The polyp, found incidentally, was a tubular adenoma with high-grade dysplasia. Due to its malignant potential, the polyp was resected with preservation of the Indiana Pouch. This case highlights the need for lifetime surveillance in urinary reservoir patients who received diversions at a young age.