Pathways to fatherhood: evaluating the priorities of self-identified gay and bisexual men pursuing family building options.

Objective: To assess the priorities and decisions of gay and bisexual men pursuing fatherhood. Design: Cross-sectional study. Setting: Internet-based survey. Patients: Gay and bisexual men who were interested in pursuing or had previously pursued family building options. Interventions: None. Main Outcome Measures: This study aimed to assess the attitudes of respondents regarding the following: mode of achieving parenthood and the relative importance of a genetic link to offspring; the relative importance of factors considered when selecting an oocyte donor (OD); and the relative importance of factors associated with selecting a gestational carrier (GC). Access to care and financial considerations were also analyzed. Results: Of the 110 respondents, most (68.2%) desired parenthood via an OD and GC. This was consistent with 53.2% of respondents reporting that a genetic link to a child was "extremely important" or "important." Most couples (86.6%) desired to use sperm from both partners. In addition, 40.5% of respondents reported that a twin gestation would be the most ideal pregnancy outcome. Medical history was considered the most important factor when selecting an OD (83.5%), whereas pregnancy history was considered the most important selection criterion for a GC (86.2%). Furthermore, 89.1% of respondents reported that the fertility services they desired were available to them, although 33.0% reported they would have to travel to another state for care. Conclusions: Understanding the circumstances of gay and bisexual men pursuing fatherhood allows for individualized care. Since several respondents desired twin pregnancies, it is important to counsel patients regarding the risks of multiple gestation and determine the motivations for this preference.

Seasonal variation in semen quality is not associated with fecundity in the Utah Population Database.

We determine whether a suspected seasonal variability in semen quality affect subsequent live birth rates. This is a retrospective, cohort analysis of men who provided semen analyses as part of fertility workup through a large andrology lab between 1996 and 2013 and corresponding birth rates using the Utah Population Database (UPDB). Semen parameters were analysed including total motile count (TMC), total sperm count, sperm concentration and progressive motility. Corresponding live births reflect those born in the state of Utah and were derived from birth certificate data available in the UPDB. Descriptive statistics were reported along with linear regression analysis with mixed effected models to test for an interaction between seasonal variation in semen quality and birth rates, accounting for age at the time of the semen analysis and abstinence time. A total of 11,929 patients and 14,765 semen samples were included. Only 3597 men (39% of men) had one or more values outside the World Health Organization reference range for their semen parameters. Linear regression demonstrated a consistent U-shaped relationship between TMC, total sperm count, and sperm concentration and season, with spring and winter yielding the highest values with a decline in the summer and fall. 7319 of these males had recorded live births for a total of 13,502 live births during the study period after a median follow-up of 7.2 years (IQR: 3.9-11.0). We did not find a significant interaction between specific semen parameters for a specific season and subsequent live births. Semen quality was the highest in the spring and winter, however there was no interaction between seasonal variability in semen quality and subsequent births. This is one of the largest studies describing seasonal variation in semen quality in humans.

Sexual Dysfunction in Men Who Have Sex With Men.

INTRODUCTION: Historically, sexual health research has focused on men who have sex with women (MSW) and most research examining the sexual health of men who have sex with men (MSM) has focused on HIV transmission. Despite a high prevalence of sexual health disorders among MSM, there is limited research that has evaluated the diversity of sexual issues in these patients. OBJECTIVES: The purpose of this review is to describe the unique sexual behaviors, concerns, and dysfunctions of MSM by evaluating the literature on sexual health in this specific patient population. METHODS: A PubMed literature search was conducted through December 2020 to identify all relevant publications related to the sexual health, sexual practices, and sexual dysfunction of MSM. Original research, review articles, and meta-analyses were reviewed, including comparisons of sexual behavior and dysfunction between MSM and non-MSM populations and between gay/bisexual men and heterosexual men. Approximately 150 relevant articles were reviewed and 100 were included in the manuscript. RESULTS: Minority stress can lead to an increase in high-risk sexual behavior, sexual dysfunction, and mental health disorders in MSM. MSM engage in a variety of sexual behaviors, which can lead to differences in sexual dysfunction, such as anodyspareunia during receptive anal intercourse. MSM have higher rates of erectile dysfunction than non-MSM counterparts. MSM have unique activators of sexual pathologies, such as insertive anal intercourse for Peyronie's disease. Prostate cancer treatment may cause MSM to change sexual roles and practices following treatment due to ED, anodyspareunia, or decrease in pleasure from receptive anal intercourse after prostatectomy. CONCLUSION: MSM have been neglected from sexual medicine research, which translates to disparities in health care. Further research that focuses on the MSM population is necessary to better educate healthcare practitioners so that MSM patients can receive adequate care that is tailored to their specific needs. Cheng PJ, Sexual Dysfunction in Men Who Have Sex With Men. Sex Med Rev 2022;10:130-141.

Multicenter urethroplasty outcomes for urethral stricture disease for patients with neurogenic bladder or bladder dysfunction requiring clean intermittent catheterization.

BACKGROUND: Our objective is to better comprehend treatment considerations for urethral stricture disease (USD) in patients requiring long-term clean intermittent catheterization (CIC). Patient characteristics, surgical outcomes and complications are unknown in this population. METHODS: Six members of the Trauma and Urologic Reconstruction Network of Surgeons (TURNS) participated in a prospective (2009 to present) and retrospective (prior to 2009) database recording patient demographics, surgical approach and outcomes. We included all patients undergoing urethroplasty who perform CIC. Descriptive statistics were used to analyze results. RESULTS: A total of 37 patients with 39 strictures were included. Bladder dysfunction was characterized as detrusor failure in 35% and neurogenic etiology in 65%. Median stricture length was 3 cm (IQR: 1.5-5.5) with 28% repaired with dorsal onlay buccal mucosal graft, 26% excision and primary anastomosis, 8% dorsal inlay, 8% ventral and dorsal, 8% flap based 8% non-transecting and 15% other. Functional success was 90%: 4 patients required DVIU or dilation due to recurrence, with 2 of those ultimately requiring repeat urethroplasty. 86% of patients returned to CIC; no patients reported new pad use for urinary leakage after urethroplasty. During a median follow-up period of 3.1 years (IQR: 1.0-5.3), no patients underwent urinary diversion. CONCLUSIONS: Urethroplasty is suitable, safe and effective for patients dependent on CIC suffering from USD. The effect of continual CIC on long-term outcomes remains uncertain.

"The Back-up Vasectomy Reversal." Simultaneous Sperm Retrieval and Vasectomy Reversal in the Couple With Advanced Maternal Age: A Cost-Effectiveness Analysis.

OBJECTIVE: To determine the cost-effectiveness of different fertility options in men who have undergone vasectomy in couples with a female of advanced maternal age (AMA). The options include vasectomy reversal (VR), sperm retrieval (SR) with in vitro fertilization (IVF), and the combination of VR and SR with IVF, which is a treatment pathway that has been understudied. MATERIALS AND METHODS: Using TreeAge software, a model-based cost-utility analysis was performed estimating the cost per quality-adjusted life years (QALY) in couples with infertility due to vasectomy and advanced female age over a period of one year. The model stratified for female age (35-37, 38-40, >40) and evaluated four strategies: VR followed by natural conception (NC), SR with IVF, VR and SR followed by failed NC and then IVF, and VR and SR followed by failed IVF and then NC. QALY estimates and outcome probabilities were obtained from the literature and average patient charges were calculated from high-volume centers. RESULTS: The most cost-effective fertility strategy was to undergo VR and try for NC (cost-per-QALY: $7,150 (35-37 y), $7,203 (38-40 y), and $7,367 (>40 y)). The second most cost-effective strategy was the "back-up vasectomy reversal": undergo VR and SR, attempt IVF and switch to NC if IVF fails. CONCLUSION: In couples with a history of vasectomy and female of AMA, it is most cost-effective to undergo a VR. If the couple opts for SR for IVF, it is more cost-effective to undergo a concomitant VR than SR alone.

Round spermatid injection into human oocytes: a systematic review and meta-analysis.

Many azoospermic men do not possess mature spermatozoa at the time of surgical sperm extraction. This study is a systematic review and meta-analysis evaluating outcomes following round spermatid injection (ROSI), a technique which utilizes immature precursors of spermatozoa for fertilization. An electronic search was performed to identify relevant articles published through October 2018. Human cohort studies in English involving male patients who had round spermatids identified and used for fertilization with human oocytes were included. Fertilization rate, pregnancy rate, and resultant delivery rate were assessed following ROSI. Meta-analysis outcomes were analyzed using a random-effects model. Data were extracted from 22 studies involving 1099 couples and 4218 embryo transfers. The fertilization rate after ROSI was 38.7% (95% confidence interval [CI]: 31.5%-46.3%), while the pregnancy rate was 3.7% (95% CI: 3.2%-4.4%). The resultant delivery rate was low, with 4.3% of embryo transfers resulting in a delivery (95% CI: 2.3%-7.7%). The pregnancy rate per couple was 13.4% (95% CI: 6.8%-19.1%) and the resultant delivery rate per couple was 8.1% (95% CI: 6.1%-14.4%). ROSI has resulted in clinical pregnancies and live births, but success rates are considerably lower than those achieved with mature spermatozoa. While this technique may be a feasible alternative for men with azoospermia who decline other options, couples should be aware that the odds of a successful delivery are greatly diminished and the prognosis is relatively poor.

Contemporary multicenter outcomes of continent cutaneous ileocecocystoplasty in the adult population over a 10-year period: A Neurogenic Bladder Research Group study.

AIMS: Evidence is sparse on the long-term outcomes of continent cutaneous ileocecocystoplasty (CCIC). We hypothesized that obesity, laparoscopic/robotic approach, and concomitant surgeries would affect morbidity after CCIC and aimed to evaluate the outcomes of CCIC in adults in a multicenter contemporary study. METHODS: We retrospectively reviewed the charts of adult patients from sites in the Neurogenic Bladder Research Group undergoing CCIC (2007-2017) who had at least 6 months of follow-up. We evaluated patient demographics, surgical details, 90-day complications, and follow-up surgeries. the Mann-Whitney U test was used to compare continuous variables and χ² and Fisher's Exact tests were used to compare categorical variables. RESULTS: We included 114 patients with a median age of 41 years. The median postoperative length of stay was 8 days. At 3 months postoperatively, major complications occurred in 18 (15.8%), and 24 patients (21.1%) were readmitted. During a median follow-up of 40 months, 48 patients (42.1%) underwent 80 additional related surgeries. Twenty-three patients (20.2%) underwent at least one channel revision, most often due to obstruction (15, 13.2%) or incontinence (4, 3.5%). Of the channel revisions, 10 (8.8%) were major and 14 (12.3%) were minor. Eleven patients (9.6%) abandoned the catheterizable channel during the follow-up period. Obesity and laparoscopic/robotic surgical approach did not affect outcomes, though concomitant surgery was associated with a higher rate of follow-up surgeries. CONCLUSIONS: In this contemporary multicenter series evaluating CCIC, we found that the short-term major complication rate was low, but many patients require follow-up surgeries, mostly related to the catheterizable channel.

Baseline Gonadotropin Levels and Testosterone Response in Hypogonadal Men Treated With Clomiphene Citrate.

OBJECTIVE: To investigate the role of baseline gonadotropins in predicting the biochemical response to clomiphene citrate (CC) treatment. METHODS: We conducted a retrospective review of data from hypogonadal men treated with CC in 2 high-volume fertility centers between 2013 and 2018. Patient age, body mass index, and baseline hormones (follicle stimulating hormone [FSH], luteinizing hormone [LH], and total testosterone [TT]) were obtained. Response to treatment was measured as changes in TT levels within 6 months of initiating CC treatment. Linear regression models adjusted for age, body mass index, and time on CC therapy were fitted to assess the associations between baseline LH and FSH levels with treatment response. RESULTS: A total of 332 men with mean ± standard deviation age of 36.2 ± 8.2 years were included. Median time to initial follow-up was 6 weeks (25th-75th interquartile range [IQR]: 4-9 weeks). TT levels increased significantly on CC treatment (mean change: 329.2 ng/dL, 95% CI: 307.4-351.0) with 73% of men having at least 200 ng/dL increase over baseline TT levels. In univariable linear regression models, only age was significantly associated with TT response. Neither the baseline LH nor FSH significantly predicted TT response in linear regression models. CONCLUSION: CC treatment results in significant increases in testosterone levels in most men. Baseline gonadotropins are not strong predictors for treatment response to CC. Adequate biochemical response with CC trial can be expected in most patients with normal or slightly elevated baseline gonadotropin levels.

The Role of the Urologist in a Reproductive Endocrinology and Infertility Practice.

With male factor infertility accounting for up to 50% of infertility cases, demand for male fertility services has increased. Integrating a reproductive urologist within a fertility center allows for treatment of both partners simultaneously with easier, more convenient access to a comprehensive male evaluation and any indicated interventions. A joint practice allows urologists to collaborate more closely with reproductive endocrinologists, which can, in turn, improve clinical care and research endeavors. This full-service, streamlined approach translates to optimized care for the infertile couple and allows for emphasis of male partner health.

Obesity and Baseline Estradiol Levels Are Independent Predictors for Initiation of Anastrozole in Hypogonadal Men on Clomiphene Citrate.

PURPOSE: To assess the conversion rate from clomiphene citrate (CC) monotherapy to combination CC+anastrozole (AZ) therapy in hypogonadal men and the predictors associated with the initiation of AZ. MATERIALS AND METHODS: A retrospective review of records from hypogonadal men treated with CC in a single fertility center was performed from 2013 to 2018. Patient age, body mass index (BMI), blood pressure, and reproductive hormones were obtained at baseline. Obesity was defined as BMI≥30 kg/m². Cox proportional hazards models were used to identify predictors of switching to combination CC+AZ therapy. RESULTS: A total of 318 men on CC were included. Median (interquartile range) age was 34 years (30-39 years) and patients were followed for a median of 9 months (4-17 months). Of these, 97 (30.5%) were started on CC+AZ therapy. These patients had higher baseline BMI and estradiol, which in multivariable regression were significant predictors for switching to CC+AZ therapy. A threshold of 18.5 pg/mL for baseline estradiol provided the highest accuracy for predicting the addition of AZ after adjusting for baseline BMI and total testosterone levels. CONCLUSIONS: In our practice, following CC monotherapy, 30% of men were initiated on CC+AZ. Obesity (BMI≥30 kg/m²) and baseline estradiol ≥18.5 pg/mL can predict the conversion to combination therapy with addition of AZ. This information can be used to counsel patients and also help to identify patients who can be started on combination therapy upfront.

Impact of paternal age on embryology and pregnancy outcomes in the setting of a euploid single-embryo transfer with ejaculated sperm: retrospective cohort study.

OBJECTIVE: To evaluate the impact of paternal age on embryology and pregnancy outcomes in the setting of a euploid single-embryo transfer. DESIGN: Retrospective cohort study. SETTING: Not applicable. PATIENTS: Couples undergoing a first in vitro fertilization cycle with fresh ejaculated sperm who used intracytoplasmic sperm injection for fertilization followed by preimplantation genetic testing for aneuploidy and single-embryo transfer of a euploid embryo between January 2012 and December 2018. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Embryology outcomes assessed were fertilization rate, blastulation rate, and euploid rate. Pregnancy outcomes assessed included positive human chorionic gonadotropin rate, delivery rate, biochemical loss rate, and clinical loss rate. RESULTS: A total of 4,058 patients were assessed. After adjusting for female age, increased paternal age in the setting of fresh ejaculated sperm use was associated with decreased blastulation and decreased euploid rate using 40 years as an age cutoff. CONCLUSIONS: In this study, advancing paternal age appears to have a detrimental impact on rates of blastocyst formation and euploid status. However, if a euploid embryo is achieved, older paternal age does not appear to affect negatively pregnancy outcomes.

Implementation of a Perioperative Venous Thromboembolism Prophylaxis Program for Patients Undergoing Radical Cystectomy on an Enhanced Recovery After Surgery Protocol.

BACKGROUND: Novel venous thromboembolism (VTE) prophylaxis programs, including postdischarge pharmacologic prophylaxis, have been associated with decreased VTE rates. Such practices have not been widely adopted in managing radical cystectomy (RC) patients. OBJECTIVE: To evaluate the effect of a perioperative VTE prophylaxis program on VTE rates after RC. DESIGN, SETTING, AND PARTICIPANTS: Single-institution, nonrandomized, pre- and post-intervention analysis of 319 patients undergoing RC at Brigham and Women's Hospital between July 2011 and April 2017. Patient and outcome data were prospectively collected as part of the American College of Surgeons National Surgical Quality Improvement Program. INTERVENTION: Before June 2015, patients only received postoperative pharmacologic and mechanical VTE prophylaxis in the inpatient setting. Starting June 2015, a perioperative VTE prophylaxis program was implemented as part of an enhanced recovery after surgery (ERAS) protocol, including a 28-d course of postdischarge enoxaparin. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome was 30-d postoperative VTE rate. Secondary outcomes were perioperative bleeding rates, 30-d complication, readmission, and mortality rates, and length of stay. Univariate analysis was performed comparing outcomes between pre- and post-intervention cohorts. RESULTS AND LIMITATIONS: Of the 319 patients who underwent RC, 210 (66%) were in the pre- and 109 (34%) in the post-intervention cohort. VTE rate was significantly lower in the post-intervention cohort (n=1, 0.9% vs n=13, 6.2%; p=0.04). Rates of perioperative bleeding (35% vs 33%; p=0.80) and 30-d readmissions related to bleeding (1% vs 3.7%; p=0.19) did not differ significantly. Single-institution data limits generalizability, and patient compliance with postdischarge enoxaparin was unknown. CONCLUSIONS: Implementation of a perioperative VTE prophylaxis program as part of an ERAS protocol that includes extended postdischarge pharmacologic prophylaxis was associated with decreased rate of VTE events after RC. Perioperative bleeding and readmissions related to bleeding did not increase with this intervention. PATIENT SUMMARY: This study evaluated whether clotting complication rates after radical cystectomy (RC) for bladder cancer can be reduced by implementing a new postoperative care pathway. This pathway reduced rates of clotting complications without increasing bleeding rates and should be considered for all patients undergoing RC.

Augmentation cystoplasty in the patient with neurogenic bladder.

PURPOSE: To review the indications and techniques of augmentation cystoplasty (AC) in patients with neurogenic bladder (NGB) while also examining the long-term outcomes, complications, and follow-up surgeries. METHODS: PubMed/MEDLINE, Cochrane Library, and Embase databases were searched for articles related to AC and NGB. RESULTS: AC is indicated for an overactive or poorly compliant bladder refractory to conservative therapies, such as anticholinergic medications and bladder botulinum toxin injections. A variety of surgical techniques using gastrointestinal segments, alternative tissues, and synthetic materials have been described, though bowel remains the most durable. Ileocystoplasty is the most common type of AC, which uses a detubularized patch of ileum that is anastomosed to a bivalved bladder. Some patients undergo concomitant surgeries at the time of AC, such as catheterizable channel creation to aid with clean intermittent catheterization, ureteral reimplantation to treat vesicoureteral reflux, and bladder outlet procedure to treat incontinence. Following AC, the majority of patients experience an improvement in bladder capacity, compliance, and continence. Most patients also experience an improvement in quality of life. AC has significant complications, such as chronic UTIs, bladder and renal calculi, metabolic disturbances, bowel problems, perforation, and malignancy. AC also has a high rate of follow-up surgeries, especially if the patient undergoes concomitant creation of a catheterizable channel. CONCLUSIONS: Enterocystoplasty remains the gold standard for AC, though more research is needed to better evaluate the morbidity of different surgical techniques and the indications for concomitant surgeries. Experimental methods of AC with tissue engineering are a promising area for further investigation.

Fertility concerns of the transgender patient.

Transgender individuals who undergo gender-affirming medical or surgical therapies are at risk for infertility. Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear. Gender-affirming surgery (GAS) that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility. It is recommended that clinicians counsel transgender patients on fertility preservation (FP) options prior to initiation of gender-affirming therapy. Transmen can choose to undergo cryopreservation of oocytes or embryos, which requires hormonal stimulation for egg retrieval. Uterus preservation allows transmen to gestate if desired. For transwomen, the option for FP is cryopreservation of sperm either through masturbation or testicular sperm extraction. Experimental and future options may include cryopreservation and in vitro maturation of ovarian or testicular tissue, which could provide prepubertal transgender youth an option for FP since they lack mature gametes. Successful uterus transplantation with subsequent live birth is a new medical breakthrough for cisgender women with uterus factor infertility. Although it has not yet been performed in transgender women, uterus transplantation is a potential solution for those who wish to get pregnant. The transgender population faces many barriers to care, such as provider discrimination, lack of information, legal barriers, scarcity of fertility centers, financial burden, and emotional cost. Further research is necessary to investigate the feasibility of experimental FP options, provide better evidence-based information to clinicians and transgender patients alike, and to improve access to and quality of reproductive services for the transgender population.

Outcomes of right colon continent urinary pouch using standardized reporting methods.

AIMS: Studies of right colon pouch urinary diversion estimate risk of perioperative complications, 1%-50%, and reoperation, 1%-69%. This wide range is due to variable outcome measurements and reporting methods; it is also unclear which factors increase the risk of complications and reoperation. We sought to characterize the impact of patient-specific factors on risk of complications, readmission, and reoperation after right colon pouch urinary diversion. METHODS: Patients undergoing right colon pouch urinary diversion from January 2010 to April 2017 were analyzed. Outcomes included: high-grade complications within 90 days (Clavien-Dindo grade ≥3), readmission within 90 days, and reoperation at any time during follow-up. Patient-specific factors were analyzed to establish any associations with these outcomes. RESULTS: During the study period, 53 patients underwent the procedure and the average follow-up was 30 (standard deviation [SD] 21.5) months; 90-day high-grade complications were 22% and readmission was 45%. The cumulative rate of any reoperation was 53% and major reoperation was 32%. Diabetes was associated with an increased risk of both postoperative complications and reoperation. Larger body mass index and prior abdominal surgery were associated with increased risk of readmission. CONCLUSIONS: Overall the rate of postoperative complications, readmissions, and reoperation was high, but in agreement with other contemporary series. This study helps to further characterize surgical outcomes after right colon pouch urinary diversion, however, similar to other studies in the literature, the rarity of the procedure limits the power to establish a link between preoperative patient factors and outcomes.

Clinical Use of Expanded Prostate Cancer Index Composite for Clinical Practice to Assess Patient Reported Prostate Cancer Quality of Life Following Robot-Assisted Radical Prostatectomy.

PURPOSE: EPIC-CP (Expanded Prostate Cancer Index Composite for Clinical Practice) is a short questionnaire that comprehensively measures patient reported health related quality of life at the point of care. We evaluated the feasibility of using EPIC-CP in the routine clinical care of patients with prostate cancer without research infrastructure. We compared longitudinal patient and practitioner reported prostate cancer outcomes. MATERIALS AND METHODS: We reviewed health related quality of life outcomes in 482 patients who underwent radical prostatectomy at our institution from 2010 to 2014. EPIC-CP was administered and interpreted in routine clinical practice without research personnel. We compared practitioner documented rates of incontinence pad use and functional erections to patient reported rates using EPIC-CP. RESULTS: A total of 708 EPIC-CP questionnaires were completed. Mean urinary incontinence domain scores were significantly higher (worse) than baseline (mean ± SD 0.6 ± 0.2) 3 and 6 months after treatment (mean 3.1 ± 2.3 and 2.2 ± 2.1, respectively, each p <0.05) but they returned to baseline at 12 months (mean 1.6 ± 1.7, p >0.05). Mean sexual domain scores were significantly worse than baseline (mean 2.4 ± 2.8) at all posttreatment time points (each p <0.05). Practitioners significantly overestimated incontinence pad-free rates at 3 months (48% vs 39%) and functional erection rates at 3 months (18% vs 12%), 6 months (38% vs 23%) and 12 months (45% vs 23%, each p <0.05). CONCLUSIONS: EPIC-CP is feasible to use in the routine clinical care of patients with prostate cancer without requiring a research infrastructure. Using EPIC-CP in clinical practice may help practitioners objectively assess and appropriately manage posttreatment side effects in patients with prostate cancer.

Resident Involvement in Radical Inguinal Orchiectomy for Testicular Cancer Does Not Adversely Impact Perioperative Outcomes - A Retrospective Study.

INTRODUCTION: To evaluate perioperative outcomes related to resident involvement (RI) in a large and prospectively collected multi-institutional database of patients undergoing orchiectomy for testicular cancer. MATERIALS AND METHODS: Using current procedural terminology and ICD-9 codes, information about patients with testicular cancer were abstracted from the American College of Surgeons National Surgical Quality Improvement Program database (2006-2013). Multivariable analyses evaluated the impact of RI on outcomes after orchiectomy. Prolonged operative time (pOT) and prolonged length of stay were defined by the 75th percentile (59 min) and postoperative inpatient stay ≥2 days, respectively. RESULTS: Overall, 267 patients underwent orchiectomy either with (38.6%) or without (61.4%) RI. In all, 89.1% of patients underwent an outpatient procedure. The median body mass index was 26.8 and baseline characteristics between the 2 groups were similar. Overall complications, re-intervention, and bleeding-related complication rates were 2.6, 0.7, and 0.4%, respectively. Although there was no difference in terms of overall complications between the groups (3.9 vs. 1.8%; p = 0.44), RI resulted in pOT (32 vs. 19.5%; p = 0.028). In multivariable analyses, RI predicted pOT (OR 1.89, 95% CI 1.06-3.37; p = 0.031), without association with prolonged length of stay and overall complications. CONCLUSIONS: RI during orchiectomy for testicular cancer does not undermine patient safety at the cost of pOT.

The Effect of Resident Involvement on Surgical Outcomes for Common Urologic Procedures: A Case Study of Uni- and Bilateral Hydrocele Repair.

OBJECTIVE: Previous studies have investigated the effect of resident involvement (RI) on surgical complications in minimally invasive and complex surgical cases. This study evaluates the effect of surgical education on outcomes in a simple general urologic procedure, unilateral and bilateral hydrocele repair, in a large prospectively collected multi-institutional database. METHODS: Relying on the American College of Surgeons National Surgical Quality Improvement Program Participant User files (2005-2013), we extracted patients who underwent unilateral or bilateral hydrocele repair using Current Procedural Terminology codes 55040, 55041, and 55060. Cases with missing information on RI were excluded. Descriptive and logistic regression analyses were performed to assess the impact of RI on perioperative outcomes. A prolonged operative time (pOT) was defined as operative time >75th percentile. RESULTS: Overall, 1378 cases were available for final analyses. The overall complication, readmission, and reoperation rates were 2.3% (32/1378), 0.5% (7/1378), and 1.4% (19/1378), respectively. A pOT was more frequently observed in bilateral procedures (35.2% vs 21.3%, P < .0001) and with RI (33.8% vs 19.0%, P < .0001). Procedures with RI had a 2.2-fold higher odds of pOT (95% confidence interval 1.7-2.8, P < .0001). Overall complications (odds ratio 1.1, 95% confidence interval 0.5-2.3) were not associated with RI (P = .789). In sensitivity analyses, all postgraduate years of training were associated with a pOT (P < .0001). CONCLUSION: Although the involvement of a resident in hydrocele repairs leads to higher odds of pOT, it does not affect patient safety, as evidenced by similar complication rates.