Decisional regret and impacts on quality of life following genitourinary reconstruction for neurogenic bladder: A comparison between acquired and congenital spinal cord injury.

INTRODUCTION: Patient expectations and baseline health are important drivers of outcomes following major genitourinary reconstructive surgery for neurogenic bladder (NGB). Differences in expectations and quality of life (QoL) improvements among different populations with NGB remain insufficiently explored in the literature. OBJECTIVE: To compare decisional regret (DR) and urinary-related QoL (UrQoL) in patients undergoing urinary diversion for NGB arising from spinal cord injury of acquired (A-SCI) and congenital (C-SCI) etiologies. We hypothesize that patients with A-SCI have higher expectations of improvement in QoL following surgery when compared with C-SCI, which may lead to higher DR and decreased UrQoL, postoperatively. DESIGN: In this cross-sectional survey study, we compared A-SCI to C-SCI in terms of DR, UrQoL, and postoperative changes in self-reported physical health, mental health, and pain using validated patient-reported outcome measures. SETTING: Participants were enrolled from a quaternary care institution via mail and MyChart. PARTICIPANTS: The A-SCI group consistied of 17 patients with traumatic spinal cord injury the C-SCI group was composed of 20 patients with spina bifida. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Decisional Regret Scale, Short form- Qualiveen (SF-Qualiveen), and Patient-reported outcomes measurement Information system-10 (PROMIS-10) Global Health surveys. RESULTS: The A-SCI group displayed poorer preoperative physical health than the C-SCI cohort, but absolute postoperative changes in this score, along with mental health score and pain level, were not significant after adjusting for baseline scores and follow-up time. SF-Qualiveen scores revealed significantly worse impact of NGB in UrQoL for A-SCI than for C-SCI when adjusted for other factors. No differences in DR were seen between the groups. CONCLUSIONS: Patients with A-SCI demonstrate lower self-reported baseline physical health compared with patients with C-SCI, which may have implications in setting patient expectations when undergoing urinary diversion. In this small cohort, we found a milder self-reported postoperative impact of NGB in UrQoL in patients with C-SCI.

Urology Residency Applicant Selection: Program Directors' New Criteria.

OBJECTIVE: To evaluate the impact of the recent changes to the urology residency application process on the criteria utilized by residency program directors (PDs) for interview invitations and their perspectives concerning these changes. METHODS: One hundred thirty-seven urology residency PDs were invited to participate in an anonymous survey to explore interview selection criteria and the impact of the increase in preference signals (PS) per applicant. RESULTS: Fifty-eight PDs (42.8%) completed the survey. The highest-ranked criteria were letters of recommendation (LoR) and successful sub-internship (sub-I) at the PD's institution, without statistically significant differences between these 2. Gender, ethnicity, and medical school prestige were the lowest rated criteria, without significant differences between these 3. Compared to before the increase in the number of PS per applicant, 80.7% of PDs reported that not receiving a PS from an applicant this cycle would more negatively impact the chances of offering an interview to that applicant. Moreover, 12.2% stated they would not interview any applicants who did not send a PS. Finally, 62.1% of PDs believed recent changes worsened the process. CONCLUSION: Recent changes impacted PDs applicant evaluation, with the highest ranked criteria being LoRs and sub-I. Paradoxically, the increase in the number of PS per applicant has increased their importance as applicants are much less likely to receive interview offers from programs they have not signaled. Lastly, most PDs believe changes have worsened the evaluation process.

Posterior Urethral Reconstruction at the Time of Rectourethral Fistula Repair: Technique and Outcomes.

OBJECTIVE: To assess the impact of posterior urethral stenosis or defect on outcomes following rectourethral fistula (RUF) repair, we present a cohort of 23 men who underwent posterior urethroplasty concurrent with RUF repair. METHODS: We identified 130 men who underwent RUF repair at our institution between 2003 and 2021. Of these, 23 (18%) underwent simultaneous posterior urethroplasty. Fifteen men received prior radiation for prostate cancer. Of the 8 men who were not radiated, 4 had a history of radical prostatectomy, 2 pelvic trauma, and 3 inflammatory bowel disease. All 23 men underwent fecal diversion prior to surgery (median, 6 months preoperatively), and 20 men suprapubic catheter placement (median, 5.5 months preoperatively). RESULTS: RUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). Intraoperatively, 20 men (87%) had urethral stenosis, and 3 (13%) had significant urethral defects due to cavitation and tissue loss. There was stenosis/stricture involving the prostatomembranous urethra in 18 cases (78%) and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (78%) and using a buccal mucosal graft in 5 (22%). Gracilis flap interposition was performed in 21 cases (91%). At a median follow-up of 55.7 months (interquartile range (IQR), 23-82 months), 20 men (87%) had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. Fourteen men (61%) reported postoperative urinary incontinence, with 7 (30%) ultimately undergoing artificial urinary sphincter placement. There were no isolated stricture recurrences requiring instrumentation. CONCLUSION: Posterior urethral stenosis associated with RUF complicates an already challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis or defect.

Diversity Attracts Diversity: 2023 AUA Match Results.

OBJECTIVE: To assess the rationale behind the choice of programs for preference signaling (PS) and subinternships by urology applicants in the 2023 cycle. METHODS: We emailed an anonymous, multiple-choice survey to the 403 prospective candidates who applied to our institution for the 2023 Urology Residency Match. RESULTS: 121 applicants (30.0%) responded to the survey. 81.8% were in favor of the continuation of PS, with 4.1% against it. When choosing where to PS or subinternship, geographic location and perceived quality of clinical training were the highest-ranked criteria. Racial/ethnic diversity of the residents influenced PS or subinternship choice for 77.8% of Black, 72.7% of Asian, 57.1% of Latinos, and 46.5% of White respondents (P < .05 for Black and Asian vs White). Institutional statements on diversity influenced PS or subinternship choice for 88.9% of Black, 55% of Asian, 64.3% of Latino, and 25.4% of White respondents (P < .05 for Black, Asian and Latino vs White). Females had an increased likelihood of PS or choosing subinternship programs with gender diversity of residents (81.6% vs 33.8, P = .002). A program with PS was associated with a 2.74 increase in likelihood of obtaining an interview compared to programs that were not PS. Of 107 matched applicants, 47.5% matched at a program where they completed a subinternship, and 25.7% matched at a signaled program. CONCLUSION: PS plays a major role in the match process. When choosing where to PS, applicants prioritize geographic location and perceived quality of training. Diversity of residents plays a major role in recruiting diverse applicants.

Management and Outcomes of Ileal Pouch-Urethral Fistulas.

OBJECTIVE: To describe a single-center experience with the management of ileal pouch-urethral fistulas (IPUF) following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS: We retrospectively identified patients with documented IPUF managed at our institution from a urethral fistula cohort and analyzed their cases. RESULTS: Thirteen patients who underwent surgeries for IPUF management from 2005-2022 were identified. Median age at IPAA was 29 years (range 11-53). Indications for IPAA included familial adenomatous polyposis (n=3) and ulcerative colitis (n=10). Median time from IPAA to fistula diagnosis was 15 years (range 0.5-38.5). Eleven patients were initially diverted with either loop (n=8) or end ileostomy (n=3). Overall, two patients had resolution of IPUF symptoms with a loop ileostomy alone and eight eventually underwent pouch excision with end ileostomy, one of which subsequently underwent redo IPAA. Seven patients were managed with primary closure of the urethral defect at the time of pouch excision, five of which also underwent gracilis muscle interposition. With a median follow-up of 4 years (range 0.3-13 years), all patients had resolution of their fistulae without any recurrences. CONCLUSION: IPUFs are a rare complication after IPAA. In this cohort, all patients had their urinary tract preserved, but most ultimately had permanent fecal diversion. These results can help guide management of this complex issue.

Preference Signaling and Virtual Interviews: The New Urology Residency Match.

OBJECTIVE: To define applicant response to the preference signaling program and continuing virtual aspects of the 2022 Urology Residency Match to guide future decisions surrounding this process. METHODS: We emailed an anonymous, de-identified 20-question, multiple choice survey to all applicants to our institution for the 2022 Urology Residency Match (RedCap). Where appropriate, comparisons were made to already published data collected in an identical manner from applicants to our institution for the 2021 Urology Residency Match. RESULTS: Of the 418 survey recipients, 155 (37%) responded to our survey. A majority of applicants (83%) thought that preference signaling should remain in future years, and 66% of applicants matched to a program to which they had signaled or where they completed a subinternship. Geographic location of programs was ranked to have the highest impact on choice of programs for preference signaling. Fifty-two percent of 2022 applicants thought that interviews should remain virtual compared with 39% of 2021 applicants (P = .03). Twenty-one percent of 2022 applicants agreed that pre/post-interview socials were well-replicated virtually compared with 10% of 2021 applicants (P = .04). CONCLUSION: A majority of urology applicants were satisfied with the preference signaling program, suggesting that preference signaling should remain in future matches. A majority of urology applicants now favor the virtual interview platform. While it is gaining greater acceptance among applicants, the virtual platform generally still carries deficiencies. Further research of the urology match process is necessary for continued optimization of the program for all stakeholders.

Twitter and Instagram Use in the Urology Residency Application Process.

OBJECTIVE: To define urology applicant attitudes and usage trends of social media (SM) during the 2021 urology match cycle. METHODS: We emailed an anonymous, de-identified 22-question, multiple choice survey to all applicants to our institution for the 2021 Urology Residency Match. We asked participants about use of SM and which aspects they found useful in the application process. Univariate descriptive analyses were conducted based on survey responses. Chi-square analyses were performed to define significant differences in use of social media and resultant match outcomes. RESULTS: Of the 528 students who registered for the 2021 AUA Match, 398 received our survey (75%), and 144 responded (27% of applicants nationwide). Of survey participants, 49% made a new account on Twitter while 30% had a preexisting account. Most participants (71%) had a preexisting Instagram account, while only 3% made a new account. Most participants agreed Twitter was used as a source to gather information about programs (84%) and learn about events (89%). Participants found SM most helpful for announcing event dates (71%) and highlighting resident social life (59%). Applicants did not match more highly on their rank lists if they used Twitter (P = .427) or Instagram (P = .166) and were not more likely to get more interviews if they used Twitter (P = .246) or Instagram (P = .114) CONCLUSION: Applicants found Twitter to be an important source of information through the virtual interview process. Despite the use of SM by most applicants, published content did not impact rank list decisions nor did SM engagement predict match outcomes.

Perineal groove: Case report.

We report the case of a newborn female with a perineal groove and review the limited literature. This is a rare congenital midline malformation of the perineal raphe with no data driven management strategies available. Our patient was managed conservatively with topical Vaseline application. At 52 days of life, her perineal groove was about 50% resolved, and at 9 months of age, it was barely perceptible. She maintained normal urinary function without evidence of infection or discomfort. We recommend this strategy for initial management of perineal grooves that have not had any symptoms or complications attributable to the condition.

Plication for Correction of Congenital Penile Curvature: With or Without Degloving?

INTRODUCTION: Previously, incisionless plication (IP) for correction of congenital penile curvature (CPC) has been performed after penile degloving via a circumscribing incision. AIM: To describe our experience with non-degloving incisionless penile plication (NDIP) for correction of CPC and compare these outcomes with those of men who underwent degloving incisionless penile plication (DIP). METHODS: We conducted a retrospective review of men ≤ 45 years of age who underwent incisionless penile plication for correction of CPC between 2008 and 2020 at two adult tertiary hospitals. Patients underwent either NDIP, performed through a 2-3 cm longitudinal incision along the proximal-to-mid shaft opposite the point of maximum penile curvature, or DIP via a sub-coronal circumscribing incision. MAIN OUTCOME MEASURES: Surgical and patient-reported outcomes were compared between the non-degloving and degloving groups. RESULTS: Among the 38 men (mean age, 26 years) who met the inclusion criteria, 25 underwent NDIP, including 6 patients with biplanar curvature (2 Ventral, 4 Dorsal, 6 Lateral). Thirteen patients underwent DIP, including 1 patient with biplanar curvature (1 ventral, 1 lateral). Curvature reduction was 50 ± 23 degrees for the NDIP group and 36 ± 10 degrees for the DIP group (P = .04). Five (20%) patients in the NDIP group and nine (69%) patients in the DIP group experienced a reduction in stretched penile length following plication (SPL) (P = .01). One patient in the NDIP group underwent an additional plication for recurrent curvature. CONCLUSION: Both NDIP and DIP are safe and highly efficacious techniques for the correction of CPC. Kusin SB, Khouri RK, Dropkin BM, et al., Plication for Correction of Congenital Penile Curvature: With or Without Degloving?. Sex Med 2021;9:100462.

The Virtual Urology Residency Match Process: Moving Beyond the Pandemic.

OBJECTIVES: To define applicant response to the 2021 Urology Residency Match Process in the COVID-19 Pandemic and to extrapolate lessons to optimize the urology resident selection process after the pandemic. METHODS: We emailed an anonymous, de-identified 22-question, multiple choice survey to all applicants to our institution for the 2021 Urology Residency Match, including a summary of the study with a survey link (RedCap). RESULTS: Of the 398 survey recipients, 144 responded (36%). Even if the match process were not limited by COVID-19, 39% of applicants thought interviews should remain in virtual format, 23% said "no," and 30% said "not sure." Nearly all applicants (97%) thought all interview offers should be released on the same day. Regarding the early match, 84% thought this should remain. When asked what factors had the most impact on rank lists, faculty and resident interviews were overwhelmingly favored. Open houses and resident "happy hours" were less important. Most applicants agreed that the faculty and resident interviews and informational talks were adequately replicated on the virtual platform. A majority of applicants (65%) spent under $2000 for the application cycle. CONCLUSION: The COVID-19 pandemic dramatically changed the urology match process. The faculty and resident interviews remained the most important factors in program ranking, and most applicants agreed those were adequately replicated in the virtual format. A plurality of applicants felt that the interview process should remain virtual in a post-COVID-19 environment. The virtual application cycle reduced the cost of applying to residency.

Male stress urinary incontinence is often underreported.

INTRODUCTION Patient-reported pads per day use is a widely used metric in grading the severity of stress urinary incontinence and guiding surgical decision-making, particularly in mild-to-moderate cases. We sought to compare patient-reported stress urinary incontinence severity by pads per day with objective findings on standing cough test. We hypothesize that patient-reported pads per day often underestimates stress urinary incontinence severity. MATERIALS AND METHODS: We retrospectively reviewed our male stress urinary incontinence surgical database and identified 299 patients with self-reported mild-to-moderate stress urinary incontinence who were evaluated with standing cough test prior to surgical intervention between 2007 and 2019. Patients were evaluated with the Male Stress Incontinence Grading Scale for urinary leakage during a standing cough test. This test has been shown to reliably and accurately predict surgical success. Binary logistic regression analysis was used to identify parameters associated with stress urinary incontinence upgrading in a multivariable model. RESULTS: Among 299 patients with reported mild-to-moderate stress urinary incontinence, 101 (34%) were upgraded to severe stress urinary incontinence by standing cough test. Prior stress urinary incontinence surgery (OR 4.1, 95% CI 2.0-8.0, p < 0.0001) and radiation (OR 3.2, 95% CI 1.7-5.7, p < 0.0001) were significantly associated with Male Stress Incontinence Grading Scale upgrading in multivariable analysis. CONCLUSIONS: Roughly one-third of men who report mild-to-moderate stress urinary incontinence actually have severe incontinence observed on physical examination. All men being evaluated for stress urinary incontinence should undergo standing cough test to accurately grade incontinence severity and guide surgical management.

Artificial Urinary Sphincter Complications: Risk Factors, Workup, and Clinical Approach.

PURPOSE OF REVIEW: To review risk factors for AUS complications and present a systematic approach to their diagnosis and management. RECENT FINDINGS: Established risk factors for AUS complications include catheterization, channel TURP, pelvic radiation, urethroplasty, anticoagulation, cardiovascular disease, diabetes mellitus, frailty index, hypertension, low albumin, and low testosterone. We present our algorithm for diagnosis and management of AUS complications. Despite being the gold standard of treatment for men with SUI, major and minor complications can occur at any point after AUS insertion. Careful consideration of the urologic, medical, and operative risk factors for each patient can help prevent complications. A systematic approach to early and late complications facilitates their identification and effective management. The evaluating urologist must have a thorough understanding of potential AUS complications in order to restore quality of life in men with bothersome SUI.

Mechanotransduction in Wound Healing: From the Cellular and Molecular Level to the Clinic.

GENERAL PURPOSE: To review the various mechanical forces that affect fibroblasts, keratinocytes, endothelial cells, and adipocytes at the cellular and molecular level as well as scar-reducing mechanical devices currently in clinical use. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Compare and contrast the responses of various types of cells to mechanical forces.2. Identify the mechanical devices and techniques that can help restore skin integrity.

Skin provides a critical protective barrier for humans that is often lost following burns, trauma, or resection. Traditionally, skin loss is treated with transfer of tissue from other areas of the body such as a skin graft or flap. Mechanical forces can provide powerful alternatives and adjuncts for skin replacement and scar modulation. This article first provides an overview of the various mechanical forces that affect fibroblasts, keratinocytes, endothelial cells, and adipocytes at the cellular and molecular level. This is followed by a review of the mechanical devices currently in clinical use that can substantially augment the restoration of skin integrity and reduce scarring. Methods described include tissue expanders, external volume expansion, negative-pressure wound therapy, and skin taping.

Assessing the Female and Underrepresented Minority Medical Student Experience in the Urology Match: Where Do We Fall Short?

OBJECTIVE: To better understand the experiences of female and underrepresented minority (URM) medical students pursuing urology and determine if discrimination was perceived at any point during the application process. METHODS: After the rank list submission deadline (January 2, 2020), we emailed an anonymous survey to all 353 applicants to our institution for the 2020 AUA Residency Match (80.0% of applicants nationally). The survey inquired about their experiences pursuing urology and the residency match process. Ordinal regression models were used to identify any significant predictors of survey responses. RESULTS: One hundred ninety applicants (136 male [72%], 54 female [28%]) completed the survey. A significantly higher percentage of females vs males noted discrimination (odds ratio: 2.53; confidence interval: 1.37-4.74, Fig. 1). URM students also reported higher frequencies of discrimination than non-URM students (odds ratio: 2.27; confidence interval: 1.07-4.83). Thirty-two percent of respondents tested positive on the Maslach Burnout Inventory; we did not identify any predictors of burnout. Higher proportions of female residents, faculty and leadership at a particular program had a more favorable impact on the rank lists of female applicants compared with males. Higher proportions of URM residents, faculty and leadership at a particular program had a more favorable impact on the rank lists of URM applicants compared with non-URM. CONCLUSION: Our collective findings suggest that URM and female medical students have less favorable experiences interacting with urology trainees and faculty than do their nonminority and male counterparts. Higher percentages of female and URM urology residents and faculty promote effective recruitment of female and URM applicants.

Extended Primary Anastomosis With Penile Plication (EPAPP): A Promising New Alternative to Perineal Urethrostomy for Reconstruction of Long Urethral Strictures.

OBJECTIVE: At present, excision and primary anastomosis (EPA) urethroplasty is a highly reliable method of reconstruction for short bulbar urethral strictures. Longer strictures are often managed with grafting techniques to ensure a tension-free repair. Here we report our initial experience with a new, extended anastomotic technique for long bulbar strictures that incorporates plication of the ventral corporal bodies to reduce the distance between the urethral ends and obviates the need for grafting. METHODS: We reviewed records for all urethroplasties performed by a single surgeon at our institution between January 2018 and February 2020. We identified a cohort of older patients with complex strictures who underwent Extended Primary Anastomosis with Penile Plication (EPAPP). Patient demographics, stricture characteristics, perioperative 75 parameters, and postoperative outcomes were evaluated. RESULTS: Of 346 urethroplasty records reviewed, 10 patients (2.9%) underwent EPAPP. Mean stricture length was 3.75 ± 1.4 cm. EPAPP patients were older than those repaired by other techniques (mean age 66.6 vs 55.6, P = .024), and most were not sexually active preoperatively. Postoperative voiding cystourethrogram confirmed urethral patency without extravasation in all patients. At a median follow up of 9.7 months (IQR 8.5-11.5) 8 patients remained asymptomatic after EPAPP alone and 2 patients required a single balloon dilation for stricture recurrence. CONCLUSION: EPAPP is a promising alternative option for the management of long bulbar strictures among appropriately selected patients.

Standing cough test stratification of moderate male stress urinary incontinence.

PURPOSE: Patient-reported history of pads per day (PPD) is widely recognized as a fundamental element of decision-making for anti-incontinence procedures. We hypothesize that SUI severity is often underestimated among men with moderate SUI. We sought to compare patient history of incontinence severity versus objective in-office physical examination findings. MATERIALS AND METHODS: We retrospectively reviewed our single-surgeon male SUI surgical database from 2007-2019. We excluded patients with incomplete preoperative or postoperative data and those who reported either mild or severe SUI, thus having more straightforward surgical counseling. For men reported to have moderate SUI, we determined the frequency of upgrading SUI severity by recording the results of an in-office standing cough test (SCT) using the Male Stress Incontinence Grading Scale (MSIGS). The correlation of MSIGS with sling success rate was calculated. Failure was defined as >1 PPD usage or need for additional incontinence procedure. RESULTS: Among 233 patients with reported moderate SUI (2-3 PPD), 89 (38%) had MSIGS 3-4 on SCT, indicating severe SUI. Among patients with 2-3 PPD preoperatively, sling success rates were significantly higher for patients with MSIGS 0-2 (76/116, 64%) compared to MSIGS 3-4 (6/18, 33%) (p <0.01). CONCLUSIONS: Many men with self-reported history of moderate SUI actually present severe SUI observed on SCT. The SCT is a useful tool to stratify moderate SUI patients to more accurately predict sling success.

Explantation of High Submuscular Reservoirs: Safety and Practical Considerations.

BACKGROUND: Over the past decade, high submuscular (HSM) placement of inflatable penile prosthesis (IPP) reservoirs has emerged as a viable alternative to space of Retzius (SOR) placement; however, data comparing the feasibility and complications of HSM vs SOR reservoir removal do not presently exist. AIM: To present a comparison of the safety, feasibility, and ease of removal of HSM vs SOR reservoirs in a tertiary care, university-based, high-volume prosthetic urology practice. METHODS: Data were retrospectively collected on patients who underwent IPP reservoir removal between January 2011 and June 2020. Cases were separated into 2 cohorts based on reservoir location. Statistical analysis was performed using Fisher's exact and Chi-squared tests for categorical variables and Student's t-test for continuous variables. Timing from IPP insertion to explant was compared between the HSM and SOR groups using the Mann-Whitney U test. OUTCOMES: Time from IPP insertion to explant, operative time, intraoperative and postoperative complications, and need for a counter incision were compared between the HSM and SOR groups. RESULTS: Between January 2011 and June 2020, 106 (73 HSM, 33 SOR) patients underwent IPP removal or replacement by a single surgeon at our institution. Average time from IPP insertion to removal was 43.6 months (24.2 HSM, 52.7 SOR, P = .07)-reservoir removal occurred at the time of device explant in 70 of 106 (66%) cases. More HSM reservoirs were explanted at the time of IPP removal compared with the SOR cohort (54 of 73, 74% HSM vs 16 of 33, 48.5% SOR, P = .01). Similar rates of complications were noted between the HSM and SOR groups (1.9% vs 6.3%, P = .35). There was no significant difference in need for counter incision between the 2 groups (24 [42%] HSM vs 4 [25%] SOR, P = .16) or in average operative times (76.5 ± 38.3 minutes HSM vs 68.1 ± 34.3 minutes SOR, P = .52). CLINICAL IMPLICATIONS: Our experience with explanting HSM reservoirs supports the safety and ease of their removal. STRENGTHS AND LIMITATIONS: Although the absolute cohort size is relatively low, this study reflects one of the largest single-institution experiences examining penile implant reservoir removal. In addition, reservoir location was not randomized but was instead determined by which patients presented with complications necessitating reservoir removal during the study period. CONCLUSIONS: HSM reservoir removal has comparable perioperative complication rates and operative times when compared with SOR reservoir removal. Kavoussi M, Bhanvadia RR, VanDyke ME, et al. Explantation of High Submuscular Reservoirs: Safety and Practical Considerations. J Sex Med 2020;17:2488-2494.