Racial and Ethnic Disparities in Pelvic Organ Prolapse Surgery in the United States: An Analysis of the ACS-NSQIP Clinical Registry.

OBJECTIVE: To assess the types of POP surgery performed and patients' morbidity and mortality according to race and ethnicity in the United States. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified patients who had undergone POP procedures and stratified them by race and ethnicity. We compared differences in patient's baseline comorbidities and distribution of POP repairs performed. We further evaluated racial and ethnic disparities concerning complications, readmissions, reoperations, and mortality rates by performing univariate and multivariate analyses. RESULTS: From 2012-2017, we identified 50,561 patients who underwent a primary POP repair procedure. The majority of patients were white (89.8%), followed by blacks (5.5%), and others (4.7%). Hispanics made up only 11.2% of the cohort. Black and Hispanic patients were younger, had higher BMI and suffered from a higher number of comorbidities than their white counterparts. There were significant differences in the types of POP procedures performed according to race and ethnicity. Despite no significant differences noted in overall complication rates, the types of complications varied by race and ethnicity. Neither race nor ethnicity was a significant predictor of reoperation or mortality. CONCLUSION: There are notable racial and ethnic disparities in patients' comorbidities and types of POP repairs performed among women undergoing POP surgery in the United States. Although black patients are at a higher risk for readmission, there were no observed differences in complication, reoperation, or mortality rates according to race and ethnicity.

Evaluation of Quality of Life After Inflatable Penile Implantation and Analysis of Factors Influencing Postsurgery Patient Satisfaction.

BACKGROUND: Most of the published literature addressing the satisfaction postinflatable penile implant (IPP) placement includes non-validated surveys. AIM: The study aims to report the survey outcomes of the English version of The QoLSPP and to evaluate the different factors that could influence these results. METHODS: Patients who underwent inflatable penile implant placement from January 2017 to December 2019 received a survey by phone and had a visit scheduled no sooner than 27 months after surgery. In the clinic, they were inquired about the penile size and underwent measurements of postoperative penile length and diameter. The survey responses were rated from zero to 5 following QoLSPP, and answers ≥3 were considered positive. An evaluation of the factors influencing the quality-of-life score of patients post-IPP placement was performed. Variables included age (<60, 60-70, >70), BMI classification, Charlson Comorbidity Index, diabetes diagnosis, implant type (AMS 700CX vs Titan), ED etiology, revisions, postoperative time in months (<30, 30-40, >40) and preoperative vs postoperative penile dimensions in those who attended the clinic. OUTCOMES: The primary outcome was to obtain accurate patient-reported satisfaction after inflatable penile implantation. RESULTS: Within the timeframe, 542 patients underwent first-time IPP placements. Of that group, 322(n) completed the surveys, and 109 patients attended the clinic to compare preoperative vs postoperative dimensions. Of note, 67 (61.4%) and 54 (49.4 %) demonstrated enlargement in length and diameter, respectively. Conversely, 12 (11%) and 4 (3.7%) experienced a shortening in length and girth. We found 66 (60.5%) patients who complained about a penile size decrease after the intervention. The survey had a positive response in 93.1% of the cases. There were no statistically significant differences in positive responses concerning the variables investigated. The subpopulation analysis of the penile-sized group neither showed response variations. CLINICAL IMPLICATIONS: The investigation allowed a better understanding of patient-reported satisfaction post-IPP placement. STRENGTHS & LIMITATIONS: The performance of all the procedures in a high-volume center by a single surgeon limits its generalization. CONCLUSION: The overall results after IPP surgery are positive in most patients who underwent the procedure and the variables investigated did not influence the overall outcomes of the QoLSPP survey in the study. Luna E, Rodriguez D, Barrios D, et al. Evaluation of Quality of Life After Inflatable Penile Implantation and Analysis of Factors Influencing Postsurgery Patient Satisfaction. J Sex Med 2022;19:1472-1478.

Permanent Deactivation of Inflatable Penile Prosthesis via Puncture.

OBJECTIVE: To describe our technique and early results for inflatable penile prosthesis (IPP) deactivation via puncture and drainage in the office setting to avoid penile explanting interventions in high-risk surgical patients. METHODS: A retrospective chart review of patients with high perioperative risk who had undergone IPP prosthesis puncture in the office setting between March 2020 and May 2021 was performed. Variables included age, the reason for penile prosthesis implantation and deactivation, time frame from implantation to deactivation, type of penile implant, follow-up time, and complications. Clinical information and procedural consent from patients with mental impairment were obtained from caretakers or legal guardians. RESULTS: In all the cases, the implants were in a good position and cycled well without difficulty before undergoing the drainage. Ten patients underwent the deactivation procedure, with ages ranging from 81 to 93 years old (mean 88 ± 3.74), 9 cases had a dementia diagnosis, and 1 case of penile implant aversion. Mean follow-up was 8.4 months ± 2.3, and there were no reported complications during the follow-up period. CONCLUSION: Permanent deactivation of IPP via in-office puncture and drainage represents a safe, feasible, and reliable option for those patients with multiple comorbidities and caretakers who desire removal of normally cycling, well-positioned, and uninfected penile implants. We strongly recommend all our patients with severe cognitive decline have their implants devices punctured to prevent any potential complications.

Would Surgeons Opt for Polypropylene Mesh if They Hypothetically Had Stress Urinary Incontinence or Pelvic Organ Prolapse?

INTRODUCTION: Mesh is routinely used to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP). However, its use remains controversial. The FDA (U.S. Food and Drug Administration) ultimately deemed mesh use for SUI and transabdominal POP repair acceptable, while cautioning against transvaginal mesh for POP repair. The objective of this study was to evaluate personal opinions regarding mesh use among clinicians who routinely treat POP and SUI if they themselves were to hypothetically have either condition. METHODS: A nonvalidated survey was sent to the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) members, and American Urogynecologic Society (AUGS) members. The questionnaire asked participants if they were to hypothetically have SUI/POP which treatment they would elect. RESULTS: A total of 141 participants completed the survey (20% response rate). A significant proportion preferred synthetic mid urethral slings (MUS) for SUI (69%, p <0.001). Surgeon volume was significantly associated with MUS preference for SUI in both univariate and multivariate analyses (OR 3.21 and 3.67, p <0.003). A significant proportion of providers preferred transabdominal repair or native tissue repair for POP (27% and 34% respectively, p <0.001). Private practice was significantly associated with transvaginal mesh preference for POP in univariate analysis but not multivariate analysis (OR 3.45, p <0.04). CONCLUSIONS: The use of mesh for SUI and POP has been controversial, leading to the FDA, SUFU and AUGS statements on synthetic mesh use. Our study found that the majority of SUFU and AUGS members who regularly perform these surgeries prefer MUS for SUI. Preferences regarding POP treatments varied.

Urology Program Directors' Perception of Pregnancy During Residency.

OBJECTIVE: To assess urology program directors' (PDs) perception of pregnancy during residency training. METHODS: A 30 question anonymous survey was sent to 142 urology PDs regarding their demographics, program information, institution policies, and self-reported opinions. Results were assessed via descriptive analysis. RESULTS: A total of 63 PDs responded with a response rate of 44%: 19% were female, 73% between 40 and 59 years of age, and 91% had children. A minority (17%) of programs had 40% or more female residents. 37% of PDs had never had a pregnant resident during their time as PD while 57% had 1 to 5 pregnant residents. On multivariate analysis, PDs age > 60 years or PD having their first child when > 30 years old were predictors for poor support of maternity leave. The majority of PDs felt their program was better/much better at being supportive toward maternity leave compared to other surgical specialties at their institution. Only 21% of PDs felt that taking maternity leave burdened other residents unfairly. Of respondents, 62% felt prepared/completely prepared to advise residents on pregnancy during residency. However, 91% of PDs affirmed it would be helpful to have formal policies in place regarding maternity/paternity leave. CONCLUSION: While the majority of PDs do not have a negative perception of pregnancy during residency, a small portion feels that pregnancy during residency is a burden on other residents. More than half of PDs feel prepared to discuss this issue with their residents. However, a large majority would find formal policies helpful.

Bladder neck and urethral erosions after Macroplastique injections.

AIMS: To evaluate the presentation, risk factors, diagnostic workup, management, and outcomes of Macroplastique (MPQ) erosions. METHODS: We performed a retrospective chart review of women experiencing MPQ erosion at two tertiary care centers (United States and United Kingdom). Data collected included age, presenting symptoms, parity, comorbidities, hormone replacement therapy, sexual activity, and smoking status. Previous surgical history, time from MPQ injection, urine culture results, and cystoscopic and imaging findings were also reviewed. Development of stress urinary incontinence (SUI) after MPQ removal and subsequent SUI treatments were recorded. RESULTS: From 2012 to 2018, 18 patients were identified with a median follow-up time of 24 months (interquartile range [IQR] 8-33). All patients presented with recurrent urinary tract infections (rUTI) and had cystoscopic evidence of MPQ erosion. The most common location of erosion was the bladder neck area (72%). Median time to presentation since MPQ injection was 14 months (IQR 11-35). The majority of patients (72%) had a previous history of anti-incontinence surgery. The overall success rate of endoscopic management defined as resolution of presenting symptoms including rUTI was 80%. The majority of patients (80%) developed recurrent SUI following MPQ resection with 33% requiring a subsequent autologous fascial sling placement. CONCLUSION: MPQ erosions present predominantly with UTI, sometimes years after the original injection, and may necessitate endoscopic management with satisfactory results in most patients. Following excision of MPQ, these patients are highly likely to experience SUI recurrence and need to be appropriately counseled. Some may require additional subsequent autologous fascial sling placement for treatment of their SUI symptoms.

Postoperative penile prosthesis pain: is it worse in diabetic patients?

Inflatable penile prosthesis (IPP) surgery is an effective, safe and satisfactory treatment option for medication-refractory erectile dysfunction. Postoperative complications include infection, mechanical failure, erosion, and pain. Current literature suggests the need for a better approach to postoperative pain management after IPP surgery. Clinical studies have demonstrated that postoperative pain is different in diabetic patients. We sought to determine if there is a difference in pain after IPP placement in diabetics. This is a single-institution retrospective review. The main outcome measure was the number of 30-day postoperative visits for pain. The secondary outcome included differences in how pain was managed. The top HbA1c quartile was compared with the other HbA1c quartiles. Diabetes was present in 92 (54.4%) patients and 96% of these had HbA1c > 8. Significant postoperative pain was more common in patients with HbA1c > 8 (41% vs 13%, p = 0.047) and resulted in more unplanned visits (27% vs 11%, p = 0.042). Patients with HbA1c > 8 with significant postoperative pain were more likely to be managed with opioids and gabapentin (30% vs 14%, p = 0.05). There were no statistical differences in age between diabetics and non-diabetics (mean 59 vs 61, p = 0.193). Hispanic and African-American patients represented 87% of the poorly controlled diabetics compared with only 13% of white patients (p < 0.001). Poorly controlled diabetics had more medical comorbidities (p < 0.001). On logistic regression, a HbA1c > 8 was predictive of an unplanned visit for pain with an OR of 2.83 (p = 0.04). Significant pain after IPP surgery was higher in diabetics with HbA1c > 8, which resulted in more unplanned 30-day postoperative visits. Patients with significant postoperative pain were managed with a combination of opioids and gabapentin. Future studies are required to optimize pain management in diabetics following IPP placement.

Cadaveric Laboratory Simulation Training of Male Stress Urinary Incontinence Treatment Improves Trainee Knowledge and Confidence.

OBJECTIVE: To assess whether a focused, simulation training course can improve trainee surgical knowledge and confidence in the treatment of male stress urinary incontinence. MATERIALS AND METHODS: Urology residents participated in a prosthetic education course as part of the 2018 SUPS and SMSNA annual meeting. The course included didactic lectures and a hands-on cadaveric laboratory. Participants completed questionnaires before and after the lab (2 weeks and 6 months) to assess procedural knowledge and confidence. Analysis of lab responses was performed using the Wilcoxon signed rank test for matched pairs. RESULTS: Thirty-two residents (median age 29, range 27-34) participated in the course. The majority were postgraduate year 4 (63%) or postgraduate year 5 (20%). Most participants reported minimal AUS or sling experience with 50% and 94% reporting less than 5 cases, respectively. Overall score from the knowledge assessment improved significantly between the pre-lab versus 2-week post-lab (P = .02) and pre-lab versus 6-month post-lab (P = .01). Similarly, procedural confidence improved between pre-lab vs 2-week post-lab (P < .001) and pre-lab versus 6-month post-lab (P < .001). Knowledge and confidence assessments were not different between year of residency training or pre-lab experience. CONCLUSIONS: Simulation training improves knowledge and confidence in prosthetic surgery for male stress incontinence. In the current climate of reduced exposure and limited availability of prosthetic educators, simulation courses can provide much needed educational value.

Single-Port Robotic-Assisted Laparoscopic Sacrocolpopexy With Magnetic Retraction: A Video Demonstration.

BACKGROUND: Abdominal sacrocolpopexy is the gold standard for treatment of apical prolapse.1 Minimally invasive surgery offers many advantages over the open approach, including incision size, blood loss, postoperative pain while maintaining similar long-term outcomes.2,3 OBJECTIVE: To assess the safety and feasibility of performing a magnetic-assisted single-port robotic sacrocolpopexy (MARS). MATERIALS: Prior to surgery, a magnetic controller was secured to the surgical bed. The Hassan technique was used to place a 25 mm SP port through a single 2.5 cm supra-umbilical incision. A 12 mm assistant port was placed 10 cm lateral to the SP port on the right side, this additional trocar placement may be obviated by using a gel-point for both ports. The SP robot was docked on the right side of the bed. The magnet was clipped onto the sigmoid mesentery and the outer magnet was repositioned to retract the sigmoid laterally. The sacral promontory was exposed, and the peritoneal incision was carried down to the vagina. The magnet was repositioned, and the bladder was reflected off the anterior vagina. The posterior dissection was carried out to reveal the posterior vagina. "Y" mesh was placed, appropriately tensioned, secured to the sacral promontory and retroperitonealized. Cystoscopy was performed. The magnet was removed from the sigmoid colon, and all incisions were closed. RESULTS: A 66-year-old G2P2 female, BMI 25, status-post prior abdominal hysterectomy presented with symptomatic stage IV prolapse. Surgery was uneventful with an operative time of 247 minutes and an estimated blood loss of 10cc. The patient was discharged the following day. At 3 months postoperatively, she had anatomic and symptomatic resolution of her prolapse. CONCLUSION: Using magnetic assistance, MARS can be offered to women who want a durable option for prolapse repair with improved cosmesis compared to conventional methods and may offer cosmetic benefits when paired with a concurrent hysterectomy.

Outcomes of Macroplastique injections for stress urinary incontinence after suburethral sling removal.

INTRODUCTION: To evaluate outcomes following urethral Macroplastique (MPQ) injection in women with stress urinary incontinence (SUI) following suburethral sling removal (SSR) for synthetic sling complications. METHODS: Following Institutional Review Board approval, charts of non-neurogenic women with SUI after SSR who underwent MPQ injection(s) and had at least 6 months minimum follow-up were reviewed from a prospectively maintained database. Demographic data, questionnaire (Urogenital Distress Inventory-6 [UDI-6] and Quality of Life) scores, and pad usage were recorded. Patients were followed with repeat questionnaires and three-dimensional ultrasound evaluating MPQ volume. Success following MPQ was defined as a composite score of a UDI-6 question 3 score of 0 to 1 at last visit and no additional anti-incontinence therapy. RESULTS: From 2011 to 2018, 70 women with mean age 62.7 years met study criteria. At a mean follow-up of 46.4 ± 1.5 months, the success rate after the first MPQ injection was 46%. Following a repeat MPQ injection when indicated, the overall success rate for the entire cohort was 69%. Despite the objective failure, the majority of patients reported subjective improvement (83%) and reduced pad usage (78%). On multivariate analysis: age, body mass index, previous hysterectomy, hormone replacement therapy, type of sling removed and baseline urodynamics (UDS) parameters were not predictors of MPQ failure. Higher parity was a predictor of MPQ failure (hazard ratio = 1.980; P = .032). CONCLUSION: MPQ injection is a durable and effective management option for SUI following SSR, although a second injection may be required to achieve the desired success.

Single-port robotic-assisted laparoscopic sacrocolpopexy with magnetic retraction: first experience using the SP da Vinci platform.

The purpose of this study was to describe technical considerations and first outcomes from a single-port robotic-assisted sacrocolpopexy (RSC) using the da Vinci SP platform (Intuitive Surgical, Sunnyvale, CA) and the Levita™ Magnetic Surgical System (San Mateo, CA, USA), a novel magnetic retraction system. Three females with pelvic organ prolapse elected to undergo RSC using the da Vinci SP platform. The supraumbilical incision length was 25 mm through which SP trocar was placed. A 12-mm assistant port was placed in the right upper quadrant. The external magnet was attached to the left side of the bed and used for bowel and bladder retraction. We then proceeded by duplicating the steps of our approach for a RSC performed using a multi-port robotic platform with necessary modifications given the SP approach. Intra-operative outcomes and peri-operative outcomes were collected and reported. The patients were women of 64, 66 and 73 years of age with BMI of 22, 25, and 34, respectively, and POP-Q stage III and IV prolapse. The RSC was performed between 198 and 247 min, estimated blood loss was 10-50 cc, and there were no complications. All patients were discharged home on post-operative day 1. All patients were doing well 1 month out with resolution of bulge symptoms. To our knowledge, this represents the first case series of robotic, magnetic-assisted sacrocolpopexies using the da Vinci SP platform and the Levita™ Magnetic Surgical System. It appears to be a safe and feasible approach, but long-term comparative studies will be necessary to assess functional outcomes.

Epidemiology of genitourinary foreign bodies in the united states emergency room setting and its association with mental health disorders.

The epidemiology of genitourinary foreign bodies (GUFB) has been mainly described through case reports and small series. The aim of this study is to investigate the epidemiologic, medical, and socioeconomic factors associated with GUFB, along with the resultant costs of care in emergency departments (EDs) nationwide. ED visits with the primary diagnosis of a GUFB between 2010 and 2014 were abstracted from the Nationwide Emergency Department Sample database. Between 2010 and 2014, a weighted estimate of 102,333 visits to the ED with GUFB were recorded in the US, representing a national incidence of 7.6 ED visits per 100,000 persons. Of these visits, 4.7% resulted in admission and males were more likely to be admitted (24.8% vs. 2.1%, p < 0.01). A third of patients had low income, 30% had no medical insurance, and a third of patients had Medicaid. Urethra/bladder and penile foreign bodies had a significant association with mental health disorders (35.6%). Vulvar/vaginal foreign bodies had a lower prevalence of mental health disorders (6.1%). Costs of managing patients in the ED averaged $3769. More importantly, penile or urethra/bladder foreign bodies incurred a higher cost ($30,071). This is the largest population-based study investigating the epidemiology of GUFB. GUFB are more common in young women and the majority of them are vulvar/vaginal. Urethral and bladder foreign bodies occurred in older male patients and are associated with longer hospital stays and costs. Over one third of male patients with urethra/bladder had significant mental health disorders.

Closed suction drain outputs at 12 and 24 hours after primary three-piece inflatable penile prosthesis surgery.

This is a single-institution retrospective study of closed suction drain outputs in primary three-piece IPP cases performed between 2014 and 2017 by a single surgeon. The aim was to investigate the impact of closed suction drains (CSD) during penile prosthesis placement. One hundred and sixty-nine patients underwent intraoperative placement of a closed suction drain. Drain outputs were measured at 12 and 24 h, and postoperative complications were documented. There were no hematomas or infections observed within the patient cohort. The drain output decreased significantly between the first and subsequent 12 h period. Surgical time was associated with statistically significant increases in CSD output at 12 and 24 h with a near linear relationship between surgical times and CSD at 12 and 24 h. Penile prosthesis placement in patients on aspirin did not affect the CSD output volume. Closed suction drains should be considered in all patients undergoing placement of inflatable penile prosthesis, particularly in those cases with longer operative time.

The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions.

INTRODUCTION: The Mulcahy salvage fundamentally altered the management of penile prosthesis infections (PPI). Central to this procedure is a sequence of antiseptic irrigations that aims to remove and eradicate pathogenic microflora from the infected field, thus preparing for immediate reimplantation. The antiseptic solutions and their respective concentrations, however, have never been evaluated for efficacy. AIM: This review critically examines 3 commonly used antiseptic irrigation solutions (povidone-iodine [PVI], hydrogen peroxide [H2O2], and chlorhexidine gluconate [CHG]) in terms of their antimicrobial activity, cytotoxicity, and clinical use. METHODS: A PubMed literature review was performed on articles published between 2003 and 2018. Both preclinical as well as clinical studies from various surgical disciplines were included in this review. MAIN OUTCOME MEASURE: The original salvage protocol selected for irrigation solutions at concentrations that are likely detrimental to native tissue. RESULTS: All 3 agents demonstrate in vitro cytotoxic effects at subclinical concentrations, but H2O2 is associated with the most significant deleterious properties. It does not seem to broaden antimicrobial coverage beyond what is covered by PVI. Dilute PVI (0.35-3.5% with exposure time of at least 3 minutes) possesses the most robust clinical evidence as an intraoperative adjunct, reducing the incidence of postoperative infectious complications. chlorhexidine gluconate is a promising new agent but lacks clinical data. CLINICAL IMPLICATION: Improvements in the salvage protocol are warranted based on current evidence. Careful selection of lavage solution and usage of the lowest necessary concentration will help achieve desired antimicrobial activity while avoiding native tissue cytotoxicity. Strength and limitation: The study is limited by its retrospective nature, and the heterogeneity of literature reviewed precluded a formal meta-analysis. Furthermore, future studies will need to address the roles of normal saline and antibiotic irrigations as intraoperative adjuncts for infection prevention. CONCLUSION: Diluted PVI (0.35-3.5% for 3 minutes) may be beneficial in the prevention of PPI. Evidence supports its use both in the setting of primary implantation as well as salvage of infected hardware. An improved, evidence-based protocol may increase positive outcomes of urologic prosthetic surgery. Pan S, Rodriguez D, Thirumavalavan N, et al. The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions. J Sex Med 2019;16:781-790.

Current practice in the management of ischemic priapism: an anonymous survey of ISSM members.

Penile shunting is the standard of care in management of ischemic priapism refractory (IPR) to non-surgical interventions. Due to high rates of impotence, corporal fibrosis, and loss of penile length, recent literature suggests these patients benefit from immediate penile prosthesis (PP) placement. An IRB-exempt anonymous electronic survey of the 2168 members of the International Society for Sexual Medicine (ISSM) was conducted. The survey included demographic information, confidence, and experience-related management of IPR. The aim was to evaluate current practice patterns in management of IPR and to investigate the role of immediate PP implantation in the management of prolonged (>36 h) IPR. The survey response rate was 11.6% (n = 251). Most respondents were urologists (173), from the USA (49.1%), and had completed a fellowship in male sexual medicine, men's health, reconstruction, or andrology (71.1%). The majority (91.3%) see at least one case of prolonged priapism (>36 h) that requires surgical management yearly. When looking at volume in training and after, our respondents had a significantly higher experience with penile prostheses (over 70%, > = 10) as compared with shunts (less than 40%, > = 10). Overall, 70.9% of respondents felt more comfortable with a malleable PP than a shunt. However, penile shunts are still preferred as the first line of surgical management by ~80% of respondents as compared with 12.7% who instead prefer a PP. We also found that under 40% of respondents currently use penile MRI or corporal biopsies in their management of prolonged assessment. This is the first study to assess current clinical practices in management of IPR globally. As in any anonymous self-reported survey-based research, recall and sampling bias are an inherent limitation. Penile shunting for IPR continues to be the preferred treatment despite emerging data. Respondents performed PP surgery routinely and feel more confident placing PP than performing penile shunting procedures.

Epidemiology of Penile Fractures in United States Emergency Departments: Access to Care Disparities May Lead to Suboptimal Outcomes.

INTRODUCTION: The epidemiology of penile fractures in the emergency setting is not well described. AIM: Examine the incidence, evaluation, management, risk factors predicting surgical repair or hospital transfer, and use of financial resources in patients presenting with penile fractures to the emergency departments (ED) nationwide in the Unites States. METHODS: ED visits with a primary diagnosis of penile fractures (International Classification of Diseases, Ninth Edition codes) between 2010-2014 were abstracted from the Nationwide Emergency Department Sample. MAIN OUTCOME MEASURE: Penile fracture incidence, disposition, hospital, and clinical factors which were associated with immediate surgical repair or transfer to another institution, and cost were investigated. RESULTS: 8,029 ED visits for penile fracture in the United States were observed, which represents a national incidence of 1.02 per 100,000 male subjects per year. No meaningful trends in incidence were observed over the 5-year period. 63.9% were treated non-surgically or discharged from the ED, 25.7% underwent surgical repair, and 10.3% were transferred to other institutions. Hospital factors which predicted surgical repair included Northeast region, teaching hospital status, trauma hospital status, high volume ED, and urban location. Clinical risk factors which predicted surgical repair included hypertension, smoking, alcohol dependence, drug abuse, erectile dysfunction, hematuria, urethral injury, and urinary retention. Factors leading to patient transfers included non-academic, rural and non-trauma hospitals, low economic income and low emergency department volume. In addition, weekend and spring presentation were associated with higher transfer rates, while summer presentation was associated with surgical repair. CLINICAL IMPLICATIONS: A large proportion of penile fractures are discharged from the ED, indicating possible health care access disparity. STRENGTHS & LIMITATIONS: This is one of the first population-based study of penile fracture incidence, disposition, risk factors which predict surgery or transfer, and cost in the US ED setting. The unexpected high number of discharges may be a result of misdiagnosis; alternatively these data may reveal previously under-reported management patterns in the community. CONCLUSION: This large retrospective study of penile fractures in the US ED setting demonstrates a stable incidence of penile fractures presenting to the US emergency departments. A quarter of patients undergo immediate surgical repair, 10% are transferred to other institutions and 63.9% of patients are discharged home. The high proportion of ED discharges may be due to access to health care disparities. Rodriguez D, Li K, Apoj M, et al. Epidemiology of Penile Fractures in United States Emergency Departments: Access to Care Disparities May Lead to Suboptimal Outcomes. J Sex Med 2019;16:248-256.

Simulation Training in Penile Implant Surgery: Assessment of Surgical Confidence and Knowledge With Cadaveric Laboratory Training.

INTRODUCTION: Constraints on surgical resident training (work-hour mandates, shorter training programs, etc.) and availability of expert surgical educators may limit the acquisition of prosthetic surgical skills. As a result, training courses are being conducted to augment the prosthetic surgery learning experience. AIM: To evaluate the impact of a hands-on cadaver-based teaching program on resident procedural knowledge and procedural confidence with placement of a penile prosthesis. MAIN OUTCOME MEASURE: Changes in procedural knowledge and self-confidence following a focused training program on penile prosthetics. METHODS: As part of the 2017 Society of Urologic Prosthetic Surgeons and the Sexual Medicine Society of North America Annual Meeting, 31 urology residents participated in a simulation lab in prosthetic urology. The lab included didactic lectures and a hands-on cadaveric laboratory. Participants completed surveys before and after the course. Wilcoxon Signed Rank tests for matched pairs were used to compare respondents' pre- and postcourse knowledge (% questions answered correctly) and confidence ratings. Prior implant experience was assessed. RESULTS: 31 residents participated in this study. The majority of the participants were 4th- (41.9%) and 5th-year residents (38.7%). Participants showed a significant improvement in procedural knowledge test scores (68.8±13.4 vs 74.2 ± 13.0, P < .05) and self-reported increased median surgical confidence levels (4 vs 3, P value < .001) after completion of the cadaveric course. Subgroup analysis demonstrated that residents with prosthetic surgery experience of <10 cases benefited the most. In addition, improvement in surgical confidence levels observed was greater than the improvement in surgical knowledge. The overall cost of the simulation training course was approximately $1,483 per resident. CONCLUSION: Simulation training in prosthetic surgery seems to improve surgical confidence and knowledge. Further research is needed to better understand the benefits and limitations of simulation training. Lentz AC, Rodríguez D, Davis LG. Simulation training in penile implant surgery: Assessment of surgical confidence and knowledge with cadaveric laboratory training. Sex Med 2018;6:332-338.

The impact of age at the time of radiotherapy for localized prostate cancer on the development of second primary malignancies.

PURPOSE: There is a known increased risk of second primary malignancy (SPM) in patients with prostate cancer (CaP) treated with radiotherapy (RT). It is unclear how age at diagnosis influences the risk of SPMs. MATERIALS AND METHODS: Using the 1973 to 2013 Surveillance, Epidemiology, and End Results Program, we studied the impact of age on SPMs (defined as a bladder or rectal tumor) after localized CaP treatment with radical prostatectomy (RP) or RT. SPM risk was compared using inverse probability of treatment weighting (IPTW)-adjusted cumulative incidence function and competing-risk proportional hazard models. Overall survival (OS) in patients with SPM was compared using Kaplan Meier and Cox regression analyses. RESULTS: A total of 579,608 patients met inclusion criteria, and 51.8% of the cohort was treated with RT. The 10- and 20-year cumulative incidences of competing risk (IPTW adjusted) of SPMs were 1.9% (95%CI = 1.8-1.9%) and 3.6% (95%CI = 3.4-3.7%) after RP vs. 2.7% (95%CI = 2.6-2.8%) and 5.4%(95%CI = 5.3-5.6%) after RT. IPTW-adjusted competing risk hazard ratio (HR) of SPM after RT compared to RP was increased in the entire cohort (HR 1.46; 95%CI = 1.39-1.53, P < 0.001) and was highest in the youngest patients: Age <55 HR = 1.83 (95% confidence interval [CI] = 1.49-2.24, P<0.001), Age 55 to 64 HR = 1.66 (95%CI = 1.54-1.79, P < 0.001), Age 65-74 HR = 1.41 (95%CI = 1.33-1.48, P < 0.001), Age ≥75 HR = 1.14 (95%CI = 0.97-1.35, P = 0.112). At 10 years, SPM-specific mortality occurred in 28.9% of patients treated with RT, though OS with SPM was worse in the youngest patients: Age <55 HR = 1.88 (95%CI = 1.25-2.81, P = 0.002), Age 55-64 HR = 1.60 (95%CI = 1.42-1.81, P < 0.001), Age 65-74 HR = 1.40 (95%CI = 1.30-1.52, P < 0.001), Age ≥ 75 HR = 1.27 (95%CI = 1.06-1.53, P = 0.009). All of the age categories had similar median follow-up times. CONCLUSION: At 10 years there is a 1.8% increased incidence of SPM after RT compared to RP, of which <30% of RT-treated patients with an SPM die as a result of a SPM. However, the risk of SPMs was greatest among younger men treated with RT for localized CaP, and this relationship could not be explained solely by follow-up time, latency time, or life expectancy. An improved understanding of those at the highest risk of SPMs may help tailor treatment and surveillance strategies.