Current opinions on the management of prolonged ischemic priapism: does penoscrotal decompression outperform corporoglanular tunneling?

Prolonged ischemic priapism presents a treatment challenge given the difficulty in achieving detumescence and effects on sexual function. To evaluate current practice patterns, an open, web-based multi-institutional survey querying surgeons' experience with and perceived efficacy of tunneling maneuvers (corporoglanular tunneling and penoscrotal decompression), as well as impressions of erectile recovery, was administered to members of societies specializing in male genital surgery. Following distribution, 141 responses were received. Tunneling procedures were the favored first-line surgical intervention in the prolonged setting (99/139, 71.2% tunneling vs. 14/139, 10.1% implant, p < .001). Although respondents were more likely to have performed corporoglanular tunneling than penoscrotal decompression (124/138, 89.9% vs. 86/137, 62.8%, p < .001), penoscrotal decompression was perceived as more effective among those who had performed both (47.3% Very or Extremely Effective for penoscrotal decompression vs. 18.7% for corporoglanular tunneling; p < .001). Many respondents who had performed both tunneling procedures felt that most regained meaningful sexual function after either corporoglanular tunneling or penoscrotal decompression (33/75, 44.0% vs. 33/74, 44.6%, p = .942). While further patient-centered investigation is warranted, this study suggests that penoscrotal decompression may outperform corporoglanular tunneling for prolonged priapism, and that recovery of sexual function may be higher than previously thought after tunneling procedures.

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.

Transurethral Incisions for Bladder Neck Contracture: Comparable Results without Intralesional Injections.

To present our 12-year experience using an endoscopic approach to manage bladder neck contracture (BNC) without adjunctive intralesional agents and compare it to published series not incorporating them, we retrospectively reviewed 123 patients treated for BNC from 2008 to 2020. All underwent 24 Fr balloon dilation followed by transurethral incision of BNC (TUIBNC) with deep incisions at 3 and 9 o'clock using a Collins knife without the use of intralesional injections. Success was defined as a patent bladder neck and 16 Fr cystoscope passage into the bladder two months later. Most with recurrent BNC underwent repeat TUIBNC. Success rates, demographics, and BNC characteristics were analyzed. The etiology of BNC in our cohort was most commonly radical prostatectomy with or without radiation (36/123, 29.3%, 40/123, 32.5%). Some had BNC treatment prior to referral (30/123, 24.4%). At 12-month follow-up, bladder neck patency was observed in 101/123 (82.1%) after one TUIBNC. An additional 15 patients (116/123, 94.3%) had success after two TUIBNCs. On univariate and multivariate analyses, ≥2 endoscopic treatments was the only factor associated with failure. TUIBNC via balloon dilation and deep bilateral incisions without the use of adjunctive intralesional injections has a high patency rate. History of two or more prior endoscopic procedures is associated with failure.

Presenting signs and symptoms of artificial urinary sphincter cuff erosion

ABSTRACT Purpose To characterize the most common presentation and clinical risk factors for artificial urinary sphincter (AUS) cuff erosion to distinguish the relative frequency of symptoms that should trigger further evaluation in these patients. Materials and Methods We retrospectively reviewed our tertiary center database to identify men who presented with AUS cuff erosion between 2007 - 2020. A similar cohort of men who underwent AUS placement without erosion were randomly selected from the same database for symptom comparison. Risk factors for cuff erosion - pelvic radiation, androgen deprivation therapy (ADT), high-grade prostate cancer (Gleason score ≥ 8) - were recorded for each patient. Presenting signs and symptoms of cuff erosion were grouped into three categories: obstructive symptoms, worsening incontinence, and localized scrotal inflammation (SI). Results Of 893 men who underwent AUS placement during the study interval, 61 (6.8%) sustained cuff erosion. Most erosion patients (40/61, 66%) presented with scrotal inflammatory changes including tenderness, erythema, and swelling. Fewer men reported obstructive symptoms (26/61, 43%) and worsening incontinence (21/61, 34%). Men with SI or obstructive symptoms presented significantly earlier than those with worsening incontinence (SI 14 ± 18 vs. obstructive symptoms 15 ± 16 vs. incontinence 37 ± 48 months after AUS insertion, p<0.01). Relative to the non-erosion control group (n=61), men who suffered erosion had a higher prevalence of pelvic radiation (71 vs. 49%, p=0.02). Conclusion AUS cuff erosion most commonly presents as SI symptoms. Obstructive voiding symptoms and worsening incontinence are also common. Any of these symptoms should prompt further investigation of cuff erosion.

Long-Term Experience with Balloon Dilation for Short Bulbar and Membranous Urethral Strictures: Establishing a Baseline in the Active Drug Treatment Era.

Transurethral balloon dilation (BD) is a minimally invasive treatment for urethral stricture disease (USD) performed primarily or as a recurrence salvage maneuver. With the introduction of drug-coated balloons, we sought to characterize patient outcomes using non-medicated balloons. A retrospective review identified patients who underwent BD from 2007 to 2021. Patient and stricture characteristics were collected. All dilations employed the 24Fr UroMaxTM system. Clinical failure was defined by patient-reported lower urinary tract symptom recurrence or need for further stricture management. Ninety-one patients underwent BD with follow-up median (IQR) 12 (3-40) months. Most (75/91, 82%) had prior treatment for USD (endoscopic 50/91 (55%), 51/91 (56%) urethroplasty) before BD. Recurrence rates did not significantly differ between treatment-naïve and salvage patients (44% vs. 52% (p = 0.55)). Median (IQR) time to failure was 6 (3-13) months. The most common complications were urinary tract infection (8%) and post-operative urinary retention requiring catheterization (3%). Radiation history was noted in 33/91 (36%) with 45% recurrence. Patients without previous radiation had a similar recurrence rate of 52% (p = 0.88). Balloon dilation had minimal complications and overall, 50% recurrence rate, consistent regardless of stricture characteristics, radiation history, or prior treatments. These results represent an important clinical benchmark for comparing outcomes using drug-coated balloons.

Presenting signs and symptoms of artificial urinary sphincter cuff erosion.

PURPOSE: To characterize the most common presentation and clinical risk factors for artificial urinary sphincter (AUS) cuff erosion to distinguish the relative frequency of symptoms that should trigger further evaluation in these patients. MATERIALS AND METHODS: We retrospectively reviewed our tertiary center database to identify men who presented with AUS cuff erosion between 2007 - 2020. A similar cohort of men who underwent AUS placement without erosion were randomly selected from the same database for symptom comparison. Risk factors for cuff erosion - pelvic radiation, androgen deprivation therapy (ADT), high-grade prostate cancer (Gleason score ≥ 8) - were recorded for each patient. Presenting signs and symptoms of cuff erosion were grouped into three categories: obstructive symptoms, worsening incontinence, and localized scrotal inflammation (SI). RESULTS: Of 893 men who underwent AUS placement during the study interval, 61 (6.8%) sustained cuff erosion. Most erosion patients (40/61, 66%) presented with scrotal inflammatory changes including tenderness, erythema, and swelling. Fewer men reported obstructive symptoms (26/61, 43%) and worsening incontinence (21/61, 34%). Men with SI or obstructive symptoms presented significantly earlier than those with worsening incontinence (SI 14 ± 18 vs. obstructive symptoms 15 ± 16 vs. incontinence 37 ± 48 months after AUS insertion, p<0.01). Relative to the non-erosion control group (n=61), men who suffered erosion had a higher prevalence of pelvic radiation (71 vs. 49%, p=0.02). CONCLUSION: AUS cuff erosion most commonly presents as SI symptoms. Obstructive voiding symptoms and worsening incontinence are also common. Any of these symptoms should prompt further investigation of cuff erosion.

Periurethral Abscess Following Urethral Reconstruction: Clinical Features and Prognosis.

OBJECTIVE: To evaluate the clinical and prognostic details of periurethral abscess (PUA) formation following urethroplasty (UP). METHODS: A retrospective review was performed to identify men who developed PUA after UP between 2007 and 2019 at a single tertiary care referral center. Patient demographics, stricture characteristics, and UP technique were recorded. Outcomes included time to PUA, presenting symptoms, wound cultures, imaging, and ultimate management. Comparative analysis between PUA and non-PUA patients was performed using Fisher's Exact test and Student's t-test. RESULTS: Among 1499 UP cases, 9 (0.6%) developed PUA. Mean stricture length was 4.6 cm with most located in the bulbar urethra (5/9, 56%), while 4/9 (44%) had undergone prior UP. PUA rates were 7/288 (2.4%) and 2/815 (0.3%) for substitution and anastomotic UP respectively. Voiding cystourethrogram (VCUG) demonstrated extravasation in 67% (4/6) of available UP cases imaged. Subsequent VCUG confirmed leak improvement or resolution in all cases. Wound cultures were frequently polymicrobial (4/6, 67%). Management included antibiotics with (6/9) and without (3/9) incision and drainage (I/D). Urinary drainage was performed in 5 patients using suprapubic tube (3/5) and foley placement (2/5). PUA resolution was observed in all patients while stricture symptom recurrence was observed in 2/9 (22%) patients with mean time to recurrence of 15 months. Overall mean follow-up time was 22 months. CONCLUSION: PUA is a rare complication of UP that may be more common in setting of postoperative urine leak. PUA is safely managed with I/D, urethral rest, and antibiotics, with low risk of recurrent stricture formation thereafter.

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.

Distance From Critical Pelvic Structures: Radiographic Comparison of High Submuscular and Space of Retzius IPP Reservoir Placement Techniques.

OBJECTIVE: To evaluate the distance from critical pelvic structures (CPS, defined as bladder and iliac vessels) among inflatable penile prosthesis (IPP) reservoirs placed into the space of Retzius (SOR) and high submuscular (HSM) locations using cross-sectional imaging. IPP reservoir placement into the HSM location has been proposed as a strategy to prevent injury due to greater distance from CPS. METHODS: Our institutional database was retrospectively reviewed to identify men who underwent IPP insertion between 2007 and 2020 and had available cross-sectional abdominopelvic imaging after the time of surgery. Patients were grouped based on reservoir placement technique (SOR vs. HSM). Staff radiologists blinded to placement technique evaluated reservoir position to determine the shortest distance between CPS and the reservoir and if a mass effect was present on CPS. Variables were analyzed using chi-squared, Fisher's exact, and student's T-tests as indicated. RESULTS: Among 1,010 IPP cases performed during the study interval, 139 (13%) were imaged. Compared with SOR reservoirs (n = 32), HSM reservoirs (n =107) were significantly less likely to induce a mass effect on the bladder (72 vs. 9%, P = <.01) or iliac vessels (34 vs. 4%, P = <.01) and were located roughly 5 times further from the bladder (10 ± 22 vs. 49 ± 36 mm, P = <.01) and iliac vessels (5 ± 9 vs. 23 ± 26 mm, P = <.01). CONCLUSION: This study radiographically confirms that IPP reservoirs are located significantly further away from CPS following HSM placement compared to SOR placement.

Long-term lower urinary tract sequelae following AUS cuff erosion.

AIMS: To examine the rate of lower urinary tract complications (LUTC) and urinary diversion (UD) after artificial urinary sphincter (AUS) explantation with the acute reconstruction of AUS cuff erosion defects. METHODS: We performed a retrospective study of patients who underwent in-situ urethroplasty (ISU) for AUS cuff erosion from June 2007 to December 2020. Outcomes included LUTC (urethral stricture, diverticulum, fistula), AUS reimplantation, and UD. Defect size was prospectively estimated acutely and a subanalysis was performed to determine the impact of erosion severity (small erosions [<33% circumferential defect] and large erosions [≥33%]) on these outcomes. Kaplan-Meier curves were created to compare survival between the two groups. RESULTS: A total of 40 patients underwent ISU for urethral cuff erosion. The median patient age was 76 years old with a median erosion circumference of 46%. The overall LUTC rate was 30% (12/40) with 35% (14/40) of patients requiring permanent UD. Secondary AUS placement occurred in 24/40 (60%) patients with 11/24 (46%) leading to repeat erosion. On subanalysis, small erosion was associated with improved LUTC-free and UD-free survival but not associated with AUS reimplantation. CONCLUSIONS: Lower urinary tract complications are common after AUS cuff erosion and can lead to the need for permanent UD. Patients with larger erosions are more likely to undergo UD and reach this end-stage condition earlier compared to patients with small erosions.

Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice.

BACKGROUND: Inflatable penile prosthesis (IPP) reservoirs are typically placed into the Space of Retzius (SOR) or alternative locations including the High Submuscular (HSM) space via transinguinal (TI) or counter incision (CI) techniques. A cadaver study showed variability in reservoir location after TI-HSM placement. AIM: To evaluate reservoir location using cross-sectional imaging following IPP insertion. METHODS: We retrospectively reviewed our institutional database and identified men who underwent virgin penoscrotal IPP insertion between 2007 and 2019. We then identified those men who subsequently underwent cross-sectional imaging prior to October 2019. Radiologists evaluated cross-sectional imaging in a blinded manner and categorized reservoir locations as follows: 1) submuscular; 2) posterior to the external oblique fascia and lateral to the rectus abdominis musculature; 3) preperitoneal; 4) retroperitoneal; 5) intraperitoneal; 6) inguinal canal; 7) subcutaneous. Patients were stratified by reservoir placement technique, transinguinal space of Retzius (TI-SOR), transinguinal high submuscular (TI-HSM), or counterincision high submuscular (CI-HSM). Clinical characteristics and outcomes were reviewed and compared. Statistical analysis was performed using Chi-squared and Fisher's exact tests. OUTCOMES: Variability exists in the TI placement of SOR and HSM reservoirs, CI-HSM reservoirs were associated with a low level of variability. RESULTS: Among 561 men who underwent virgin IPP insertion during the 12-year study period, 114 had postoperative cross-sectional imaging (29 TI-SOR, 80 TI-HSM, and 5 CI-HSM). Among the 114 patients imaged, TI-HSM reservoirs were more likely than TI-SOR to be located anterior to the transversalis fascia (48 vs 14%, P < .01) and were less likely to be located in the preperitoneal space (18 vs 62%, P < .01). Rates of intraperitoneal reservoir location were similar between the TI-HSM and TI-SOR groups (5 vs 7%, P = .66). Among imaged CI-HSM reservoirs, 4 (80%) were anterior to the transversalis fascia and 1 (20%) was within the inguinal canal. Among all 536 transinguinal cases (131 TI-SOR and 405 TI-HSM), rates of reservoir-related complications requiring operative intervention were similar between groups (5 vs 2%, P = .24). No complications were noted among the 25 patients in the CI-HSM cohort. CLINICAL IMPLICATIONS: The level of variability seen in this study did not seem to impact patient safety, complications were rare in all cohorts. STRENGTHS AND LIMITATIONS: This study is the first and largest of its kind in evaluating reservoir positioning in live patients with long-term follow-up. This study is limited in its retrospective and nonrandomized nature. CONCLUSIONS: Despite variability with both TI-HSM and TI-SOR techniques, reservoir related complications remain rare. Kavoussi M, Cook G, Nordeck S, et al. Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice. J Sex Med 2021;18:2039-2044.

Restoration of Continence after Prostatectomy is Associated With Weight Loss: A Pilot Study.

OBJECTIVES: To examine association between post-prostatectomy incontinence (PPI) severity and weight changes before and after restoration of continence via artificial urinary sphincter (AUS). METHODS: Single surgeon, retrospective review of urologic prosthetic surgery (UPS) after radical prostatectomy (RP). A cohort of post-RP inflatable penile prosthesis (IPP) patients served as a surgical control. Body Mass Index (BMI) and total body weight were assessed pre and post-UPS. Multivariable linear regression was utilized to assess BMI changes post-UPS. RESULTS: 187 AUS and 63 IPP patients met selection criteria. Greater PPI severity was associated with faster BMI gain after RP (coeff. 0.14 kg/m2, P = 0.03, per pad used) and magnitude of incontinence improvement (mean reduction in daily pad use) after AUS insertion was associated with greater BMI reduction at 12 months post-UPS (coeff. - 0.13 kg/m2, P = 0.04). On multivariable regression, AUS insertion was associated with a decrease in BMI by - 2.83 kg/m2 12 months post-UPS (P = 0.02). Twelve months post-UPS, men with AUS exhibited a mean BMI reduction of -1.0 kg/m2 compared to a mean BMI increase in the IPP cohort of 0.4 kg/m2 (P < 0.01). Compared to IPP, AUS patients experienced absolute body weight reduction by 6 kg [Median(IQR): 90.4 (80.3-100.1) vs 96.4 (87.1-108.8) kg, P = 0.03], with nearly one-third having clinically significant weight loss (>5% body weight) at 12 months post-UPS (31.8% vs 8.3%, P < 0.01). CONCLUSION: Severe PPI appears to be associated with weight gain and correction of PPI via AUS insertion with weight loss.

Penile Extra-Tunical Graft Reconstruction of Peyronie's Disease Concavity Deformities.

OBJECTIVES: To report our initial experience with the extra-tunical grafting (ETG) procedure. This procedure was recently introduced by UCSF investigators as a tunica-sparing technique for management of penile concavity deformities. METHODS: We retrospectively reviewed records of patients who underwent ETG at our tertiary-care referral center between 2017 - 2020.  A collagen graft made from bovine pericardium (Lyoplant) was placed overlying the defect without violating the tunica albuginea or mobilizing the neurovascular bundle. The stretched penile length (SPL) and circumference at the location of deformity were measured intra-operatively. Patient reported outcomes were evaluated by an anonymous 10-question online survey. RESULTS: 19 men underwent ETG with a median follow-up of 59 (IQR: 24 - 708) days. ETG was performed via either a window (15/19, 78%) or a de-gloving (4/19, 21%) incision with concomitant penile plication performed in 16/19 (84%) patients. Penile circumference increased by an average of 1.4 cm + 0.5 (P = 0.03) at the location of deformity, while pre- and post-operative SPL were similar (14.0 + 1.4 vs 14.0 + 1.3 cm, P = 0.95). Overall patient satisfaction was reported by 13/15 (86%) patients. Twelve out of 15 (80%) patients reported concavity deformity to be "improved", with 73% reporting "much better". Among 8 patients with follow up greater than six months, graft palpability was reported in 4/8 (50%) patients but was not bothersome. CONCLUSION: The ETG procedure appears to be safe and effective for the treatment of penile concavity deformities.  Patient outcomes and satisfaction are favorable at intermediate follow up.

Same Day Discharge Versus Overnight Observation Protocols - Similar Outcomes Following Artificial Urinary Sphincter Surgery.

OBJECTIVES: To analyze our institutional experience transitioning from overnight observation (OBS) to same day surgery (SDS) for artificial urinary sphincter (AUS) procedures. Prior research has questioned the need for OBS following AUS surgery. METHODS: We retrospectively reviewed AUS surgeries performed by a single surgeon at our tertiary academic medical center between 08/2013 and 01/2020. Patients were grouped based on discharge status: OBS vs SDS. Cost savings associated with SDS were estimated using room and bed charges from a contemporary group of AUS patients. RESULTS: We identified 525 AUS cases that met inclusion criteria. Men in the SDS group (n = 318) were more likely to have undergone a virgin AUS insertion and were slightly younger and healthier. Men in the OBS group (n = 207) were more likely to suffer an immediate postoperative complication (1% vs 0%, P < .01) and to be readmitted within 90 days of surgery (15% vs 5%, P < .01). The groups did not vary with respect to multiple other perioperative outcomes measures. Among patients who underwent AUS surgery between 09/2017 and 08/2020, those with OBS status (n = 39) had mean additional room and bed charges of $ 745 ± 302 vs none for SDS patients (n = 183). CONCLUSION: SDS for AUS insertion is safe, effective, and associated with significant cost savings. Routine overnight observation after AUS insertion appears to be unnecessary.

Hydrogel Spacer Rectal Wall Infiltration Associated With Severe Rectal Injury and Related Complications After Dose Intensified Prostate Cancer Stereotactic Ablative Radiation Therapy.

The risk of rectal toxicity during and after prostate cancer radiation therapy is common to all treatment regimens. Hydrogel rectal spacers are increasingly being used to mitigate this risk and to facilitate dose-escalation, but also may infiltrate the rectal wall, with unclear clinical implication. We present a case of significant infiltration associated with severe late rectal injury (grade 4) and further grade 3 to 4 sequelae (recto-urethral fistula and associated osteomyelitis requiring exenteration) after high-dose stereotactic body radiation therapy for localized prostate cancer. The injury's temporal pattern associated with the expected timing of gel dissolution and displacement of infiltrated rectal layers potentially toward high dose regions together suggest a contributing role of the infiltration to the injury. In light of the rapid increase of hydrogel rectal spacer utilization, we review the case's evolution, concerning imaging findings, and associated literature and make suggestions regarding treatment planning and endoscopic assessment in the setting of infiltration or expected injury.

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.

Most men with artificial urinary sphincter cuff erosion have low serum testosterone levels.

AIMS: To evaluate the relationship between serum testosterone (T) levels and artificial urinary sphincter (AUS) cuff erosion in a population of incontinent men who underwent AUS placement. METHODS: A retrospective analysis of our single-surgeon AUS database was performed to identify men with T levels within 24 months of AUS placement. Men were stratified into two groups based on serum testosterone: low serum testosterone (LT) (<280 ng/dl) and normal serum testosterone (NT) (>280 ng/dl). Multivariable analysis was performed to control for risk factors. The outcome of interest was the incidence of and time to spontaneous urethral cuff erosion; other risk factors for cuff erosion were also evaluated. RESULTS: Among 161 AUS patients with serum testosterone levels, 84 (52.2%) had LT (mean: 136.8 ng/dl, SD: 150.4 ng/dl) and 77 (47.8%) had NT (mean: 455.8 ng/dl, SD: 197.3 ng/dl). Cuff erosion was identified in 42 men (26.1%) at a median of 7.1 months postoperatively (interquartile range: 3.6-13.4 months), most of whom (30/42, 71.4%) were testosterone deficient. LT levels were less common (54/119, 45.4%) in the non-erosion cohort (p = 0.004). Men with low T were nearly three times as likely to suffer AUS erosion than men with normal T (odds ratio = 2.519, p = 0.021). LT level was the only factor associated with AUS erosion on multivariable analysis. CONCLUSIONS: LT is an independent risk factor for AUS cuff erosion. Men with LT are more likely to present with cuff erosion, but there is no difference in time to erosion.