The impact of verbal goal setting on operating room turnover time: a randomized trial.

INTRODUCTION AND HYPOTHESIS: Operating room turnover times are highly variable, with longer times having a significant negative impact on hospital costs, surgeon volume, and satisfaction. The primary aim of this randomized trial was to examine the impact of a verbalized time goal on the likelihood of meeting institutional goals. METHODS: This is a prospective, single-blind, randomized study conducted across four operative sites: inpatient main campus and three outpatient centers. Sequential cases for the same surgeon in the same room were randomized to receive a verbal prompt versus usual care, in which no goal setting was verbalized. Multivariate and univariate statistical analyses were performed. RESULTS: From July through October 2022, five attending surgeons randomized 88 cases (44 verbal prompt, 44 usual care). Of these, 30 were at the main inpatient hospital. The case mixture included 36% vaginal, 27% endoscopy, 8% open, 10% robotic, and others. Average turnover time was 51.7 and 35.3 min for inpatient and outpatient cases respectively. Overall, only 39.8% of cases hit the institutional turnover time goal. Verbal prompting did not significantly increase the likelihood of achieving the institutional goal (38.4% vs 43.4% p = 0.352) except for in minor surgery (64.0 vs 39.0%, p = 0.0477). A verbal prompt reduced turnover time in major surgery (59.7 vs 47.8 min, p = 0.0445). CONCLUSION: Our academic center achieved goal turnover times in only 39.8% of cases. Although verbal prompting did not significantly improve the likelihood of meeting institutional goals in the group as a whole, some subgroups were significantly improved.

Persistent need for ongoing medical or surgical therapy despite UroLift: Data from an academic center.

INTRODUCTION: The prostatic urethral lift (PUL) is a popular surgical option for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). Prior 5-year data from the multicenter L.I.F.T. trial suggested durability and a surgical retreatment rate of 13.6% at five years. We assessed the proportion of patients who had ongoing medical or surgical BPH management following PUL. METHODS: With institutional review board approval, cases of PUL performed from 2015-2020 at our academic institution were retrospectively reviewed for management of BPH following PUL. RESULTS: A total of 209 men were identified, with followup available for 198 (95%). Mean age was 68.9 years and mean followup was 18.5 months. Mean prostate size was 43 g. Patients were discharged from recovery in 97% of cases, with 29% discharged with indwelling or intermittent catheterization. The rate of 30-day complications was 18%, with 89% graded Clavien I-II. Postoperatively, mean improvements in International Prostate Symptom Score (IPSS) and quality of life subscore (QoL) were 5.3 and 1.1 points, respectively. Unplanned emergency room or clinic visits within 30 days of the procedure occurred in 14% and 17% of men, respectively, with 4% requiring hospital readmission. In followup, α-blockers and/or 5α-reductase inhibitors were continued or initiated postoperatively for 44% of men; 20% of men required repeat surgical intervention at a mean of 19.2 months (1.4-56.4), consisting of repeat PUL (30%), transurethral resection of prostate (28%), or thulium laser enucleation (18%). Overall, 53% of men needed medication and/or repeat surgery for BPH following PUL, and this was independent of age, race, prostate volume, intravesical prostate protrusion, baseline IPSS and QOL, stricture, number of implants used, or a history of urinary retention (p>0.05). CONCLUSIONS: Most men undergoing PUL require ongoing medical and/or surgical management for BPH. Patients should be counseled as to the likelihood of failure as a unimodal therapy long-term.

Safety and Feasibility Study of Autologous Engineered Urethral Constructs for the Treatment of Strictures: Clinical Trial Update.

Autologous engineered urethral constructs are a promising treatment option for definitive management of long and complex urethral strictures, with the prospect of eliminating stricture recurrence.

ChatGPT Performance on the American Urological Association Self-assessment Study Program and the Potential Influence of Artificial Intelligence in Urologic Training.

OBJECTIVE: To assess chat generative pre-trained transformer's (ChatGPT) performance on the American Urological Association Self-Assessment Study Program (AUA SASP) and stratify performance by question stem complexity. METHODS: Questions from the 2021-2022 AUA SASP program were administered to ChatGPT version 3 (ChatGPT-3). Questions were administered to the model utilizing a standardized prompt. The answer choice selected by ChatGPT was then used to answer the question stem in the AUA SASP program. ChatGPT was then prompted to assign a question stem order (first, second, third) to each question. The percentage of correctly answered questions was determined for each order level. All responses provided by ChatGPT were qualitatively assessed for appropriate rationale. RESULTS: A total of 268 questions were administered to ChatGPT. ChatGPT performed better on 2021 compared to the 2022 AUA SASP question set, answering 42.3% versus 30.0% of questions correctly (P < .05). Hundred percent of answer explanations provided appropriate, relevant rationale regardless of whether the answer was correct. Further stratification included assessment by question order level. ChatGPT performed progressively better on the 2021 question set with decreasing order levels, with first-order questions reaching 53.8% (n = 14). However, differences in proportions did not reach statistical significance (P > .05). CONCLUSION: ChatGPT answered many high-level questions correctly and provided a reasonable rationale for each answer choice. While ChatGPT was unable to answer numerous first-order questions, future language processing model learning may lead to the optimization of its fund of knowledge. This may lead to the utilization of artificial intelligence like ChatGPT as an educational tool for urology trainees and professors.

Investigating the Impact of Kratom (Mitragyna speciosa) Use Upon Male Sexual Health.

Purpose: Kratom (Mitragyna speciosa) exhibits µ-receptor agonism and is used as an opioid substitute. While opioids are known to inhibit sexual behavior, less is known regarding kratom. We conducted a pilot study to assess the subjective impact of kratom upon male sexual health including erectile and ejaculatory function. Patients and Methods: Twitter and Reddit (r/Kratom) were accessed to disseminate our survey featuring validated instruments (the International Index of Erectile Function, IIEF, and the premature ejaculation diagnostic tool, PEDT). Sexual health prior to and after 4 weeks of kratom use was assessed. Results: Most males surveyed (n = 165) were 18-40 years old (84.9%), with 95.8% of respondents using it at least weekly and 82.4% using kratom for ≥1 year. Reasons for use included treating pain (39.4%), and mental health conditions (63.6%). Kratom was associated with a positive (37.7%) and negative (20.5%) impact on sexual health. Kratom subjectively increased time to ejaculation in 104 (66.6%) patients, perceived as positive by 62 (59.6%). Seventy-eight patients answered questions about premature ejaculation. The median (with interquartile range, IQR, following;) pre-kratom and kratom use scores were 13.0; 8.0 and 6.5; 5.0, respectively (p < 0.001). Ejaculation before 5 minutes improved after kratom (51.3% vs 12.8%) (p < 0.0001). Following kratom use, patients reported lack of frustration with ejaculation prior to desire (21.8% vs 61.5%) (p < 0.001). The erectile function domain of the IIEF was statistically significantly different however - clinically similar pre-kratom use (29.0; 5.75) versus 27.0; 6.75 during kratom use (p = 0.037). Conclusion: Clinicians treating male sexual health should be aware of kratom and its potential effect on ejaculatory and erectile function.

A Comparative Analysis of Ergonomic Risk Utilizing the 4K-3D Exoscope Versus Standard Operating Microscope for Male Fertility Microsurgery.

OBJECTIVE: To stratify ergonomic risk in a urologic microsurgeon using the 4K-3D exoscope versus the operating microscope (OM) with wearable technology. METHODS: The surgeon was calibrated with wearable sensor inertial measurement units (IMUs) on the head and upper arms. Each inertial measurement units contained an accelerometer, magnetometer, and gyroscope to measure surgeon joint angle change during microscopic procedures for male fertility. The validated modified rapid upper limb assessment was used to determine the proportion of time spent in ranges of risk. Categories 1-4 were assigned for the head and upper extremities (4= highest ergonomic risk). Chi-squared analysis was used to analyze differences in proportions. RESULTS: A total of 500 and 479 minutes from 4K-3D exoscope and OM guided surgeries were analyzed. The 4K-3D exoscope significantly favored upper arm category 1 positioning compared to the OM (56.2% vs 37.7%; P < .0001). The OM exposed the surgeon to higher category 3 positioning (14.6% vs 1.6%; P <.0001). More time was spent with the neck "extended" using the 4K-3D exoscope (51.8% vs 19.5%; P < .0001) with 67% of neck extension between 0-10° (category 1). Overall, more time was spent with the neck in risk group 1-2 with the OM (P < .0001). CONCLUSION: The 4K-3D exoscope offers favorable ergonomic positioning for the upper extremities which may reduce work stress-related injury. More operative time was spent with the neck in mild extension with 4K-3D exoscope utilization. However, the OM favored longer operative times in low-risk neck ergonomic positions.

Understanding the dopaminergic pathway relative to men's sexual dysfunction in patients with Parkinson's disease: a narrative review with implications for future research.

Parkinson's disease (PD) is often most recognized for motor symptoms but associated non-motor symptoms such as sexual dysfunction can significantly impact quality of life. This condition involves a hormonal disruption and has a predilection for male patients, yet there are no formal guidelines for screening or management of sexual health pathology in these patients. While prior publications have addressed the presence of sexual dysfunction (SD) among men with PD, there has been a paucity of work examining the hypothalamic-pituitary-gonadal (HPG) axis and the interplay between dopamine, prolactin (PRL), and testosterone. This review provides an overview of data extracted from the existing peer-reviewed literature regarding hormonal and sexual health changes in men with PD and the impact of dopaminergic and/or androgen replacement therapy. Furthermore, while some research suggests that PD patients are at higher risk for prolactin elevation and testosterone deficiency, heterogeneity of the data limits extrapolation. Additionally, data related to pharmacologic optimization of the HPG axis in this patient population is similarly limited. Prospective studies are needed to better characterize the hormonal pathophysiology of PD as it relates to sexual dysfunction such that men at risk can be effectively identified so as to offer interventions that may improve quality of life.

Safety and Efficacy of Phenylephrine Administration for the Treatment of Ischemic Priapism: An Opportunity for Quality Improvement in Periprocedural Safety Assessment.

OBJECTIVE: To determine the safety and efficacy of hourly, high dose phenylephrine (>1000 µg) for acute ischemic priapism (AIP) through monitoring adverse hemodynamic events amongst risk profiles. METHODS: An IRB-approved retrospective review of patients with AIP from 2010 to 2020. Patients were stratified to a low or high dose phenylephrine group based on cumulative, hourly dose of ≤1000 µg and > 1000 µg respectively and examined for successful resolution of their AIP. The safety profile of phenylephrine for patients at risk for adverse hemodynamic events was examined. RESULTS: A total of 123 patients were identified with a median age of 40 (range: 7-76) years with median time from AIP onset to presentation of 11 (2-168) hours. A total of 97 men received phenylephrine (78.9%) and detumescence was achieved nonoperatively in 62 of these men (63.9%) with a mean priapism duration of 8.7 hours. Those resolving with phenylephrine administration had a mean duration of 8.8 ± 5.6 vs 57.3 ± 37.1 hours without resolution P < .001. Among low and high dose phenylephrine groups (500 and 2000 µg respectively), the median duration of AIP was 10 and 12 hours respectively without a difference in AIP resolution (P > .05). Twenty-one patients (17.1%) were deemed at risk for phenylephrine complication of which 4 (4.1%) had phenylephrine discontinued due to hemodynamic changes. CONCLUSION: Nonoperative resolution of AIP with phenylephrine does not appear to be dose-dependent and hemodynamic changes secondary to phenylephrine administration may be underreported. Future work should utilize standardized risk assessment and periprocedural monitoring for hemodynamic change.

The Diagnosis and Management of Recurrent Ischemic Priapism, Priapism in Sickle Cell Patients, and Non-Ischemic Priapism: An AUA/SMSNA Guideline.

PURPOSE: Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing. METHODOLOGY: A comprehensive search of the literature on acute ischemic priapism and non-ischemic priapism (NIP) was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. A search of the literature on NIP, recurrent priapism, prolonged erection following intracavernosal vasoactive medication, and priapism in patients with sickle cell disease was conducted by Pacific Northwest Evidence-based Practice Center for articles published between 1946 and February 19, 2021. Searches identified 4117 potentially relevant articles, and 3437 of these were excluded at the title or abstract level for not meeting inclusion criteria. Full texts for the remaining 680 articles were ordered, and ultimately 203 unique articles were included in the report. RESULTS: This Guideline provides a clinical framework for the treatment (non-surgical and surgical) of NIP, recurrent ischemic priapism, and priapism in patients with sickle cell disease. The treatment of patients with a prolonged erection following intracavernosal vasoactive medication is also included. The AUA guideline on the diagnosis of priapism and the treatment of acute ischemic priapism was published in 2021. CONCLUSIONS: All patients with priapism should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event should be provided early intervention when indicated. NIP is not an emergency and treatment must be based on patient objectives, available resources, and clinician experience. Management of recurrent ischemic priapism requires treatment of acute episodes and a focus on future prevention of an acute ischemic event. Sickle cell disease patients presenting with an acute ischemic priapism event should initially be managed with a focus on urologic relief of the erection; standard sickle cell assessment and interventions should be considered concurrent with urologic intervention. Treatment protocols for a prolonged, iatrogenic erection must be differentiated from protocols for true priapism.

Platelet-Rich Plasma and Cellular Therapies for Sexual Medicine and Beyond.

INTRODUCTION: Efforts to understand and unlock the body's potential for regeneration have increased dramatically in recent years. So-called "biohacking" hopes to improve functionality and reverse disease processes. OBJECTIVES: This review will seek to summarize the available data for the use of platelet-rich plasma, cellular therapies, and other novel therapeutics within sexual medicine. METHODS: The PubMed database search was performed using the keywords "Stem cell therapy in Erectile dysfunction (ED)", "Gene therapy in ED", "Novel therapeutics for ED", and "Biohacking". Popular news articles for regulation of stem cell therapy were reviewed. RESULTS: Research efforts have managed to produce an array of novel therapeutics, including stem cell therapy and platelet-rich plasma. Although the use of these items has been largely focused within specialties other than urology, applications involving sexual medicine have been documented and appear to be increasing. CONCLUSION: Despite evidence of these technologies being adopted within clinical practices as revenue-generators, quality data to support efficacy are quite limited. Matz EL, Scarberry K, Terlecki R. Platelet-Rich Plasma and Cellular Therapies for Sexual Medicine and Beyond. Sex Med Rev 2022;10:174-179.

A new paradigm for surgical revision of the artificial urinary sphincter for recurrent stress urinary incontinence: Wilson's Workshop 11.

Although the artificial urinary sphincter (AUS) is widely regarded as the "gold standard" for surgical correction of male stress urinary incontinence, long-term durability for symptom control is variable. A significant number of men will experience a decline in device-related improvement over time. With erosion of initial success, men sufficiently bothered by recurrent incontinence not caused by device malfunction may seek surgical revision. Secondary surgery requires careful consideration on the part of the prosthetic urologist and a keen awareness of sound surgical techniques. The armamentarium for revision has traditionally consisted of strategies involving cuff downsizing and/or relocation, modification of the pressure regulating balloon, urethral wrapping, addition of a tandem cuff, or use of transcorporal cuff placement. These options will be presented in view of their evidence and theoretical advantages and disadvantages. In addition, we will discuss a newer approach of growing popularity that serves to challenge existing dogma and shift the paradigm of AUS revision surgery.

Stem Cell and Gene-Based Therapy for Erectile Dysfunction: Current Status and Future Needs.

Erectile dysfunction affects an increasing number of men. The mainstays of management include oral medications, local erectogenic agents, and surgical placement of prosthetic devices. Newer technologies such as stem cell and gene therapy have been investigated as a means to restore spontaneous erectile capacity. Mesenchymal stem cells are thought to produce a local immunomodulatory and pro-repair milieu at the area of injury or needed repair. Gene therapy involves targeting the erectogenic pathway to augment factors involved in producing a natural erection. Such therapies are considered experimental and should be used in the setting of a clinical trial with appropriate oversight.

Acute Ischemic Priapism: An AUA/SMSNA Guideline.

PURPOSE: Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation and results in a prolonged and uncontrolled erection. Given its time-dependent and progressive nature, priapism is a situation that both urologists and emergency medicine practitioners must be familiar with and comfortable managing. Acute ischemic priapism, characterized by little or no cavernous blood flow and abnormal cavernous blood gases (ie, hypoxic, hypercarbic, acidotic) represents a medical emergency and may lead to cavernosal fibrosis and subsequent erectile dysfunction. MATERIALS AND METHODS: A comprehensive search of the literature was performed by Emergency Care Research Institute for articles published between January 1, 1960 and May 1, 2020. Searches identified 2948 potentially relevant articles, and 2516 of these were excluded at the title or abstract level for not meeting inclusion criteria for any key question. Full texts for the remaining 432 articles were reviewed, and ultimately 137 unique articles were included in the report. RESULTS: This Guideline was developed to inform clinicians on the proper diagnosis and surgical and non-surgical treatment of patients with acute ischemic priapism. This Guideline addresses the role of imaging, adjunctive laboratory testing, early involvement of urologists when presenting to the emergency room, discussion of conservative therapies, enhanced data for patient counseling on risks of erectile dysfunction and surgical complications, specific recommendations on intracavernosal phenylephrine with or without irrigation, the inclusion of novel surgical techniques (eg, tunneling), and early penile prosthesis placement. CONCLUSIONS: All patients with priapism should be evaluated emergently to identify the sub-type of priapism (acute ischemic versus non-ischemic) and those with an acute ischemic event should be provided early intervention. Treatment of the acute ischemic patient must be based on patient objectives, available resources, and clinician experience. As such, a single pathway for managing the condition is oversimplified and no longer appropriate. Using a diversified approach, some men may be treated with intracavernosal injections of phenylephrine alone, others with aspiration/irrigation or distal shunting, and some may undergo non-emergent placement of a penile prosthesis.

Second opinion pathologic review in the management of prostate cancer.

INTRODUCTION Inter-institutional re-review of prostate needle biopsy (PNBx) material is required at many institutions before definitive treatment, but adds time and cost and may not significantly alter urologic management. We aim to determine the utility of universal PNBx re-review on influencing the decision to recommend definitive local therapy for patients with prostate cancer. MATERIALS AND METHODS: From 2017-2020, 590 prostate biopsy specimens from outside institutions were re-reviewed at our center for patients considering prostatectomy. Clinical and pathologic characteristics from initial and secondary review were analyzed. Potential for change in treatment candidacy (CTC) was determined by re-diagnosis to non-malignant tissue or change in candidacy for active surveillance (AS) versus definitive treatment (i.e. prostatectomy or radiation therapy). Thus, the following scenarios were considered CTC: downgrading to non-malignant tissue, downgrading ISUP Grade Group (GG) ≥ 2 to GG1, and upgrading GG1 to GG ≥ 2. Any changes between GG2 to GG5 were not considered CTC, as definitive treatment would be offered to all groups. RESULTS: Overall, 55 patients (9.3%) had potential for CTC based on secondary review, all of whom had initial pathologic GG (iGG) ≤ 2. Of the 152 patients with iGG1, 8 were downgraded to no malignancy and 41 were upgraded to GG2 or GG3. Of the 185 patients with iGG2, 6 were downgraded to GG1. No patients with iGG ≥ 3 qualified for a CTC. Features associated with CTC included iGG, number of positive cores, and highest core percentage. Upon multivariable analysis, only iGG1 diagnosis was predictive of CTC (OR 23.66, p < 0.001). CONCLUSION: Second review may be helpful in determining need for definitive treatment in patients with GG1 and GG2 prostate cancer, i.e. those considering AS. This process appears unnecessary in GG3+ patients, as management for patients considering surgery would not change. This may allow for judicious redirection of hospital resources.

Patient Education Is Associated With Reduced Delay to Presentation for Management of Ischemic Priapism: A Retrospective Review of 123 Men.

BACKGROUND: Adverse outcomes secondary to ischemic priapism (IP) are associated with time to presentation and management. AIM: To characterize patterns in presentation delay as a function of etiology and patient education regarding IP risk. METHODS: Following institutional review board approval, charts of IP patients presenting to our institution from 2010 to 2020 were reviewed. One episode of IP per patient was included for analysis. OUTCOMES: Priapism duration in patients presenting with IP. RESULTS: We identified 123 unique patients with IP. Common etiologies included erectogenic intracavernosal injection (24%), trazodone (16%), and other psychiatric medications (16%). Patients with sickle cell anemia or trait and intracavernosal injection-related IP presented sooner than idiopathic cases and those from psychiatric medication (P < .001). Etiology and provider education on IP risk were associated with presentation ≥ 24 hours. Upon multivariate analysis, only a lack of provider education was independently associated with presentation ≥ 24 hours. CLINICAL IMPLICATIONS: Men who received provider-based education on the risk of IP associated with their condition or medication regimen were more likely to seek prompt medical attention for IP and, therefore, less likely to require surgery. STRENGTHS & LIMITATIONS: This manuscript represents one of the largest series on priapism, an area of urologic practice in need of more evidence-based guidance. The numbers are not inflated by including multiple episodes per patient, and the data collected include etiology, time to presentation, and treatment. Limitations include a retrospective chart review study design at a single institution. CONCLUSION: Educational initiatives on the risk of IP associated with particular disease states and medications should target at-risk individuals, as well as prescribers of medications associated with IP. Dutta1 R, Matz1 EL, Overholt TL, et al. Patient Education Is Associated With Reduced Delay to Presentation for Management of Ischemic Priapism: A Retrospective Review of 123 Men. J Sex Med 2021;18:385-390.

Fertility potential in adult men treated for uncorrected bilateral cryptorchidism: A systematic literature review and analysis of case reports.

OBJECTIVE: Reports of adult orchidopexy for bilateral undescended testicles (bUDT) are sparse, and fertility outcomes are not well established. Our aim was to determine prognosis for restoration of spermatogenesis among adult men (≥18 years) undergoing orchidopexy for bUDT. METHODS: A systematic literature review, conforming to the PRISMA statement, was conducted using the PubMed/MEDLINE and EMBASE databases through March 2020 using search terms "adult" AND "bilateral orchidopexy" OR "bilateral cryptorchidism." Relevant referenced articles from non-indexed journal were identified by Google Scholar search and additionally included. RESULTS: Fifty-seven publications including adult men with uncorrected bilateral UDTs were identified. Baseline semen analysis was reported in 157 men, all of whom demonstrated azoospermia. Testosterone values were reported in 82 cases and were normal in 89%. Germ cells could not be identified in 72.6% of histologic specimens from 62 testicles. Abdominal testicles more frequently lacked germ cells (90%, p = 0.038) on univariate analysis. Eleven cases identified ejaculated spermatozoa following adult bilateral orchidopexy (8 publications). Sperm extraction (TESE) during orchidopexy or orchiectomy was reported in 13 men without success. Delayed TESE (median 10 months) was performed in 22 persistently azoospermic men with success in 10 (45.5%), none of whom had abdominal testicles prior to orchidopexy. Six men experienced successful paternity via natural conception (3) or assisted reproduction (3). CONCLUSION: Fertility is possible in adult men with inguinal bUDT following orchidopexy. Subsequent sperm retrieval may involve ejaculated specimens or delayed TESE. TESE performed prior to or at time of orchidopexy is unlikely to be of benefit.

Salvage Penile Plication Is an Effective Modality for Resolving Residual Curvature After Surgery for Peyronie's Disease.

INTRODUCTION: Penile plication is highly successful in appropriately selected patients with Peyronie's disease; however, a minority of patients experience residual curvature or delayed recurrence of curvature. Revision surgery outcomes are seldomly reported. AIM: To determine the efficacy of salvage penile plication for the correction of residual and recurrent curvature. METHODS: Our institutional review board-approved prospective single-surgeon database of patients with Peyronie's disease was reviewed for cases performed from 2011 to 2019. Patients requiring salvage procedures were analyzed. A successful salvage was defined by residual curvature <20° with patient-reported satisfaction. Potential etiologies for initial plication failure were examined. MAIN OUTCOME MEASURE: The outcomes of this study are subjective and patient-reported success of salvage plication. RESULTS: Data analysis identified 134 men treated surgically for Peyronie's disease. Management involved plication in 105 (78.4%), incision and grafting in 14 (10.4%), excision and grafting with inflatable penile prosthesis in 7 (5.2%), plication with inflatable penile prosthesis in 6 (4.5%), or grafting, plication, and inflatable penile prosthesis in 2 (1.5%). Mean preoperative degree of curvature before initial surgery was 55° (30°-90°). Of this cohort, 5.2% (n=7) required salvage plication for a median residual or recurrent curvature of 45° (35°-90°). Initially, 3 men (43%) received an 8-dot plication, 3 (43%) underwent 16-dot plication, and 1 (14%) received plaque incision and grafting. Among salvage patients, 4 (57%) had initially satisfying results followed by recurrence of curvature and 3 (43%) desired correction of residual curvature. Salvage plication entailed an 8-dot plication in 3 (42.9%) and a 16-dot plication procedure in 4 (57.1%). The median time to salvage surgery was 9 (3-15) months, with all patients showing intraoperative resolution of curvature. At a median follow-up of 12 (1-20) months, 6 (85.7%) patients reported satisfaction with residual curvature <20°. CONCLUSION: Patients with residual or delayed recurrence of curvature after plication for Peyronie's disease can be effectively managed with salvage plication. Deebel NA, Scarberry K, Dutta R, et al. Salvage Penile Plication Is an Effective Modality for Resolving Residual Curvature After Surgery for Peyronie's Disease. Sex Med 2020;8:686-690.

Sustained Glycemic Control Observed in Diabetic Men Who Improve Hemoglobin A1c Values to Allow for Elective Penile Prosthesis Placement.

OBJECTIVES: We hypothesize that men with diabetes mellitus whose inflatable penile prosthesis (IPP) implantation is delayed for unacceptably high hemoglobin A1c (HbA1c) will have durable improvements in their glycemic control after achieving acceptable HbA1c levels for surgery. METHODS: Per institutional protocol, an A1c <9% must be documented prior to IPP placement. After IRB approval, a single surgeon IPP database was retrospectively queried for data specific to diabetes mellitus management. Men without HbA1c values at ≥1-year follow-up were excluded. Univariate and multivariate statistical analyses were performed to assess associations with sustained HbA1c control. RESULTS: From January 2011 to March 2019, 138 diabetics undergoing IPP were identified. Thirty-seven were excluding for insufficient follow-up. Nineteen of the 101 analyzed men (18.8%) were delayed a median 4 months (range 2-17) for elevated HbA1c values (median 10.1, range 9.1-12.3). Following improvements, median preoperative HbA1c remained higher (8.2% vs 7.0%) in delayed men (P < .001). Among delayed recipients, 11 (58%) improved without medication changes while insulin was newly initiated (5) or dosage was increased (5) in 42%. At 32 months follow-up, a HbA1c <9% was similarly maintained in delayed and nondelayed men (74% vs 87%, P = .17). Delayed men more commonly required insulin therapy at follow-up (89.5% vs 54.9%, P = .008), but had a similar median change in BMI (+0.1 vs +0.1, P = .65). Device infection occurred in 1 nondelayed patient (0.7%). CONCLUSION: Men who improve HbA1c for IPP surgery are likely to demonstrate persistent improvement. IPP implantation appears to be safe in diabetic men with HbA1c <9%.

Hip Joint Pathology Among Men Referred to Urology for Chronic Orchialgia: A Source for Misdiagnosis and Opportunity for Quality Improvement.

OBJECTIVE: To evaluate the findings of magnetic resonance imaging (MRI) of the ipsilateral hip(s) as part of the workup of men with chronic orchialgia (CO). METHODS: Following IRB approval, a retrospective chart review was performed from a single surgeon database of all men with a diagnosis of CO from June 2018 to October 2019 who underwent subsequent hip MRI evaluation. RESULTS: Ten men were identified. Median age was 51 years and median duration of pain was 10 months. MRI was obtained after testis pathology was ruled out. Pain was noted in the groin (100%) and hip (50%). Hip MRI identified overt labral tears in 8 men (10/12 hips evaluated, 83%) and labral fraying in the remaining 2 (16.7%). Standard plain film radiography was performed in 6 men prior to MRI, all of which were negative. Following MRI, 5 men underwent hip injection with steroid and local analgesic with lasting resolution (2 men) or significant improvement in pain (2 men; 80%, follow-up 3-15 months). Two men had complete resolution of pain with 8 weeks of physical therapy. CONCLUSION: Hip MRI has a high rate of diagnosis of labral tear in appropriately selected men referred to the urologist for CO. Identification of orthopedic pathology may avoid unnecessary antibiotics, opiates, or urological surgery. Referrals to orthopedics and/or physical therapy for intervention may lead to resolution of pain.