Systematic Review of the Impact of Varicocele Grade on Response to Surgical Management.

PURPOSE: We evaluated the impact of varicocele grade on the response to varicocelectomy or spermatic vein embolization. MATERIALS AND METHODS: We systematically reviewed the published English language literature to identify studies on changes in semen quality and pregnancy outcomes after varicocele treatment, stratified by varicocele grade. Descriptive statistics and continuous random effects models were used to study the impact of varicocele grade and the surgical approach on the response to treatment. Result heterogeneity among studies was analyzed using the I2 statistic. Quality assessment of nonrandomized studies was done with the Newcastle-Ottawa Scale. Publication bias was analyzed using funnel plots and the Egger test. RESULTS: We identified 20 studies describing the outcome of varicocele treatment stratified by varicocele grade in a total of 2,001 infertile men with varicocele. A microsurgical approach (inguinal, subinguinal and/or Palomo) was used in 11 of the 20 studies (55%). Varicocele treatment was associated with improvements in sperm concentration and overall motility in patients with all grades of varicocele. Semen quality improvements were directly related to varicocele grade. The mean sperm concentration improvement in men with grades 1, 2, 2-3 and 3 varicoceles were 5.5, 8.9, 12.7 and 16.0 million sperm per ml, respectively. The mean improvement in the percent of overall motility in men with grades 1, 2, 2-3 and 3 varicoceles was 9.6%, 10.6%, 10.8% and 17.7%, respectively. Pregnancy outcomes were assessed but could not be analyzed systematically due to the lack of adequate published data. CONCLUSIONS: Mean improvements in the sperm concentration and the percent of overall motility after treatment of grade 1 varicocele were statistically significant but small in magnitude. In contrast, mean improvements in the sperm concentration and the percent of overall motility after treatment of grade 2-3 varicoceles were greater and highly likely to be clinically significant. Incorporating varicocele grade into shared decision making discussions with affected couples may improve the ability to select patients who are the best candidates for treatment.

Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses.

BACKGROUND: Fungal infections of inflatable penile prostheses (IPPs) are inadequately understood in the literature. AIM: To review a multi-institution database of IPP infections to examine for common patient and surgical factors related to IPP fungal infections. METHODS: This is a retrospective Institutional Review Board-approved analysis of 217 patients at 26 institutions who underwent salvage or device explant between 2001 and 2018. Patient data were compiled after an extensive record review. OUTCOMES: 26 patients (12%) with fungal infections were identified. RESULTS: 23 of 26 patients (83%) with a fungal IPP infection were either diabetic or overweight. 15 patients had undergone primary IPP implantation, and the other 11 had previously undergone an average of 1.7 IPP-related surgeries (range 1-3; median 2). The average age at implantation was 63 years (range 31-92; median 63). 18 of the 26 patients with fungal infection had diabetes (69%), with a mean hemoglobin A1c (HbA1c) value of 8.4 (range 5.8-13.3; median 7.5). Twenty-two patients (85%) were overweight or obese. The mean body mass index for all patients was 30.1 kg/m2 (range 23.7-45 kg/m2; median 28.4 kg/m2), and that for diabetic patients was 30.8 kg/m2 (range 24.1-45 kg/m2, median 29.7 kg/m2). Ninety-one percent of implants were placed with intravenous antibiotics, consistent with current American Urological Association guidelines: an aminoglycoside plus first- or second-generation cephalosporin or vancomycin or ampicillin/sulbactam or piperacillin/tazobactam. 65% (17 of 26) of infected IPPs had only fungal growth in culture. No patient had concomitant immunosuppressive disease or recent antibiotic exposure before IPP implantation. CLINICAL IMPLICATIONS: More than two-thirds of the fungal infections occurred in diabetic patients and 85% occurred in overweight or obese patients, suggesting that antifungal prophylaxis may be appropriate in these patients. STRENGTHS & LIMITATIONS: This is the largest series of fungal infections reported to date in the penile prosthesis literature. The overall number of such cases, however, remains small. CONCLUSION: Fungal infections represent 12% of all penile prosthesis infections in our series and were seen mostly in diabetic or overweight patients, who may benefit from antifungal prophylaxis. Gross MS, Reinstatler L, Henry GD, et al. Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses. J Sex Med 2019;16:1100-1105.

The association between elevated serum oestradiol levels and clinically significant erectile dysfunction in men presenting for andrological evaluation.

The goal of this study was to investigate the association between serum oestradiol levels and clinically significant erectile dysfunction in a cohort of men presenting for andrological evaluation. Retrospective review was conducted of patients that presented to a urologist with practice in andrology over an 18-month period. Patients completed the Male Sexual Health Questionnaire and had serum total testosterone and oestradiol measurements prior to 10:30 a.m. via immunoassay. t Tests, chi-square tests and multivariate logistic regression were used to compare clinical characteristics between those with adequate erectile function (erection scale score > 2) vs. clinically significant erectile dysfunction (erection scale score ≤ 2). Among 256 patients, average age was 49 years (SD 15), average serum oestradiol was 22.3 pg/ml (SD 10.6), and average serum total testosterone was 465.9 pg/ml (SD 206.3). On multivariate logistic regression, serum oestradiol was associated with clinically significant erectile dysfunction (OR 1.52 per SD increase, 95% CI 1.11-2.09, p = 0.009) when controlling for serum total testosterone, age, body mass index and smoking status. These results warrant future studies on the utility of measuring serum oestradiol in patients with erectile dysfunction and the use of aromatase inhibitors in patients with erectile dysfunction and elevated serum oestradiol.

Trends in Penile Prosthetics: Influence of Patient Demographics, Surgeon Volume, and Hospital Volume on Type of Penile Prosthesis Inserted in New York State.

INTRODUCTION: Penile prostheses (PPs) are a discrete, well-tolerated treatment option for men with medical refractory erectile dysfunction. Despite the increasing prevalence of erectile dysfunction, multiple series evaluating inpatient data have found a decrease in the frequency of PP surgery during the past decade. AIMS: To investigate trends in PP surgery and factors affecting the choice of different PPs in New York State. METHODS: This study used the New York State Department of Health Statewide Planning and Research Cooperative (SPARCS) data cohort that includes longitudinal information on hospital discharges, ambulatory surgery, emergency department visits, and outpatient services. Patients older than 18 years who underwent inflatable or non-inflatable PP insertion from 2000 to 2014 were included in the study. OUTCOMES: Influence of patient demographics, surgeon volume, and hospital volume on type of PP inserted. RESULTS: Since 2000, 14,114 patients received PP surgery in New York State; 12,352 PPs (88%) were inflatable and 1,762 (12%) were non-inflatable, with facility-level variation from 0% to 100%. There was an increasing trend in the number of annual procedures performed, with rates of non-inflatable PP insertion decreasing annually (P < .01). More procedures were performed in the ambulatory setting over time (P < .01). Important predictors of device choice were insurance type, year of insertion, hospital and surgeon volume, and the presence of comorbidities. CLINICAL IMPLICATIONS: Major influences in choice of PP inserted include racial and socioeconomic factors and surgeon and hospital surgical volume. STRENGTHS AND LIMITATIONS: Use of the SPARCS database, which captures inpatient and outpatient services, allows for more accurate insight into trends in contrast to inpatient sampling alone. However, SPARCS is limited to patients within New York State and the results might not be generalizable to men in other states. Also, patient preference was not accounted for in these analyses, which can play a role in PP selection. CONCLUSIONS: During the past 14 years, there has been an increasing trend in inflatable PP surgery for the management of erectile dysfunction. Most procedures are performed in the ambulatory setting and not previously captured by prior studies using inpatient data. Kashanian JA, Golan R, Sun T, et al. Trends in Penile Prosthetics: Influence of Patient Demographics, Surgeon Volume, and Hospital Volume on Type of Penile Prosthesis Inserted in New York State. J Sex Med 2018;15:245-250.

Impact of Surgeon Case Volume on Reoperation Rates after Inflatable Penile Prosthesis Surgery.

PURPOSE: We investigated the impact of surgeon annual case volume on reoperation rates after inflatable penile prosthesis surgery. MATERIALS AND METHODS: The New York Statewide Planning and Research Cooperative System database was queried for inflatable penile prosthesis cases from 1995 to 2014. Multivariate proportional hazards regression was performed to estimate the impact of surgeon annual case volume on inflatable penile prosthesis reoperation rates. We stratified our analysis by indication for reoperation to determine if surgeon volume had a similar effect on infectious and noninfectious complications. RESULTS: A total of 14,969 men underwent inflatable penile prosthesis insertion. Median followup was 95.1 months (range 0.5 to 226.7) from the time of implant. The rates of overall reoperation, reoperation for infection and reoperation for noninfectious complications were 6.4%, 2.5% and 3.9%, respectively. Implants placed by lower volume implanters were more likely to require reoperation for infection but not for noninfectious complications. Multivariable analysis demonstrated that compared with patients treated by surgeons in the highest quartile of annual case volume (more than 31 cases per year), patients treated by surgeons in the lowest (0 to 2 cases per year), second (3 to 7 cases per year) and third (8 to 31 cases per year) annual case volume quartiles were 2.5 (p <0.001), 2.4 (p <0.001) and 2.1 (p=0.01) times more likely to require reoperation for inflatable penile prosthesis infection, respectively. CONCLUSIONS: Patients treated by higher volume implanters are less likely to require reoperation after inflatable penile prosthesis insertion than those treated by lower volume surgeons. This trend appears to be driven by associations between surgeon volume and the risk of prosthesis infection.

Three-Dimensional Photography for Quantitative Assessment of Penile Volume-Loss Deformities in Peyronie's Disease.

BACKGROUND: Non-curvature penile deformities are prevalent and bothersome manifestations of Peyronie's disease (PD), but the quantitative metrics that are currently used to describe these deformities are inadequate and non-standardized, presenting a barrier to clinical research and patient care. AIM: To introduce erect penile volume (EPV) and percentage of erect penile volume loss (percent EPVL) as novel metrics that provide detailed quantitative information about non-curvature penile deformities and to study the feasibility and reliability of three-dimensional (3D) photography for measurement of quantitative penile parameters. METHODS: We constructed seven penis models simulating deformities found in PD. The 3D photographs of each model were captured in triplicate by four observers using a 3D camera. Computer software was used to generate automated measurements of EPV, percent EPVL, penile length, minimum circumference, maximum circumference, and angle of curvature. The automated measurements were statistically compared with measurements obtained using water-displacement experiments, a tape measure, and a goniometer. OUTCOMES: Accuracy of 3D photography for average measurements of all parameters compared with manual measurements; inter-test, intra-observer, and inter-observer reliabilities of EPV and percent EPVL measurements as assessed by the intraclass correlation coefficient. RESULTS: The 3D images were captured in a median of 52 seconds (interquartile range = 45-61). On average, 3D photography was accurate to within 0.3% for measurement of penile length. It overestimated maximum and minimum circumferences by averages of 4.2% and 1.6%, respectively; overestimated EPV by an average of 7.1%; and underestimated percent EPVL by an average of 1.9%. All inter-test, inter-observer, and intra-observer intraclass correlation coefficients for EPV and percent EPVL measurements were greater than 0.75, reflective of excellent methodologic reliability. CLINICAL TRANSLATION: By providing highly descriptive and reliable measurements of penile parameters, 3D photography can empower researchers to better study volume-loss deformities in PD and enable clinicians to offer improved clinical assessment, communication, and documentation. STRENGTHS AND LIMITATIONS: This is the first study to apply 3D photography to the assessment of PD and to accurately measure the novel parameters of EPV and percent EPVL. This proof-of-concept study is limited by the lack of data in human subjects, which could present additional challenges in obtaining reliable measurements. CONCLUSION: EPV and percent EPVL are novel metrics that can be quickly, accurately, and reliably measured using computational analysis of 3D photographs and can be useful in describing non-curvature volume-loss deformities resulting from PD. Margolin EJ, Mlynarczyk CM, Muhall JP, et al. Three-Dimensional Photography for Quantitative Assessment of Penile Volume-Loss Deformities in Peyronie's Disease. J Sex Med 2017;14:829-833.

Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis.

INTRODUCTION: Penile prosthesis infections remain challenging despite advancements in surgical technique, device improvements, and adoption of antibiotic prophylaxis guidelines. AIM: To investigate penile prosthesis infection microbiology to consider which changes in practice could decrease infection rates, to evaluate current antibiotic prophylaxis guidelines, and to develop a proposed algorithm for penile prosthesis infections. METHODS: This retrospective institutional review board-exempt multi-institutional study from 25 centers reviewed intraoperative cultures obtained at explantation or Mulcahy salvage of infected three-piece inflatable penile prostheses (IPPs). Antibiotic usage was recorded at implantation, admission for infection, and explantation or salvage surgery. Cultures were obtained from purulent material in the implant space and from the biofilm on the device. MAIN OUTCOME MEASURES: Intraoperative culture data from infected IPPs. RESULTS: Two hundred twenty-seven intraoperative cultures (2002-2016) were obtained at salvage or explantation. No culture growth occurred in 33% of cases and gram-positive and gram-negative organisms were found in 73% and 39% of positive cultures, respectively. Candida species (11.1%), anaerobes (10.5%) and methicillin-resistant Staphylococcus aureus (9.2%) constituted nearly one third of 153 positive cultures. Multi-organism infections occurred in 25% of positive cultures. Antibiotic regimens at initial implantation were generally consistent with American Urological Association (AUA) and European Association of Urology (EAU) guidelines. However, the micro-organisms identified in this study were covered by these guidelines in only 62% to 86% of cases. Antibiotic selection at admissions for infection and salvage or explantation varied widely compared with those at IPP implantation. CONCLUSION: This study documents a high incidence of anaerobic, Candida, and methicillin-resistant S aureus infections. In addition, approximately one third of infected penile prosthesis cases had negative cultures. Micro-organisms identified in this study were not covered by the AUA and EAU antibiotic guidelines in at least 14% to 38% of cases. These findings suggest broadening antibiotic prophylaxis guidelines and creating a management algorithm for IPP infections might lower infection rates and improve salvage success. Gross MS, Phillips EA, Carrasquillo RJ, et al. Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis. J Sex Med 2017;14:455-463.

Risk Factors for Priapism Readmission.

INTRODUCTION: Priapism is a urologic emergency with a tendency to recur in some patients. The frequency of, time to, and risk factors for priapism recurrence have not been well characterized. AIM: To identify predictors of priapism readmission. METHODS: We used the New York Statewide Planning and Research Cooperative System database to identify patients presenting to emergency departments with priapism from 2005 through 2014. Patients were tracked up to 12 months after initial presentation. Proportional hazards regression was used to identify risk factors for priapism readmission. MAIN OUTCOME MEASURES: Readmissions for priapism. RESULTS: The analytic cohort included 3,372 men with a diagnosis of priapism. The average age at first presentation was 39 ± 18 years and 40% were black. Within 1 year, 24% of patients were readmitted for recurrent priapism, 68% of whom were readmitted within 60 days. On multivariate analysis, sickle cell disease (hazard ratio [HR] = 2.5, 95% CI = 2.0-3.0), drug abuse or psychiatric disease (HR = 1.9, 95% CI = 1.6-2.2), erectile dysfunction history (HR = 1.9, 95% CI = 1.5-2.3), other than commercial medical insurance (HR = 1.2, 95% CI = 1.0-1.4), and inpatient admission for initial priapism event (HR = 0.5, 95% CI = 0.4-0.6) were significant risk factors for readmission. CONCLUSION: Nearly one fourth of patients with priapism were readmitted for recurrent priapism within 1 year of initial presentation. Most readmissions were within 60 days. Future research should focus on strategies to decrease recurrences in high-risk patients.

Variation in Penile Hemodynamics by Anatomic Location of Cavernosal Artery Imaging in Penile Duplex Doppler Ultrasound.

INTRODUCTION: Standard operating procedures (SOP) for penile duplex Doppler ultrasound (PDDU) were published in 2013 to promote uniform vascular assessment for erectile dysfunction (ED). However, SOPs do not specify a standard anatomic location for cavernosal artery (CA) imaging. AIM: The aim of this study was to determine the effects of CA imaging location on measured penile hemodynamics assessed by PDDU. METHODS: PDDU was performed in men with ED and/or Peyronie's disease. CA peak systolic velocity (PSV) and end diastolic velocity (EDV) were measured at three points: the origin of the CA within the penile crus, the proximal CA, and mid-CA. Differences in PSV and EDV were assessed by Friedman test and categorical vascular outcomes by Fisher's exact test. Data were analyzed for the main cohort, the subgroup with maximal smooth muscle relaxation (SMR) as defined by negative EDV, and the subgroup with valid-for-intromission erections. MAIN OUTCOME MEASURES: Mean PSV and EDV at three specified CA locations and the vascular diagnoses resulting from these measurements. RESULTS: One hundred four CAs were imaged in 52 men. Mean PSVs at the crus, proximal, and mid-CA were 52.9 ± 20.2, 29.5 ± 15.1, and 21.6 ± 10.6 cm/s, respectively (P < 0.0001); mean EDVs were 2.1 ± 8.9, 3.2 ± 5.4, and 3.3 ± 3.5 cm/s, respectively (P = 0.1225). The distribution of arteriogenic (P < 0.0001) and venogenic (P < 0.0001) diagnoses both differed significantly by location. Significant differences in vasculogenic diagnoses were also observed in the subgroup of CAs with definite maximal SMR (n = 38, arteriogenic P < 0.0001, venogenic P = 0.007) and in those with valid-for-intromission erections (n = 68, arteriogenic P < 0.0001, venogenic P = 0.0002). CONCLUSION: There is large variability in measured PSV and EDV on PDDU depending on the site of Doppler imaging, which can often sway clinical diagnosis. Future guidelines should attempt to incorporate standard locations of CA imaging, and new normative values may be necessary for each location.

Contemporary management of male infertility.

Knowledge of normal male reproductive function and familiarity with the diagnostic evaluation and treatment of male subfertility is beneficial for most physicians. Male subfertility is often correctable, may be genetically transmissible, and may be associated with occult health-threatening conditions. Herein we present an overview of male reproductive medicine, which has been revolutionized in the past two decades by dramatic scientific and therapeutic advances. The development of intracytoplasmic sperm injection and its successful application to sperm retrieved from the epididymis or testis have made biological paternity possible in men previously considered sterile. Microsurgical techniques for vasal-epididymal reconstruction and sperm retrieval have been refined. Novel tests of semen quality have been developed. Medical therapies to improve sperm production, such as estrogen receptor modulation and aromatase inhibition, have been used increasingly in clinical practice. Finally, associations between male subfertility and a spectrum of health-threatening conditions have been recognized.

Genetic evaluation of the azoospermic or severely oligozoospermic male.

PURPOSE OF REVIEW: The purpose of this review is to provide a contemporary overview of the genetic evaluation of azoospermic or severely oligozoospermic men. RECENT FINDINGS: Genetic tests should be selected based upon the initial clinical evaluation. Patients with vasal agenesis or unexplained obstructive azoospermia and low semen volume should be tested for abnormalities of the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Cytogenetic testing (karyotype) and Y chromosome microdeletion (YCMD) screening are indicated in all cases when severely impaired sperm production due to testicular failure is suspected. Mutational screening of commonly implicated genes should be considered when congenital hypogonadotropic hypogonadism is clinically apparent. SUMMARY: A clinically directed genetic evaluation is indicated in all azoospermic and severely oligozoospermic men. Such genetic testing is informative about the cause of infertility, the prognosis for biological paternity using assisted reproduction, and the risks of genetic abnormalities and disease in offspring. Future genetic testing may reveal a predisposition for medical conditions beyond infertility that warrant clinical management.

Diagnosis of the gr/gr Y chromosome microdeletion does not help in the treatment of infertile American men.

PURPOSE: The phenotypic effects of the gr/gr partial azoospermia factor c deletion vary geographically and to our knowledge have not been reported in the American population. We evaluated the clinical characteristics of infertile American men with the gr/gr deletion. MATERIALS AND METHODS: We retrospectively reviewed clinical data on 1,410 infertile men tested for the gr/gr deletion. We analyzed sperm concentration and the outcome of microdissection testicular sperm extraction with respect to gr/gr status. RESULTS: We identified 73 men with gr/gr deletions, including 43 of 989 (4.3%) with azoospermia, 18 of 317 (5.7%) with severe oligospermia (less than 5 million sperm per ml), 6 of 61 (9.8%) with oligospermia (5 to less than 20 million sperm per ml) and 6 of 43 (14%) infertile men with normospermia (greater than 20 million sperm per ml). A gr/gr deletion correlated with higher sperm production. The gr/gr deletion rate was higher in men with normospermia than in those with a sperm concentration of less than 20 million and less than 5 million per ml (p = 0.021 and 0.006, respectively). Microdissection testicular sperm extraction was done in 22 azoospermic men with gr/gr deletions and sperm were retrieved in 14 (64%). This retrieval rate was similar to that at our center in men with idiopathic nonobstructive azoospermia (p = 0.13). CONCLUSIONS: Diagnosis of the gr/gr deletion did not predict impaired sperm production in our patient population and did not appear to alter the prognosis for surgical sperm retrieval. Despite the established modulatory impact of the gr/gr deletion on sperm production in some populations at this time the clinical value of testing infertile American men for the gr/gr deletion is not clear.

Interpretation of the semen analysis and initial male factor management.

A practical approach to semen analysis (SA) interpretation and the initial management of subfertile men is presented. Each parameter of the SA is described and management recommendations based upon SA findings are provided. The indications for and interpretation of adjunctive diagnostic testing for male factor subfertility are also discussed.

Indications and strategies for fertility preservation in men.

Fertility preservation is feasible in the majority of men. Herein, we review the reproductive toxicities of commonly encountered clinical threats to male fertility, including cancer, radiotherapy, chemotherapy, surgery, and nonmalignant diseases treated with immunosuppression. Other scenarios, in which fertility preservation may be considered, such as Klinefelter syndrome, acute testicular injury, and sudden unexpected death, are also discussed. We provide an algorithmic approach to fertility preservation in men, and review strategies for sperm acquisition in cases of ejaculatory dysfunction and azoospermia. Lastly, emerging options for fertility preservation in prepubertal boys are discussed.

Worldwide trends in penile implantation surgery: data from over 63,000 implants.

BACKGROUND: Penile prosthesis implantation represents the gold standard of treatment for severe or medically refractory erectile dysfunction (ED). We sought to address the paucity of currently available literature about global penile prosthesis usage in regard to geography, patient age, surgical approach, implanter volume, and etiology of ED. METHODS: From device manufacturer information, we compiled data on over 63,000 implants performed worldwide. Data was grouped and then analyzed to examine trends in penile implantation between the years of 2005-2012. RESULTS: The number of implants was seen to steadily increase over the study period. Of the 63,013 total procedures recorded, 85.9% were performed within the United States. 60-78% of procedures were done using the penoscrotal (PS) approach, with only Belgium/Netherlands as an outlier with an infrapubic (INF) majority. The US was notable for having an increasing number of implanters doing 16-30, 31-50, or >100 implants yearly. Etiology of ED worldwide was variable, but "organic," post-prostatectomy, and diabetes accounted for the vast majority of cases worldwide. CONCLUSIONS: Penile prosthesis implantation is an increasing practice, as evidenced by a steady increase in the number of implants performed over a 7-year study period. Acceptance of this treatment option for ED is variable by region with the US leading the annual number of implantations by a wide margin. Worldwide, there appears to be a predominance of surgeons placing implants via the PS approach.

Multicenter investigation on the influence of climate in penile prosthesis infection.

The purpose of this study is to investigate the relationship between inflatable penile prosthesis (IPP) infection, time of year, climate, temperature and humidity. This is a retrospective IRB-approved analysis of 211 patients at 25 institutions who underwent salvage procedure or device explant between 2001 and 2016. Patient data were compiled after an extensive review of all aspects of their electronic medical records. Climate data were compiled from monthly norms based on location, as well as specific data regarding temperature, dew point, and humidity from dates of surgery. Rigorous statistical analysis was performed. We found that penile prosthesis infections occurred more commonly in June (n = 24) and less frequently during the winter months (n = 39), with the lowest number occurring in March (n = 11). One-hundred thirty-nine infections occurred at average daily temperatures greater than 55 °F, compared to 72 infections at less than 55 °F. The incidence rate ratio for this trend was 1.93, with a p-value of <0.001. Humidity results were similar, and fungal infections correlate with daily humidity. Infected implants performed in the fall and summer were over 3 and 2.3 times, respectively, more likely to grow Gram-positive bacteria compared to implants performed in spring (p = 0.004; p = 0.039). This was consistent across geographic location, including in the Southern hemisphere. We found trends between climate factors and IPP infection like those seen and proven in other surgical literature. To our knowledge these data represent the first exploration of the relationship between temperature and infection in prosthetic urology.

Receiving Industry Payments is Associated with Prescribing Habits of Tadalafil.

INTRODUCTION: We evaluated whether industry payments for tadalafil are associated with prescribing habits among urologists and primary care physicians. METHODS: The Medicare Part D Public Use File and Open Payments Program database were linked to identify urologists and primary care physicians who prescribed and received a payment for tadalafil in 2015. We determined whether the presence and extent of payment were associated with tadalafil prescription habits. Statistical tests included the chi-squared test, Mann-Whitney U test, logistic regression and Pearson correlation coefficient. RESULTS: Within 2015 Medicare Part D 2,602 urologists and 3,095 primary care physicians prescribed tadalafil. In the 2015 Open Payments/General Payments database 2,304 urologists and 12,465 primary care physicians received a payment from Eli Lilly and Company pertaining to tadalafil. The range of individual payments was $10.21 to $15,478.88 (median $25.16) for urologists and $1.39 to $21,681 (median $20.11) for primary care physicians. The presence of payment was associated with prescription of tadalafil for primary care physicians (OR 4.48, 95% CI 3.67-5.50, p <0.001) but not for urologists (p=0.922). Urologist prescription was not associated with increasing payment amount or greater number of payments. For primary care physicians there was an association of prescribing tadalafil with increasing payment amount (OR 1.01, 95% CI 1.00-1.02, p=0.02) and increasing number of payments (OR 1.15, 95% CI 1.03-1.28, p=0.01). There were weak but statistically significant correlations between claim count and payment amount for urologists and primary care physicians (r=0.063 and r=0.1, respectively, p <0.05). CONCLUSIONS: There is a significant relationship between payments and tadalafil prescribing habits. Scrutiny of these relationships has value in improving transparency and reflects the importance of the Open Payments system.

Diabetes Is a Risk Factor for Inflatable Penile Prosthesis Infection: Analysis of a Large Statewide Database.

INTRODUCTION: Although diabetes mellitus (DM) is often discussed as a risk factor for inflatable penile prosthesis (IPP) infection, the link between DM diagnosis and IPP infection remains controversial. High-quality population-based data linking DM to an increased risk of IPP infection have not been published. AIM: To evaluate the association of DM with IPP infection in a large public New York state database. METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for men who underwent initial IPP insertion from 1995-2014. Diabetic patients were identified using ICD-9-CM codes. Patients presenting for first operation with diagnosis or Current Procedural Terminology codes suggestive of prior IPP surgery were excluded. Chi-squared analyses were performed to compare infection rates in diabetics and non-diabetics within the pre- and postantibiotic impregnated eras. Multivariate Cox proportional hazards models were constructed to evaluate whether or not DM was independently associated with IPP infection in the time periods before (1995-2003) and after (2004-2014) the widespread availability of antibiotic impregnated penile prostheses. MAIN OUTCOME MEASURE: Time to prosthesis infection was measured. RESULTS: 14,969 patients underwent initial IPP insertion during the study period. The overall infection rate was 343/14,969 (2.3%). Infections occurred at a median 3.9 months after implant (interquartile ratio: 1.0-25.0 months). Infectious complications were experienced by 3% (133/4,478) of diabetic patients and 2% (210/10,491) of non-diabetic patients (P < .001). Diabetes was associated with a significantly increased IPP infection risk on multivariable analysis controlling for age, race, comorbidities, insurance status, annual surgeon volume, and era of implantation (Hazard Ratio: 1.32, 95% CI: 1.05-1.66, P = .016). CONCLUSION: Our analysis supports the notion that DM is a risk factor for IPP infection. This has important implications for patient selection and counseling, and raises the question of whether this increased risk can be mitigated by optimization of glycemic control before surgery. Lipsky MJ, Onyeji I, Golan R, et al. Diabetes Is a Risk Factor for Inflatable Penile Prosthesis Infection: Analysis of a Large Statewide Database. Sex Med 2019;7:35-40.

Penile Length: Measurement Technique and Applications.

INTRODUCTION: Penile size has long been an important fixation in men's lives. On the one hand, a smaller penis has been associated with anxiety and apprehension; on the other hand, a larger penis has generally been related to virility and strength. These perceptions predominate during an erection, when penile size is representative of a man's masculinity. AIM: To assess adult penile length and summarize average penile length assessments from the literature; analyze how various urologic diseases and therapies affect penile length and volume; and review how surgical treatments for Peyronie's disease, penile prosthesis implantation, and radical prostatectomy can affect penile size to appropriately counsel patients seeking such therapies and set realistic goals for patients. METHODS: To achieve the aim of this review, we analyzed the literature on penile size and volume and how these can be affected by various urologic diagnoses and therapies. We summarize common diagnoses and therapies that can affect penile size. MAIN OUTCOME MEASURE: We thoroughly discuss how the aforementioned diagnoses and therapies can negatively affect penile size. In doing so, we allow readers to understand the intricacies of penile size when faced with such diagnoses and therapies in their patients. RESULTS: Surgical treatments for Peyronie's disease, penile prosthesis implantation for refractory erectile dysfunction, and radical prostatectomy for prostate cancer can lead to a decrease in penile size. CONCLUSION: Urologists must recognize that the different therapies they offer can affect a man's penile size, often negatively. This in turn can lead to poorer satisfaction outcomes in patients. Davoudzadeh EP, Davoudzadeh NP, Margolin E, et al. Penile Length: Measurement Technique and Applications. Sex Med Rev 2018;6:261-271.