Delayed placement of an inflatable penile prosthesis is associated with a high complication rate in men with a history of ischemic priapism.

BACKGROUND: Corporal fibrosis is known to result from prolonged priapism; however, the impact of the timing of penile prosthesis placement after priapism on complication rates is poorly understood. AIM: We sought to evaluate the impact of timing of inflatable penile prosthesis (IPP) placement on complications in men with a history of ischemic priapism. METHODS: We performed a multicenter, retrospective cohort study of patients with a history of priapism undergoing IPP placement by 10 experienced implantation surgeons. We defined early placement as ≤6 months from priapism to IPP. We identified a 1:1 propensity-matched group of men without a history of priapism and compared complication rates between men who had early placement, late placement, and no history of priapism. OUTCOMES: Our primary outcome was postoperative noninfectious complications, and secondary outcomes included intraoperative complications and postoperative infection. RESULTS: A total of 124 men were included in the study with a mean age of 50.3 ± 12.7 years. A total of 62 had a history of priapism and 62 were matched control subjects. The median duration of priapism was 37 (range, 3-168) hours and the median time from ischemic priapism to IPP placement was 15 months (range, 3 days to 23 years). Fifteen (24%) men underwent early (≤6 months) IPP placement at a median time of 2 months (range, 3 days to 6 months) following the ischemic priapism event. The remaining 47 (76%) underwent placement >6 months following priapism at a median time of 31.5 months (range, 7 months to 23 years). The complication rate in the delayed placement group was 40.5% compared with 0% in the early placement group and control group. Cylinder-related complications such as migration or leak accounted for 8 (57%) of 14 of the postoperative noninfectious complications. Full-sized cylinders were used in all patients who had a cylinder related complication. CLINICAL IMPLICATIONS: Priapism patients should be referred to prosthetic experts early to decrease complication rates in those needing an IPP. STRENGTHS AND LIMITATIONS: This is a multicenter study from experienced prosthetic urologists but is limited by the retrospective nature and small number of patients in the early placement group. CONCLUSION: IPP complication rates are high in men with a history of ischemic priapism, especially when implantation is delayed beyond 6 months.

The fragile urethra: what to do next?-a narrative review.

Background and Objective: Although the artificial urinary sphincter (AUS) has demonstrated successful outcomes in treating male stress urinary incontinence (SUI) for the past five decades, this procedure also carries inherent risks, including recurrent SUI, device malfunction, local tissue compromise, and infection/erosion, all of which may require revision surgery with or without device replacement. Patients that are at the highest risk for such untoward events often possess unhealthy urethral tissue (termed a "fragile urethra") that is compromised and unable to provide optimal cuff coaptation and continence. Accordingly, there are several techniques to address recalcitrant SUI in the setting of a fragile urethra to afford an improved chance of return to continence. Here, we review characteristics of patients that are at higher risk for an untoward outcome following AUS implantation and further define strategies to promote optimal success with device implantation. The aim of this paper is to review the available literature and describe surgical options for male SUI in patients with known or anticipated urethral tissue compromise. Methods: A thorough literature review was completed by querying PubMed for relevant articles. Search terms included artificial urinary sphincter, failure, recalcitrant, urethral atrophy, fragile urethra, revision, radiation, cystectomy, incontinence, and/or urethroplasty published between 1975 and 2022. Key Content and Findings: Options for management of the fragile urethra include cuff relocation, cuff downsizing, tandem cuff placement, transcorporal cuff placement, pressure regulating balloon exchange with increased or decreased pressure, bulbospongiosus preservation, sub-cuff ventral capsulotomy, urethral wrapping with graft, and in select cases, urinary diversion, or complete device removal with a return to SUI. Proper patient selection is paramount to optimize outcomes. Advantages and disadvantages of each strategy are reviewed. Conclusions: Numerous techniques are viable options for patients with recalcitrant SUI in the setting of a fragile urethra, but high-quality evidence with reproducible outcomes for many of these strategies remain limited. Proper patient selection as well as adequate counseling by experienced implant surgeons may help optimize outcomes. Further multi-institutional investigations with longer term outcomes are needed to improve patient selection and counseling with shared decision-making prior to any intervention.

Penoscrotal inflatable penile prosthesis recipients often fully recover from pain at two weeks following placement.

The symptoms and duration of pain following inflatable penile prosthesis (IPP) surgery remains poorly understood. We characterize postoperative pain following penoscrotal 3-piece inflatable penile prosthesis placement in patients managed with a standardized pain management protocol. This is a single-center prospective analysis of 96 virginal penoscrotal 3-piece IPP recipients (9/2019 to 9/2021) excluding patients with chronic pain, IPPs performed with alternative approaches or concomitantly with other surgeries and those with infections. Standardized pain questionnaire was performed by phone on post-operative day (POD) 2, 7, 14, and 30. The primary outcome was self-reported pain scores, measured by pain score 0-10 (0 = no pain, 10 = unbearable, "worst pain you have ever felt") at various locations (incision, penile, scrotal, abdominal) over the first 30 days postoperatively. A majority of pain reported was outside the scrotal area with 67.6% of complaints in the shaft, glans, abdomen and incision. From POD2 to POD30, there was a significant decrease in severe pain from 46.2 to 11.1% (p = 0.05) with an increase in mild pain from 23.1 to 62.4% (p = 0.05). Roughly half of the participants (47.9%, n = 46) reported no pain by POD14. Penoscrotal IPP recipients often fully recover from pain at the two-week period following surgery and those with lingering discomfort predominantly complain of penile shaft and glans pain.

How Do I Match? A Survey Study on the Impact of Step 1 Becoming Pass/Fail.

BACKGROUND: Step 1 has historically been a major criterion to evaluate students for residency match. With Step 1 now being pass/fail (P/F), students are uncertain how to distinguish their applications. We aim to understand student's opinions surrounding the scoring change as this is the first class of students applying to residency in the P/F era. MATERIALS AND METHODS: An electronic survey was sent to 3rd and 4th year American medical students. RESULTS: Of the 255 students surveyed, 61.6% prefer Step 1 in the P/F format. Students applying for highly competitive specialties (HCS) preferred numerical scoring (55.6%). On a 5-point Likert scale, students entering HCS believed more strongly that they would have a better chance at matching if Step 1 was graded numerically (3.47 vs 2.71) and creates an unfair advantage for those who can afford to pursue a research year (3.46 vs 2.95). Students entering HCS felt finances played a significant role in whether they took a research year and felt added pressure to engage in research. Respondents believe that students from prestigious medical schools, well-connected students, and MD students will benefit most. CONCLUSIONS: While students mostly prefer P/F scoring, there were differences of opinion between those going into HCS and LCS. Students indicated that those who have financial means are at a distinct advantage as they can afford to utilize a research year to distinguish their applications. Future efforts should be made to address student concerns and unintended consequences of the scoring change to create an equitable system.

Climacturia: what treatment options do we offer to those with and without concomitant erectile dysfunction?

Radical prostatectomy for prostate cancer carries many sequelae, including climacturia, which is not commonly discussed and often under-recognized. To better understand treatment options for incontinence and climacturia, as well as those at time of penile implantation surgery, we completed a comprehensive literature review to identify nonoperative and operative treatments for patients with climacturia alone and those with concomitant climacturia and erectile dysfunction. Nonoperative interventions include behavioral modifications, physical therapy, and tension loops. Operative interventions include the artificial urinary sphincter, male urethral slings, Mini-Jupette sling, and a periurethral prosthesis. We also explore options that can be offered to patients who are also in need of penile prosthesis for concomitant erectile dysfunction. Contemporary work suggests that synchronous implantation of certain devices to treat both climacturia and erectile dysfunction can be done with proven safety and efficacy.

Is There Any Benefit to the Use of Antibiotics with Indwelling Catheters after Urologic Surgery in Adults.

Antibiotic stewardship in urologic reconstruction is critically important, as many patients will require indwelling catheters for days to weeks following surgery and thus are at risk of both developing catheter-associated urinary tract infections (CAUTI) as well as multi-drug resistant (MDR) uropathogens. Accordingly, limiting antibiotic use, when safe, should help reduce antibiotic resistance and the prevalence of MDR organisms. However, there is significant heterogeneity in how antibiotics are prescribed to patients who need indwelling urethral catheters post-operatively. We performed a literature review to determine if there are benefits in the use of antibiotics for various clinical scenarios that require post-operative indwelling catheters for greater than 24 h. In general, for patients undergoing prostatectomy, transurethral resection of the prostate, and/or urethroplasty, antibiotic administration may be limited without increased risk of CAUTI. However, more work is needed to identify optimal antibiotic regimens for these and alternative urologic procedures, whether certain sub-populations benefit from longer courses of antibiotics, and effective non-antibiotic or non-systemic therapies.

Characterization of genital injuries secondary to foreign bodies from 2011 to 2020.

PURPOSE: To identify demographic trends of foreign object genital injuries presenting to emergency departments from 2011 to 2020. MATERIALS AND METHODS: The National Electronic Injury Surveillance System database reports consumer product-related injuries in United States ED visits. The database was queried to identify 375 cases of genital injuries from 2011 to 2020. Inclusion criteria consisted of cases reporting injuries involving the urethra, penis, or scrotum. Data was reported and analyzed using linear regression. RESULTS: Based on 375 cases, an estimated 13,170 (95% confidence interval, 10,817-15,522) patients in the US suffered genital injuries due to foreign bodies between 2011 and 2020. These injuries involved the penis (65.9%), urethra (30.7%) and scrotum (3.5%). Of all patients, 11.8% required hospital admission after treatment of which injuries to the urethra were most common (44.0%). Most of these patients were ages 19 to 64 (66.1%). Consumer products most implicated included rings (50.7%), zippers (17.1%), and pens and pencils (10.3%). Injuries due to zippers and swimming apparel occurred significantly more frequently in patients ages 0-18 (p<0.05). Injuries due to kitchen gadgets occurred significantly more in patients ages ≥65 (p<0.05). Pens, pencils, and massage devices were items that routinely resulted in urethral injuries, often requiring hospitalization. Linear regression showed genital injuries related to foreign objects significantly increased from 2011 to 2020 (p<0.001). CONCLUSIONS: Due to the nature of injury caused to genitalia by intentional and unintentional exposure to foreign bodies, educating individuals on this topic in sexual education classes is necessary for preventing future injuries.

Single Dilation in Primary Inflatable Penile Prosthesis Placement Is Associated With Fewer Corporal Complications Than Sequential Dilation.

OBJECTIVE: To assess the difference in outcomes between single dilation (SingD) and sequential dilation (SeqD) in primary penile implantation, hypothesizing that patients who undergo SeqD had higher rates of noninfectious complications. METHODS: We performed a multicenter, retrospective study of men undergoing primary inflatable penile prosthesis placement. Intraoperative complications and postoperative noninfectious outcomes were assessed between the two groups. Multivariable analysis was performed to identify predictors of complications. RESULTS: A total of 3293 patients met inclusion criteria. After matching, there were 379 patients who underwent SingD and 379 patients who underwent SeqD. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length (20 cm with interquartile range [IQR] 18-21 cm vs 20 cm with IQR 18-20 cm respectively, P = .4). On multivariable analysis, SeqD (OR 5.23 with IQR 2.74-10, P < .001) and older age (OR 1.04 with IQR 1.01-1.06, P = .007) were predictive of postoperative noninfectious complications. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length. SeqD and older age were predictive of postoperative noninfectious complications. CONCLUSION: During inflatable penile prosthesis placement in the uncomplicated patient without fibrosis, SingD is a safe technique to utilize during implantation that will minimize postoperative adverse events, and promote device longevity without loss of cylinder length.

Pain management strategies in urethral reconstruction: a narrative review.

Background and Objective: Few investigations explore pain recovery comprehensively following urethral reconstruction, and understanding pain pathways that lead to discomfort following reconstruction has posed challenges. Options for pain control aside from opioids continue to be in the early forms of investigation, and remain an important strategy to combat the well-documented burden of the opioid epidemic. We conduct a detailed assessment of pain pathways in patients undergoing urethral reconstruction and further outline non-narcotic based pain management strategies in those undergoing urethroplasty. Methods: We performed a literature review to describe pain pathways involved in urethral reconstruction with buccal graft, and postoperative pain recovery. We searched for pain management techniques performed by fields similar to urology, and those being utilized in urethroplasty with buccal graft. Key Content and Findings: Innervation of the penoscrotal areas and mouth are well-defined, but understanding postoperative pain after urethroplasty remains a challenge. Preventative analgesia, nerve blocks, and multimodal analgesia have been employed by colorectal and gynecological surgeons. Urologists have utilized similar techniques for patients undergoing urethral reconstruction with buccal graft. Conclusions: Few investigations explore pain recovery comprehensively following urethral reconstruction, but we believe that utilizing a combination of preventative analgesia, nerve blocks, and multimodal analgesia will have acceptable outcomes in post-surgical patients undergoing recovery. Additional work is required to further explore how combined pain management strategies can optimally reduce postoperative pain.

Capnocytophaga sepsis causing purpura fulminans in a 50-year-old man with chronic opioid use.

We present a case of polymicrobial sepsis with Capnocytophaga spp. complicated by purpura fulminans following a dog-bite in a 50-year-old-man with an extensive history of opioid use disorder. Generally, severe Capnocytophaga cases are thought to occur in patients with underlying immune deficiencies. However, this case highlights the importance of maintaining clinical suspicion for Capnocytophaga infection in immunocompetent patients, and we discuss the role of chronic opioid-use in severe infection.

Characterization of Pediatric Genital Injuries Due to Consumer Products From 2011 to 2020.

OBJECTIVE: To describe demographic trends of consumer product-related injuries in the pediatric cohort from 2011 - 2020. METHODS: The National Electronic Injury Surveillance System (NEISS) database surveying emergency department visits was retrospectively searched for all pediatric genitourinary injuries from 2011 to 2020. Data on demographics, diagnosis, products, disposition, and anatomy injured were collected on patients between the ages of 0-19 years. Statistical analysis was performed using linear regression. RESULTS: There were 12,953 reported pediatric cases involving injuries of the genital region from 2011 to 2020 with a national estimate of 324,636 (95% CI 241,527 - 407,746) pediatric genital injuries, comprising 0.76% of total pediatric injuries in the past decade. Of these patients, female (54.2%), white (39.7%) individuals sustained the most injuries, and items most commonly responsible included bicycles (9.4%), playground equipment (6.9%), toilets (4.6%), beds (4.5%), bathtubs and showers (4.4%), soaps (4.4%), chairs (4.1%), and razors and shavers (2.3%). Urethral injuries were due to chemical injuries from soaps (22%), furniture (17%), playground injuries (17%), insertion of foreign bodies into the urethra (13%), bicycles (10%), and swimming related injuries (4%). Genital injuries in children 0-5 years old were primarily caused by furniture (47.8%), while injuries in the 6-10, 11-15, and 16-19 age groups were attributed to sports and recreation (41.2%, 24.6%, 12.2% respectively). There was no significant change in the annual number of pediatric genital injuries from 2011 to 2020 (R2 = 0.38, P = 0.057). CONCLUSION: Identifying factors involved in pediatric genital trauma can allow for increased legislation, surveillance, and prevention of such injuries in targeted age groups.

The adolescent glans penis: Functional and aesthetic issues following childhood hypospadias repair.

INTRODUCTION: As children with childhood hypospadias repairs transition into adolescence, the function and appearance of the genitalia acquire greater importance. For some, the direction and shape of the urinary stream can be embarrassing if abnormal, and the appearance of the glans penis and meatus are a concern as they develop the capacity for self-awareness. OBJECTIVE: Herein, we address the surgical correction and outcomes of urine spraying with or without fistulae, and cosmesis over 12 years. We also analyze if any specific prior repairs were more related to their complaints i.e. cosmesis, spraying, and/or fistulae. STUDY DESIGN: We retrospectively reviewed hypospadias revisions by a single surgeon over 12 years. We included adolescents and young adults who complained of abnormal urinary stream and/or aesthetic complaints. Patients then evaluated the post op result as very good, good, acceptable, or unsatisfactory. RESULTS: Of 542 patients who underwent revisionary procedures, 90 (16.6%) presented with complaints of urinary spraying, and appearance of the glans penis and/or meatus (see figure). Of these, 19 (21.1%) presented with aesthetic complaints alone, 37 (41.1%) presented with aesthetic complaints and spraying, and 34 (37.7%) presented with aesthetic concerns, spraying, and were noted to have urethral fistula either during preoperative examination or during surgery. 3/90 patients (3.3%) developed wound infection and dehiscence (one had a tubularized incised plate repair, another a Thiersch-Duplay repair, and the primary repair of the third patient was unknown). CONCLUSIONS: Adolescents and young adults who underwent hypospadias repair during childhood can return with concerns regarding functional and aesthetic abnormalities of the glans penis. Glans sculpting and meatal contouring may be utilized to normalize the urinary stream and achieve a normal aesthetic appearance of the glans penis. Surgeons should follow these patients through adolescence and into adulthood, because complications from hypospadias repairs acquire greater significance later and young adults seek to normalize their phalluses.

Management of ischemic tissues and skin flaps in Re-Operative and complex hypospadias repair using vasodilators and hyperbaric oxygen.

INTRODUCTION: Repeated and multiple surgeries for hypospadias result in varying degrees of scarring and hypovascularity of penile tissues which may result in poor healing and increasing complication rates with each additional repair. Vasodilator agents such as Nitroglycerine (NTG) can be helpful in the immediate postoperative period to improve flap viability. Hyperbaric oxygen therapy (HBOT) has well-established benefits to promote angiogenesis and wound healing. We hypothesized that NTG and HBOT, methods to promote blood flow and wound healing, would provide better outcomes in redo hypospadias surgeries and reduce complication rates; and, that HBOT and NTG would provide better outcomes compared to NTG alone. OBJECTIVES: Herein, the authors review the results of their strategy of the past 5.5 years in managing these compromised hypovascular tissues using 2% NTG and HBOT for redo surgery of hypospadias. STUDY DESIGN: Between 2014 and 2019, 82 patients (2-24 years old) exhibiting varying degrees of scarring of skin and subcutaneous tissues underwent re-operative repair of hypospadias complications following failed surgeries (3-9 operations, average 5.5 failed previous repairs). There were two groups of patients: Group I (49 patients) received trimodal therapy consisting of NTG, HBOT, and local steroids. The patients were examined every 3 weeks and every 3 months thereafter. The postoperative site was photographed by the parents or by the older patient prior to each visit. Group II (33 patients) received NTG and local steroids, but not HBOT for various reasons. RESULTS: In Group I: 44/49 (88.8%) of the repairs were successful. The complications in this group included a distal repair breakdown (n = 2) and urethral fistula (n = 3). In Group II, a successful outcome was noted in 23/33 (69.6%). The follow up of the 78 patients who completed their repairs varied between 5 months and 4 years. Results are highlighted in the table. DISCUSSION: In accordance to previously published data, the study results further support promising outcomes of application of NTG and HBOT to improve flap viability. Limitations include non-randomization of our treatment groups resulting in a retrospective evaluation of our protocol; and, the intrinsic heterogeneity of our patient population, previous surgical repairs, and scar tissues. CONCLUSIONS: The proposed treatment of combining NTG and HBOT appears to result in reversal of tissue hypoxia and improved wound healing. This preliminary report shows improved outcomes with less morbidity in a group of patients with multiple hypospadias surgical failures and it warrants further application in a larger number of patients.

PubMed-Indexed Research Productivity of Students Matching at Top Urology Programs: 2017-2020.

OBJECTIVE: To evaluate the number of PubMed-indexed research projects of medical students matching at top-ranked urology programs as compared to the average publications reported in the Electronic Residency Applicant Service (ERAS). METHODS: Doximity Residency Navigator was used to generate the top 50 residency programs when sorted by reputation. Residents were then found using program websites. PubMed was queried for peer-reviewed publications of incoming interns through post graduate year 3 residents as of February 2020. All PubMed-indexed research was recorded before September 15th of the residents' fourth year of medical school. We recorded the number of publications, first/last author publications, and urology-specific publications. RESULTS: The average number of publications across all 4 years was 2.38 ± 4.19. The average for urology-specific publications was 1.05 ± 3.19 and for first/last author publications was 0.80 ± 1.77. Most matched applicants had at least one PubMed-indexed publication (61.2%) and having over 3 placed them in the 75th percentile. It is uncommon for students to have urology specific or first/last author publications (34.0%, 36.5%). Top 10 programs matched applicants with significantly more research in each of the aforementioned categories and as program reputation declined, so did the publications of the applicants they matched. CONCLUSION: Most research that matched urology applicant's report in ERAS is not PubMed Indexed. Most had at least one PubMed-indexed publication by the time they submitted ERAS and those at top programs had more. It would be helpful to students and faculty advisors if ERAS published research metrics for matched and unmatched applicants separating PubMed-indexed work from posters and presentations.

A review of Agent Orange and its associated oncologic risk of genitourinary cancers.

Agent Orange is an herbicide sprayed widely in Vietnam that is linked to a variety of malignancies in as early as 1991.Since then, there has been concern for, and subsequent interest in studying, the potential connection between Agent Orange and other malignancies. In the past 2 decades, there have been significant changes in the opinion of the National Academy of Science regarding Agent Orange and certain genitourinary malignancies. Herein, we review the literature regarding the potential link between Agent Orange and various urological cancers, including prostate, bladder, testicular, and renal cancers.