Methodological rigour in preclinical urology: a systematic review reporting research quality over a 14-year period.

OBJECTIVE: To investigate the prevalence and trends of essential study design elements in preclinical urological studies, as well as key factors that may improve methodological rigour, as the demand for methodological rigour in preclinical studies is increasing since research reproducibility and transparency in the medico-scientific field are being questioned. METHODS AND RESULTS: PubMed was searched to include preclinical urological studies published between July 2007 to June 2021. A total of 3768 articles met the inclusion criteria. Data on study design elements and animal models used were collected. Citation density was also examined as a surrogate marker of study influence. We performed an analysis of the prevalence of seven critical study design elements and temporal patterns over 14 years. Randomisation was reported in 50.0%, blinding in 15.0%, sample size estimation in 1.0%, inclusion of both sexes in 6.3%, statistical analysis in 97.1%, housing and husbandry in 47.7%, and inclusion/exclusion criteria in 5.0%. Temporal analysis showed that the implementation of these study design elements has increased, except for inclusion of both sexes and inclusion/exclusion criteria. Reporting study design elements were associated with increased citation density in randomisation and statistical analysis. CONCLUSIONS: The risk of bias is prevalent in 14-year publications describing preclinical urological research, and the quality of methodological rigour is barely related to the citation density of the article. Yet five study design elements (randomisation, blinding, sample size estimation, statistical analysis, and housing and husbandry) proposed by both the National Institutes of Health and Animal Research: Reporting of In Vivo Experiments guidelines have been either well reported or are being well reported over time. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022233125.

Comparison of Hematocrit Change in Testosterone-deficient Men Treated With Intranasal Testosterone Gel vs Intramuscular Testosterone Cypionate: A Randomized Clinical Trial.

PURPOSE: Our primary aim was to compare changes in hematocrit in testosterone-deficient men treated with intranasal testosterone gel vs intramuscular testosterone cypionate. MATERIALS AND METHODS: This 2-arm, open-label, randomized trial recruited men with testosterone deficiency at the University of Miami between August 2020 and October 2022. Men with 2 total testosterone levels <350 ng/dL and hypogonadal symptoms, aged 18-75 years were randomly assigned to receive either intranasal testosterone gel 11 mg 3 times daily or intramuscular testosterone cypionate 200 mg every 2 weeks. The primary outcome was change in hematocrit after 4 months of treatment. Secondary outcomes were changes in serum testosterone, estradiol, prostate-specific antigen, 17-hydroxyprogesterone, and the 6-item International Index of Erectile Function. RESULTS: Of the 81 men randomized, 54 completed treatment (intranasal n=23; intramuscular n=31). The mean age was 47.5 vs 49.5 years, with mean baseline testosterone of 244.6 vs 240.7 ng/dL and mean hematocrit of 44.4% vs 42.7% in intranasal vs intramuscular groups, respectively. Men who received intramuscular injections had a significant increase after 4 months of treatment in mean hematocrit from 42.7% to 46.6% (P < .0001), but there was no significant change in men who received intranasal gel (P = .233). Men in both groups experienced significantly increased serum testosterone levels throughout the study period, though a larger increase was seen in men treated with intramuscular injections (mean change 511 vs 283, P = .025). Men who received injections also experienced an increase in estradiol (mean change 22.9, P < .001), decrease in 17-hydroxyprogesterone (mean change -39.8, P < .0001), and increase in the 6-item International Index of Erectile Function score (mean change 4.8, P = .015); men treated with intranasal gel experienced no such changes. Prostate-specific antigen levels were stable in both groups. CONCLUSIONS: Intranasal testosterone gel does not appear to significantly affect hematocrit levels. Men who wish to avoid polycythemia or changes in estradiol or 17-hydroxyprogesterone levels may benefit from short-acting testosterone therapy formulations such as intranasal gel.

Evaluation and management of male genital tract infections in the setting of male infertility: an updated review.

PURPOSE OF REVIEW: Male infertility may be secondary to male genital tract infection (MGTI) in an estimated 15% of cases. In the absence of overt clinical signs, evaluation for MGTI beyond semen analysis is not well established. Therefore, we review the literature on the evaluation and management of MGTI in the setting of male infertility. RECENT FINDINGS: A set of international guidelines recommends semen culture and PCR testing, but the significance of positive results remains unclear. Clinical trials evaluating anti-inflammatory or antibiotic treatment report improvements in sperm parameters and leukocytospermia, but data on the effect on conception rates are lacking. Human papillomavirus (HPV) and the novel coronavirus (SARS-CoV-2) have been associated with poor semen parameters and decreased conception rates. SUMMARY: The finding of leukocytospermia on semen analysis prompts further evaluation for MGTI, including focused physical examination. The role of routine semen culture is controversial. Treatment options include anti-inflammatories; frequent ejaculation; and antibiotics, which should not be used in the absence of symptoms or microbiological infection. SARS-CoV-2 represents a subacute threat to fertility that should be screened for in the reproductive history along with HPV and other viruses.

Practice Comparison and Cost Analysis of Direct-to-Consumer Telemedicine Platforms Offering Testosterone Therapy.

BACKGROUND: Direct-to-consumer telemedicine platforms have expanded their reach to include services for the evaluation and treatment of testosterone deficiency. AIM: We aim to (i) evaluate the treatment practices and costs associated with receiving testosterone therapy through direct-to-consumer telemedicine platforms; (ii) compare these practices to the American Urological Association guidelines; and (iii) compare the cost of receiving similar care at a tertiary center. METHODS: Google was queried to identify telemedicine platforms offing testosterone therapy. Websites were analyzed for information regarding the initial consultation, initial laboratory evaluation, follow up, treatment monitoring regimen, and associated costs of receiving testosterone therapy. The costs for similar services at a tertiary care center were estimated using a single institution's online cost estimator for a patient with no insurance, private insurance, or Medicare. OUTCOMES: Evaluation and treatment practices of each platform were compared to the American Urological Association guidelines, and a cost analysis was completed for the cost of (i) undergoing an initial evaluation, and (ii) receiving 12 months of treatment through each platform and at a tertiary center. RESULTS: Three online platforms met inclusion criteria: Hone, Regenex Health, and TRT Nation. The initial evaluation and follow up of patients on TTh were similar between the online platforms and practice guidelines. The costs of the initial consultation were lowest for the patient with Medicare at a tertiary center and via the telemedicine platforms. Conversely, the cost of 12 months of intramuscular testosterone treatment was highest via the telemedicine platforms, ranging from $1,586 to $4,200, as compared to the tertiary center, which ranged from $134.01 to $1,333.04 with varying insurance models. Costs of ongoing treatment with transdermal testosterone are similarly higher via DTC platforms. CLINICAL IMPLICATIONS: Patients with private insurance or Medicare should be counseled that ongoing treatment through telemedicine platforms will likely incur a greater cost than receiving such care at a tertiary center that can utilize insurance coverage. STRENGTHS & LIMITATIONS: Practice and cost comparisons include accurate, up-to-date information based on each platform's website. Limitations include the analysis of only three telemedicine platforms, and the ability to describe only the information provided on each website. In addition, cost estimates for the tertiary center only include a single type of private and public insurance, limiting generalizability. CONCLUSION: This observational study indicates that direct-to-consumer telemedicine platforms are largely following practice guidelines in the evaluation and treatment of testosterone, however, there is a high cost associated with ongoing treatment. Jesse E, Sellke N, Rivero M-J, et al. Practice Comparison and Cost Analysis of Direct-to-Consumer Telemedicine Platforms Offering Testosterone Therapy. J Sex Med 2022;19:1608-1615.

Ejaculation Disorders in Male Patients with Cancer: A Systematic Review and Meta-Analysis of Prevalence.

PURPOSE: Ejaculatory dysfunction (EjD) and erectile dysfunction after cancer treatment are clinically important complications, but their exact prevalence by various kinds of cancer site and type of treatment is unknown. The aim of this systematic review and meta-analysis was to examine the available evidence and provide pooled estimates for prevalence of EjD and erectile dysfunction in relation to all cancer sites and identify characteristics associated with EjD in cancer patients. MATERIALS AND METHODS: We performed a systematic review and meta-analysis of cross-sectional and case-control studies. We searched 4 electronic databases (Medline®, CINAHL, PsychInfo and Embase®) until July 22, 2020. All retrospective or prospective studies reporting the prevalence of EjD in male patients with cancer were included in this review. A random effects meta-analysis was conducted calculating prevalence proportions with 95% confidence intervals. Prevalence proportions were calculated for the incidences of EjD by cancer site and type of treatment. RESULTS: A total of 64 studies (a total of 10,057 participants) were included for analysis. The most common cancer sites were bladder, colon, testis and rectum. The prevalence rates of EjD after surgical intervention ranged from 14.5% (95% CI 2.2-56.3) in colon cancer to 53.0% (95% CI 23.3-80.7) in bladder cancer. The prevalence rates of erectile dysfunction ranged from 6.8% (95% CI 0.8-39.1) in bladder cancer to 68.7% (95% CI 55.2-79.6) in cancer of the rectum. CONCLUSIONS: In a large study-level meta-analysis, we looked at a high prevalence of EjD and erectile dysfunction at various cancer sites and across different treatment types. Prospective studies of EjD and erectile dysfunction after various kinds of cancer treatments are warranted.

Do Antifungals and Local Anesthetic Affect the Efficacy of Antibiotic Dipping Solution?

BACKGROUND: The rates of infection after inflatable penile prosthesis (IPP) range from 1% to 3%; however, with changes in antibiotic practice intraoperatively and the incorporation of local anesthetic dips, it is unclear whether this incidence of infection is affected. AIM: To evaluate whether the utilization of local anesthetic dips and antifungal solutions affect the efficacy of previously established dips across multiple species and strains. METHODS: Strains of four different species of bacteria and one fungus were prepared in a standardized confluency. A standardized, and sterile protocol was used to punch out 6mm circular discs from the reservoir of a Coloplast Titan device. The discs were submerged in a standardized concentration of antimicrobials (combinations of Bactrim, Rifampin + Gentamicin, Vancomycin, Zosyn, and Amphotericin B) and plated. The zone of inhibition (ZOI) was measured at 24, 48, and 72 hours. Five repetitions of each organism was performed (>1700 discs), and the mean ZOI was calculated. Saline and DMSO were used as control on each plate. OUTCOMES: Main outcome was the ZOI identified with each antibiotic solution, and the secondary outcome was the efficacy of the antibiotic over the course of 72 hours. RESULTS: Difference in antibiotic efficacy was seen when each bacterial species was evaluated separately, with rifampin and gentamicin having less efficacy towards all organisms other than S. epidermidis. When looking specifically at the Candida species, amphotericin B was significantly better than other antibiotic solutions. In regards to efficacy of antibiotics over 72 hours, all treatment groups showed a decrease in ZOI over time. However, treatment groups that included rifampin demonstrated the ability to inhibit S. aureus and S. epidermidis over the 72-hour period. CLINICAL IMPLICATIONS: To improve clinical practice and alleviate concerns that incorporation of local anesthetic and antifungals may decrease the efficacy of antibiotic solutions. STRENGTHS AND LIMITATIONS: A major strength of the study is that it is the most robust and scientifically sound study performed on this topic with approximately 1700 repetitions. It is also the first study of its kind to include a wide spectrum of bacterial and fungal strains and antibiotic solutions along with temporal data on drug elution over a 72-hour period. A limitation of the study is the in vitro model, and this needs to be validated in a clinical setting. CONCLUSIONS: Dipping prosthetics in antifungal and local anesthetic does not decrease the efficacy of the antimicrobials. The drug elution capabilities of the hydrophilic coating lasts primarily for 24-48hours. Mishra K, Bukavina L, Long L, et al. Do Antifungals and Local Anesthetic Affect the Efficacy of Antibiotic Dipping Solution?. J Sex Med 2021;18:966-973.

Alternative Treatment for Erectile Dysfunction: a Growing Arsenal in Men's Health.

PURPOSE OF REVIEW: To highlight and review encouraging preliminary studies behind several alternative products and interventions for erectile dysfunction (ED). RECENT FINDINGS: Alternative treatments for ED are becoming more prevalent with increased consumer interest. "Natural" products are sold online, and numerous clinics offer various off-label and investigational interventions. These alternative treatments have demonstrated varying degrees of efficacy in randomized trials and meta-analyses, but none of these interventions has robust enough evidence to be considered first-line therapy. These treatments may find a role in combination with guideline treatments or may be used in novel penile rehabilitation research protocols. With growing interest in alternative treatment for men's health, an awareness of the literature is imperative for patient counsel. Alternative treatments, like L-arginine, have a growing body of evidence for efficacy in combination with PDE5i, and low-intensity shock wave therapy and stem cell therapy continue to demonstrate encouraging outcomes in ED trials.

Testosterone therapy and risk of breast cancer development: a systematic review.

PURPOSE OF REVIEW: We aim to conduct a systematic review of the literature, document all reported cases of breast cancer development in cis men and female-to-male (FtM) transgender men undergoing testosterone replacement therapy (TRT), and determine if testosterone poses a substantial risk of breast cancer development and recurrence. RECENT FINDINGS: A systematic search through December 2019 was performed. Out of 1890, 15 studies were eligible for inclusion in the final analyses. In total, 22 patients have developed breast cancer while on testosterone treatment. Four cases were cis men, whereas 18 cases were FtM. Age ranged from 18 to 61 years. Testosterone treatment duration ranged from 5 weeks up to 25 years. SUMMARY: There is a relatively higher incidence of BCa in FtM on CSH therapy compared with cis men on TRT. Because of the small sample size of reported cases, we cannot delineate the exact relationship between testosterone therapy and BCa development. Additionally, we have limited data to suggest that TRT should or should not be contraindicated in cis men and FtM with a prior history of breast cancer.

Testosterone Imposters: An Analysis of Popular Online Testosterone Boosting Supplements.

INTRODUCTION: Testosterone-boosting supplements (T-Boosters) are prominently featured on Amazon.com, with numerous dedicated pages and claims that they "naturally" increase testosterone levels. AIM: To evaluate the highest rated and frequently reviewed T-Boosters on Amazon.com to facilitate patient counseling regarding marketing myths, T-Booster formulations, and evidence for efficacy and safety. METHODS: The Amazon marketplace was queried using the key words "testosterone" + "booster," with default search settings and ranking items based on relevance. The top 5 T-Boosters identified on July 22, 2018, were reviewed based on price, ratings, reviews, manufacturer details, and ingredients. Consumer reviews were categorized using core themes in the Androgen Deficiency in the Aging Male (ADAM) questionnaire as a proxy to understand T-Booster efficacy and reanalyzed after filtration of untrustworthy comments using ReviewMeta.com, a proprietary Amazon customer review analysis software. MAIN OUTCOME MEASURES: Quantitative and qualitative evaluation of T-Boosters on Amazon.com was performed. RESULTS: The top 5 T-Boosters had an average ± SD of 2,761 ± 5,112 reviews and a rating of 4.56 ± 0.25 stars. 19 unique ingredients were identified across these T-Boosters, and literature review revealed 191 studies involving the 10 most common ingredients, of which 19% involved human subjects, 53% animal models, 15% in vitro studies, and 12% case reports or review articles. Among 37 human studies, 30% observed an increase in T levels, 3% a decrease, 46% no effect, and 22% were indeterminate. Analysis of top customer reviews from the first 2 pages of reviews for each supplement revealed differences in the ADAM score before and after ReviewMeta.com filtration. After filtration, there was a 91% decrease in users reporting increased libido, a 59% decrease in reports of increased energy, a 93% decrease in reports of improved strength/endurance, a 60% decrease in reports of improved erections, an elimination of reports of improved work performance, a 67% decrease in reports of improved sleep, and an 89% decrease in reports of improved sports ability. CLINICAL IMPLICATIONS: Our study can serve as a guide for providers to counsel patients about the efficacy of popular online T-Boosters as well as the prevalence of disingenuous reviews associated with these products on online marketplaces like Amazon.com. STRENGTHS & LIMITATIONS: Strengths include the novel approach to assess consumers' perceptions and satisfaction of T-Boosters, as well as summary information that clinicians can provide patients. Limitations include selection bias, a small number of supplements analyzed, and the proprietary nature of the Amazon review analysis software. CONCLUSION: T-Boosters are easily available online. Our investigation revealed that limited human studies have evaluated T-Boosters, resulting in no definitive findings of efficacy. In the absence of additional human studies, patients should be cautioned before considering T-Boosters, given the availability of highly effective therapies approved by the Food and Drug Administration. Balasubramanian A, Thirumavalavan N, Srivatsav A, et al. Testosterone Imposters: An Analysis of Popular Online Testosterone Boosting Supplements. J Sex Med 2019;16:203-212.

An Analysis of Popular Online Erectile Dysfunction Supplements.

INTRODUCTION: Erectile dysfunction supplements (ED-Ss) are featured on online marketplaces like Amazon.com, with dedicated pages and claims that they naturally treat ED. However, their efficacy and safety are largely unknown, limiting the ability to counsel patients regarding their use. AIM: To evaluate the highest rated and most frequently reviewed ED-Ss on Amazon.com to facilitate patient counseling regarding marketing myths, ingredient profiles, and evidence for product efficacy and safety. METHODS: The Amazon marketplace was queried using the key term "erectile dysfunction" with default search settings and ranking items based on relevance. The top 6 ED-S products identified on September 29, 2018, were reviewed based on price, ratings, reviews, manufacturer, and ingredients. Consumer reviews were categorized using subtopics within the International Index of Erectile Function (IIEF) questionnaire to better understand ED-S efficacy and then reanalyzed following filtration of untrustworthy comments using ReviewMeta.com, a proprietary Amazon review analysis software. OUTCOMES: Quantitative and qualitative evaluation of ED-S products sold on Amazon.com. RESULTS: The top 6 ED-Ss had an average of 2,121 ± 1,282 reviews and a mean rating of 3.92 ± 0.42 stars. A total of 21 ingredients were identified in these ED-Ss. Ginseng, horny goat weed, L-arginine, and tongkat ali were the most popular ingredients included in the analyzed products. Our literature review identified 413 studies involving the 21 identified ingredients, of which 59 (16%) involved human subjects. Among these 69 human studies, only 12 (17%) investigated supplement ingredients individually and reported improvement in ED. Analysis of top-ranked customer reviews from the first 2 pages of reviews for each supplement revealed differences in IIEF scores before and after ReviewMeta.com filtration. After filtration, we observed a 77% decrease in reviews reporting improved erection strength, an 83% decrease in reviews reporting improved ability to maintain erection, a 90% decrease in reviews reporting increased sexual satisfaction, an 88% decrease in reviews reporting increased enjoyment with intercourse, and an 89% decrease in reviews reporting increased erection confidence. STRENGTHS & LIMITATIONS: Study strengths include a novel approach to ascertaining consumers' perceptions and satisfaction with ED-Ss and practical summary information that clinicians can provide to patients. Limitations include selection bias, the small number of supplements analyzed, and the proprietary nature of the Amazon review analysis software. CONCLUSIONS: Our investigation revealed that human studies evaluating the efficacy of ED-S ingredients are limited and have yielded no definitive findings of the effects on ED. Patients considering ED-S use should receive appropriate counseling, given the prevalence of disingenuous reviews and the ready availability of Food and Drug Administration-approved drug therapies. Balasubramanian A, Thirumavalavan N, Srivatsav A, et al. An Analysis of Popular Online Erectile Dysfunction Supplements. J Sex Med 2019;16:843-852.

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

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

Human Chorionic Gonadotropin monotherapy for the treatment of hypogonadal symptoms in men with total testosterone > 300 ng/dL.

PURPOSE: The 2018 American Urological Association guidelines on the Evaluation and Management of Testosterone Deficiency recommended that 300 ng/dL be used as the threshold for prescribing testosterone replacement therapy (TRT). However, it is not uncommon for men to present with signs and symptoms of testosterone deficiency, despite having testosterone levels greater than 300 ng/dL. There exists scant literature regarding the use of hCG monotherapy for the treatment of hypogonadism in men not interested in fertility. We sought to evaluate serum testosterone response and duration of therapy of hCG monotherapy for men with symptoms of hypogonadism, but total testosterone levels > 300 ng/dL. MATERIALS AND METHODS: We performed a multi-institutional retrospective case series of men receiving hCG monotherapy for symptomatic hypogonadism. We evaluated patient age, treatment indication, hCG dosage, past medical history, physical exam findings and serum testosterone and gonadotropins before and after therapy. Descriptive analysis was performed and Mann Whitney U Test was utilized for statistical analysis. RESULTS: Of the 20 men included in the study, treatment indications included low libido (45%), lack of energy (50%), and erectile dysfunction (45%). Mean testosterone improved by 49.9% from a baseline of 362 ng/dL (SD 158) to 519.8 ng/dL (SD 265.6), (p=0.006). Median duration of therapy was 8 months (SD 5 months). Fifty percent of patients reported symptom improvement. CONCLUSIONS: Treatment of hypogonadal symptoms with hCG for men who have a baseline testosterone level > 300 ng/dL appears to be safe and effi cacious with no adverse events.

Surgeons Corner: Cavernoscopy for Rear Tip Extender Removal.

INTRODUCTION: Cavernoscopy (using a cystoscope in the corpora) is traditionally used to retrieve rear tip extenders (RTEs) that are embedded at the time of removal or replacement of inflatable penile prostheses. AIM: To describe indications and techniques of cavernoscopy. METHODS: We describe our preferred method of cavernoscopy to retrieve retained rear tips and present a thorough review of the literature regarding cavernoscopy. MAIN OUTCOME MEASURE: Ability of cavernoscopy to retrieve embedded rear tips without causing complications. RESULTS: Cavernoscopy is feasible anecdotally in case reports, but other less-invasive methods of retrieving RTEs seem to have similar efficacy. CONCLUSION: Cavernoscopy is a technically feasible procedure that can be attempted as part of a stepwise algorithm for removing retained RTEs. Thirumavalavan N, Hoover CRV, Gross MS. Surgeons Corner: Cavernoscopy for Rear Tip Extender Removal. J Sex Med 2018;15:1195-1197.

Rear Tip Extenders and Penile Prosthesis Rigidity: A Laboratory Study of Coloplast Prostheses.

BACKGROUND: Rear tip extenders (RTEs) are used commonly in penile prostheses, but their effect on erectile rigidity has not been extensively studied. AIM: To determine whether RTEs affect erectile rigidity in inflatable penile prostheses and determine what length of RTE should be used for a given corporal length-in this case, 22 cm. METHODS: To assess the effect of RTEs on erectile rigidity, we created a penile model simulating 2 corpora cavernosa that accommodated cylinders of varying lengths. Once the cylinders were inflated, a 200-g weight was then uniformly placed on the tip of the cylinders and deflection was measured using a ruler. Measurements were repeated for varying cylinder/RTE lengths to total 22 cm of overall corporal length. OUTCOMES: Differences in rigidity and angular deflection based on RTE length were assessed. RESULTS: Increasing the length of RTEs increased the deflection in our model, indicative of decreased axial rigidity. CLINICAL TRANSLATIONS: The current work implies that having additional RTEs may decrease penile rigidity and in turn, patient satisfaction. STRENGTHS AND LIMITATIONS: Though assessing effect of RTEs on erectile rigidity is novel, the exact ability of our model to predict in-vivo behavior is unknown. CONCLUSION: An inflatable penile prosthesis represents a heterogeneous beam given that it is composed of a non-inflatable rear combined to an inflatable cylinder. In this model greater bending deflection was associated with more RTE length. Greater RTE length decreases the size of the inflatable device that can be implanted. The erect penis is subject to axial stress and bending deflection. Though further work is needed, these data support the notion that maximizing inflatable length by minimizing RTEs will improve overall erectile rigidity dynamics. Thirumavalavan N, Cordon BH, Gross MS, et al. Rear Tip Extenders and Penile Prosthesis Rigidity: A Laboratory Study of Coloplast Prostheses. J Sex Med 2018;15:1030-1033.

Techniques of Ectopic Reservoir Placement and Their Pitfalls.

BACKGROUND: Ectopic placement of penile prosthesis reservoirs has become more common in patients whose space of Retzius has been compromised. AIM: To describe techniques and instruments used to place penile prosthesis reservoirs ectopically. METHODS: We present our method of placing ectopic reservoirs and review the literature for other techniques. We also catalog the instruments used for this purpose. OUTCOMES: Similar to traditional reservoir placement, successful ectopic reservoir implantation requires good cosmetic and functional success and low complication rates. RESULTS: Ectopic reservoir placement has been shown to be effective, to safely avoid bowel, bladder, and vascular injury, and to maintain excellent function and cosmesis. Multiple tools for ectopic placement have been described, but no data exist comparing their effectiveness and complications. Examples include dissection of the space anterior to the transversalis muscle using the surgeon's finger, a pediatric Yankauer suction tip, or a Foerster lung clamp. Instruments described to grasp and advance the reservoir include a sponge stick, a Foerster lung clamp, and the ectopic reservoir insertion tool (Sontec, Centennial, CO, USA). The effect of different instruments on the integrity of reservoir has not been extensively studied. CLINICAL IMPLICATIONS: Attention to technique and the instruments used to dissect the ectopic space and grasp the reservoir are crucial to successful ectopic reservoir placement. STRENGTHS AND LIMITATIONS: Reports of vascular, bowel, or bladder injuries during ectopic placement are exceedingly rare, as are reports of injury to reservoirs caused by traumatic grasping. However, no methods or tools have been compared in head-to-head trials. CONCLUSION: Ectopic placement is safe and effective, but differences between methods and instruments have not been delineated. Thirumavalavan N, Gross MS, Munarriz R. Techniques of Ectopic Reservoir Placement and Their Pitfalls. J Sex Med 2017;14:1451-1454.

Hypogonadism and renal failure: An update.

The prevalence of both hypogonadism and renal failure is increasing. Hypogonadism in men with renal failure carries with it significant morbidity, including anemia and premature cardiovascular disease. It remains unclear whether testosterone therapy can affect the morbidity and mortality associated with renal failure. As such, in this review, we sought to evaluate the current literature addressing hypogonadism and testosterone replacement, specifically in men with renal failure. The articles chosen for this review were selected by performing a broad search using Pubmed, Embase and Scopus including the terms hypogonadism and renal failure from 1990 to the present. This review is based on both primary sources as well as review articles. Hypogonadism in renal failure has a multifactorial etiology, including co-morbid conditions such as diabetes, hypertension, old age and obesity. Renal failure can lead to decreased luteinizing hormone production and decreased prolactin clearance that could impair testosterone production. Given the increasing prevalence of hypogonadism and the potential morbidity associated with hypogonadism in men with renal failure, careful evaluation of serum testosterone would be valuable. Testosterone replacement therapy should be considered in men with symptomatic hypogonadism and renal failure, and may ameliorate some of the morbidity associated with renal failure. Patients with all stages of renal disease are at an increased risk of hypogonadism that could be associated with significant morbidity. Testosterone replacement therapy may reduce some of the morbidity of renal failure, although it carries risk.

The association of socioeconomic status with semen parameters in a cohort of men in the United States.

BACKGROUND: Socioeconomic differences are present within the population of men who experience infertility and seek treatment. OBJECTIVE: To study the association of socioeconomic status with semen parameters in a group of men using mail-in semen analyses. MATERIALS AND METHODS: The records of 11,134 men that used mail-in semen analyses from a fertility company were identified. Their demographic information, semen parameters, and ZIP codes were collected. Area deprivation index (ADI) was used as a proxy for socioeconomic status and was calculated for each individual using their ZIP codes in order to measure their level of socioeconomic deprivation. A higher ADI signifies a more deprived area. The association between ADI and the semen parameters of this group was measured using linear regression analysis adjusted for age. RESULTS: 11,134 men were included in the study with a median age of 35 years (interquartile range (IQR): 32-40) and a median ADI of 83 (IQR: 68-97). The cohort had a median sperm concentration of 31 million/mL (IQR: 14-59), median total sperm count of 123 million (IQR: 57-224), median total motile sperm of 35 million (IQR: 9-95), median total motility of 32% (IQR: 15-52), progressive motility of 22% (IQR: 9-38), and morphology percent normal of 4% (IQR: 2-7). Higher ADI, indicating lower socioeconomic status, was negatively associated with various semen parameters, including sperm concentration, total sperm count, total motile sperm, and total and progressive motility. DISCUSSION AND CONCLUSION: Men who live in more deprived areas are more likely to have worse semen parameters. Further research is needed to thoroughly examine the impact of socioeconomic status on male fertility. A comprehensive approach that targets upstream social, economic, and healthcare factors can possibly alleviate the negative association of socioeconomic status with fertility and semen parameters.

Driving Time and Compliance With Postvasectomy Semen Analysis Drop-Off.

OBJECTIVE: Current literature demonstrates low rates of compliance with postvasectomy semen analysis (PVSA). This study sought to determine factors that correlate with noncompliance with PVSA. METHODS: A retrospective chart review was conducted for patients who underwent vasectomy within our institution. ArcGIS was used to securely calculate the shortest driving time from each patient's home to the single PVSA drop-off site. Kruskal-Wallis and chi-square tests analyzed characteristics of patients who did and did not submit PVSA samples, and odds ratios were calculated via multivariable logistic regression. RESULTS: Overall, 515 of 850 patients met inclusion criteria and 219 (42.5%) of these had no recorded PVSA. Of those with a PVSA, 59% were completed within 16 weeks. Compliance with PVSA was associated with a shorter median driving time (30.6 minutes vs 34.2 minutes), more vasectomy in the operating room (19% vs 10%), and attending a follow-up appointment (40% vs 17%) (P < .005 for all). Age at vasectomy, race, ethnicity, BMI, paternity, and location of preoperative consultation did not significantly differ between the groups. Each 30 minutes of driving time was associated with a 48% reduction in the odds of a patient submitting PVSA at any time (OR 0.52 [0.37, 0.73]). CONCLUSION: As driving time to a drop-off center appears to be a significant barrier to PVSA compliance, providers should consider alternative collection methods such as at-home or in-office semen analysis.

Testosterone deficiency in men with end stage renal disease and kidney transplantation: a narrative review.

Testosterone deficiency is a prevalent condition that frequently affects individuals with end-stage renal disease (ESRD) and those who have undergone renal transplantation. While the etiology of this condition is complex, its implications in this population are far-reaching, impacting various domains such as endocrine profile, sexual and erectile function, bone mineral density (BMD), anemia, and graft survival following renal transplantation. Herein, we review the most recent literature exploring the pathophysiology of testosterone deficiency in ESRD and renal transplant patients, examining its diverse effects on this demographic, and assessing the advantages of testosterone replacement therapy (TRT). Existing evidence suggests that TRT is a safe intervention in ESRD and renal transplant patients, demonstrating improvements across multiple domains. Despite valuable insights from numerous studies, a critical need persists for larger, high-quality prospective studies to comprehensively grasp the nuances of TRT, especially in this vulnerable population. Proactive screening and treatment of testosterone deficiency may prove beneficial, emphasizing the urgency for further research in this area.