Faculty Bibliography

Gender dysphoria, or the incongruence between gender identification and sex assigned at birth with associated discomfort or distress, manifests in transgender patients, whose multifaceted care includes puberty suppression, cross-sex hormonal therapy, and gender-affirming surgery. Discussion of fertility preservation (FP) is paramount because many treatments compromise future fertility, and although transgender patients demonstrate desire for children, use of FP remains low for a plethora of reasons. In transgender women, established FP options include ejaculated sperm cryopreservation, electroejaculation, or testicular sperm extraction. Further research is needed regarding reproductive health and FP in transgender patients.

BACKGROUND AND AIMS/OBJECTIVE:There is significant data that support the efficacy and safety of Fecal Microbiota Transplant ( FMT) in Recurrent Clostridium Difficile Infection (RCDI). The objective of our study was to determine the success rate of FMT in patients diagnosed with severe and complicated CDI with impending colectomy in the ICU setting. METHODS:This was a 2 center study, which consisted of 9 patients who met criteria of severe and complicated CDI and had impending colectomy. All 9 patients failed conventional antibiotic therapy and were deemed too unstable to undergo colectomy. Hence, FMT was considered as the next step in management. RESULTS:Following FMT there was marked improvement in clinical status with resolution of diarrhea, reduced vasopressor requirement, reduction in abdominal distention and pain.The primary cure rate of our study after a single round of FMT was 78% (7/9). 8 out of the 9 patients (88.88%) avoided a colectomy during the same hospital admission. CDI related death was 12.5% (1/9) and non CDI death was 12.5% (1/9). CONCLUSION/CONCLUSIONS:Our success with FMT in fulminant CDI shows that this therapeutic modality is a promising alternative and could be a potential bowel saving intervention.

OBJECTIVES: The aim of this study was to compare testicular metabolite concentrations between fertile control subjects and infertile men. MATERIALS AND METHODS: Single voxel proton magnetic resonance spectroscopy ((1)H-MRS) was performed in the testes with and without water suppression at 3 T in 9 fertile control subjects and 9 infertile patients (8 with azoospermia and 1 with oligospermia). In controls only, the T1 and T2 values of water and metabolites were also measured. Absolute metabolite concentrations were calculated using the unsuppressed water signal as a reference and correcting for the relative T1 and T2 weighting of the water and metabolite signals. RESULTS: Testicular T1 values of water, total choline, and total creatine were 2028 +/- 125 milliseconds, 1164 +/- 105 milliseconds, and 1421 +/- 314 milliseconds, respectively (mean +/- standard deviation). T2 values were 154 +/- 11 milliseconds, 342 +/- 53 milliseconds, and 285 +/- 167 milliseconds, respectively. Total choline concentration was lower in patients (mean, 1.5 mmol/L; range, 0.9-2.1 mmol/L) than controls (mean, 4.4 mmol/L; range, 3.2-5.7 mmol/L; P = 4 x 10(-)(5)). Total creatine concentration was likewise reduced in patients (mean, 1.1 mmol/L; range, undetectable -2.7 mmol/L) compared with controls (mean, 3.6 mmol/L; range, 2.5-4.7 mmol/L; P = 1.6 x 10(-)(4)). The myo-inositol signal normalized to the water reference was also lower in patients than controls (P = 4 x 10(-)(5)). CONCLUSIONS: Testicular metabolite concentrations, measured by proton spectroscopy at 3 T, may be valuable as noninvasive biomarkers of spermatogenesis.

Purpose The association between exposure to testosterone replacement therapy (TRT) and prostate cancer risk is controversial. The objective was to examine this association through nationwide, population-based registry data. Methods We performed a nested case-control study in the National Prostate Cancer Register of Sweden, which includes all 38,570 prostate cancer cases diagnosed from 2009 to 2012, and 192,838 age-matched men free of prostate cancer. Multivariable conditional logistic regression was used to examine associations between TRT and risk of prostate cancer (overall, favorable, and aggressive). Results Two hundred eighty-four patients with prostate cancer (1%) and 1,378 control cases (1%) filled prescriptions for TRT. In multivariable analysis, no association was found between TRT and overall prostate cancer risk (odds ratio [OR], 1.03; 95% CI, 0.90 to 1.17). However, patients who received TRT had more favorable-risk prostate cancer (OR, 1.35; 95% CI, 1.16 to 1.56) and a lower risk of aggressive prostate cancer (OR, 0.50; 95% CI, 0.37 to 0.67). The increase in favorable-risk prostate cancer was already observed within the first year of TRT (OR, 1.61; 95% CI, 1.10 to 2.34), whereas the lower risk of aggressive disease was observed after > 1 year of TRT (OR, 0.44; 95% CI, 0.32 to 0.61). After adjusting for previous biopsy findings as an indicator of diagnostic activity, TRT remained significantly associated with more favorable-risk prostate cancer and lower risk of aggressive prostate cancer. Conclusion The early increase in favorable-risk prostate cancer among patients who received TRT suggests a detection bias, whereas the decrease in risk of aggressive prostate cancer is a novel finding that warrants further investigation.

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;XX:XXX-XXX.

INTRODUCTION & OBJECTIVES: Penile prosthesis infections remain challenging despite advancements in surgical technique, device improvements and adoption of antibiotic prophylaxis guidelines. This study investigated penile prosthesis infection microbiology to consider which changes in practice could decrease infection rates. MATERIAL & METHODS: This retrospective IRB-exempt multi-institutional study reviewed intraoperative cultures obtained at explant or Mulcahy salvage of infected penile prostheses (IPPs). Antibiotic usage was recorded at implantation, admission for infection, and explant/salvage surgery. RESULTS: 227 intraoperative cultures (2002-2016) were obtained at salvage or explant. No culture growth occurred in 33% of cases and Gram-positive and negative organisms were found in 73% and 39% of the positive cultures respectively. Candida species (11.1%), anaerobes (10.5%), and MRSA (9.2%) comprised 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 AUA and EAU guidelines. However, the microorganisms identified in this study were covered by these guidelines in only 62-86% of cases. Antibiotic selection at admissions for infection and salvage or explant surgery varied widely compared to those at IPP implantation. CONCLUSIONS: This study documents a high incidence of anaerobic, Candida and MRSA infections. In addition, approximately 1/3 of infected penile prosthesis cases had negative cultures. Microorganisms identified in this study were not covered by the AUA and EAU antibiotic guidelines in at least 14-38% of cases. These findings suggest broadening antibiotic prophylaxis guidelines and creating a management algorithm for IPP infections may lower infection rates and improve salvage success