Faculty Bibliography

PURPOSE/UNASSIGNED:Available data is conflicting and limited regarding the antimicrobial effectiveness of 0.05% Chlorhexidine Gluconate (0.05% CHG) with hydrophilic inflatable penile prostheses (IPP). We utilized a large multi-institutional cohort to explore the relationship between intraoperative 0.05% CHG use and hydrophilic IPP infection. MATERIALS AND METHODS/UNASSIGNED:We conducted a retrospective, multi-institutional review of patients who underwent hydrophilic IPP implantation. Consecutive cases involving intraoperative 0.05% CHG as an irrigant and/or dip were compared to a similar number of consecutive control cases without 0.05% CHG. The primary outcome was IPP explant for infection. Predictors of infection were assessed with multivariable logistic regression analysis. Exploratory subgroup analyses further characterized specific 0.05% CHG scenarios. RESULTS/UNASSIGNED:Among 14 participating institutions, 2,150 hydrophilic IPP cases were analyzed. Intraoperative 0.05% CHG was associated with a significantly higher rate of infection compared to using antimicrobials as an irrigant and dip (4.6% v 2.1%, p<0.001). Odds of infection were 2.07 times higher with intraoperative 0.05% CHG (CI 1.37-3.76, p=0.002). On subgroup analysis, the incidence of infection with use of 0.05% CHG as irrigant and dip was 4.5% compared to 3.8% when 0.05% CHG irrigation was used with antimicrobial dip. The rate of infection with 0.05% CHG use was 3.5% for primary surgeries and 12% for revision surgeries. CONCLUSIONS/UNASSIGNED:Use of 0.05% CHG with hydrophilic inflatable penile prostheses was associated with an elevated infection rate. For hydrophilic IPP surgery, caution with 0.05% CHG use is warranted pending additional prospective evaluation.

BACKGROUND:Intracavernosal injection (ICI) therapy for erectile dysfunction (ED) and prostate cancer treatments all carry a risk of corporal fibrosis, potentially making placement of an inflatable penile prosthesis more difficult. AIM/OBJECTIVE:To evaluate the association between history of ICI, history of prostate cancer treatment (prostatectomy, radiation) and complications of inflatable penile prosthesis (IPP) placement. METHODS:A retrospective cohort study was performed of primary IPP cases from 2016 to 2021 across 16 institutions. Patients were stratified by development of intraoperative complications (crossover, corporal perforation, or urethral injury) and between-group differences in risk factors were assessed. Multivariable logistic regression was used to assess for predictors of intraoperative complications and postoperative infection. OUTCOMES/RESULTS:The primary outcome was intraoperative complications, and secondary outcome was implant infection. RESULTS:A total of 2540 patients met inclusion criteria. Intraoperative complications occurred in 36 (1.4%) patients. On multivariable regression, a history of ICI, prostatectomy, and radiation were all significant predictors of intraoperative complications (OR 2.11, P = 0.03; OR 2.27, P = 0.03; OR 2.40, P = 0.04, respectively). Age, body mass index, diabetes, hypertension, vascular disease, smoking, and Peyronie's disease were not predictors of intraoperative complications. None of the variables were significant predictors of infection. CLINICAL IMPLICATIONS/CONCLUSIONS:Prosthetic urologists should counsel patients that a history of ICI or prostate cancer treatment with radical prostatectomy and/or radiation are associated with an increased risk of intraoperative complications. STRENGTHS AND LIMITATIONS/UNASSIGNED:Strengths of this study include the utilization of a large, multicenter, international dataset. The study is limited by retrospective nature, a lack of granular data as to the type and duration of ICI therapy, and inherent selection bias in that all cases were performed by dedicated implant surgeons. CONCLUSION/CONCLUSIONS:In men undergoing IPP placement, a history of ICI, a history of radical prostatectomy, and a history of radiation are all independently associated with increased risk of intraoperative complications.

PURPOSE/OBJECTIVE:With the introduction of the AUA Quality Registry (AQUA), physician practice styles and adherence to clinical guidelines are under closer scrutiny. While adherence is critical for optimal healthcare, it has not been studied in men's health. This survey-based study assessed adherence to American Urological Association (AUA) clinical guidelines on erectile dysfunction (ED), Peyronie's disease, priapism, infertility, and ejaculatory disorders among members of the New York section of the AUA. MATERIALS AND METHODS/METHODS:An anonymous questionnaire was emailed to members, covering five non-oncologic men's health guideline categories. Each category included two to four specific guidelines, with responses recorded on a Likert scale. Respondents could provide rationale for their answers or omit questions if they did not treat a specific condition. RESULTS:Among 82 urologists, most treated ED and ejaculatory dysfunction but less commonly treated Peyronie's, priapism, and infertility. Some guidelines were frequently not followed. For instance, 57% never prescribed tramadol or α1-adrenoreceptor antagonists for premature ejaculation after first-line therapy failure. Half never performed in-office intracavernosal injection tests for Peyronie's. For priapism, 52% never used ultrasound in initial evaluations, and 45% rarely referred men with ED to mental health professionals. CONCLUSIONS:This pilot study highlights generally high adherence to AUA guidelines but identifies gaps in areas driven by expert opinion. Findings suggest a need for targeted educational initiatives, particularly in Peyronie's diagnosis and mental health integration for ED, to enhance patient care and outcomes. Such initiatives are crucial in refining the approach to men's health, ultimately enhancing patient care and outcomes.

OBJECTIVES/OBJECTIVE:To evaluate the pre- and intraoperative variables that impact the integrity of the corporal bodies over time after inflatable penile prosthesis (IPP) placement, as predictors of intraoperative corporal perforation and delayed cylinder complications have not been well characterized. PATIENTS AND METHODS/METHODS:We retrospectively reviewed a 16-centre multi-institutional database of IPP surgeries performed by experienced implanters from 2016 to 2021. Poor corporal integrity (PCI) was defined as intraoperative (iPCI) corporal complications or postoperative (pPCI) corporal complications. Multivariable analysis was performed to identify independent predictors of PCI, iPCI, and pPCI. Primary outcomes included intra- and postoperative corporal complications. RESULTS:We identified 5153 patients for analysis from 5406 IPP cases, finding 152 (2.95%) cases of PCI. On multivariable analysis, predictors of PCI included revision IPP surgery (odds ratio [OR] 8.16, 95% confidence interval [CI] 5.15-12.92; P < 0.001), sequential dilatation (OR 2.12, 95% CI 1.32-3.39; P = 0.002), coronary artery disease (CAD)/peripheral vascular disease (PVD) (OR 1.81, 95% CI 1.18-2.77; P = 0.006), older age (OR 1.02, 95% CI 1.01-1.04; P = 0.013), and corporal scarring (OR 1.58, 95% CI 1.0-2.5; P = 0.049). Predictors of iPCI included revision IPP surgery (OR 7.34, 95% CI 4.18-12.88; P < 0.001), corporal scarring (OR 2.77, 95% CI 1.64-4.69; P < 0.001), radiation therapy (OR 2.25, 95% CI 1.0-5.04; P = 0.049), and older age (OR 1.03, 95% CI 1.0-1.05; P = 0.025). Revision IPP surgery (OR 7.92, 95% CI 3.69-17.01; P < 0.001), sequential dilatation (OR 3.4, 95% CI 1.61-7.19; P = 0.001), CAD/PVD (OR 2.98, 95% CI 1.56-5.72; P = 0.001), and history of priapism (OR 3.59, 95% CI 1.08-11.99; P = 0.038) were predictive of pPCI. CONCLUSION/CONCLUSIONS:Coronary artery disease/PVD, being of older age, having corporal scarring, undergoing IPP revision surgery and sequential dilatation were predictive risk factors for complications associated with PCI. Identifying patients who are at risk of having PCI may improve patient-specific counselling, consideration of referral to more experienced implanters, and surgical planning to potentially promote longer-term device viability.

PURPOSE/OBJECTIVE:Surgical resident autonomy in procedures has been eroding over time, due to multiple factors that include duty hour restrictions, focus on operating time, complication rate, and trust among supervising physicians. This study examines whether urology residents at the Veterans Affairs hospitals (VA) have experienced decreased surgical autonomy and contributing factors. METHODS:The national VA Surgical Quality Improvement Program (VASQIP) was queried for the most common urologic procedures between 2004 to 2019 with resident involvement. The most frequent surgeries were transurethral resection of prostate (TURP); transurethral resection of small, medium, or large tumor (TURBT); photo vaporization of prostate, scrotal surgery, and ureteral stent placement. The cases were stratified by resident involvement: attending as primary (AP), attending and resident (AR), resident as primary (RP). RESULTS:93,756 urology cases were selected from 2004 to 2019. The above procedures accounted for 76.5% of all urologic cases. The percentage of RP cases decreased from 44.4% of cases in 2004 to 25.1% in 2019. Reduction in RP cases was seen in all of the 7 examined urology cases. Cases with resident involvement had patients with more medical comorbidities. Mean operative times were not significantly different. The 30-day composite complications and 30-day return to operating room were greatest for AR. Postoperative morbidity and all-cause mortality were not significantly different. CONCLUSIONS:Urology resident autonomy has decreased within the VA healthcare system over the past 15 years. Mean operative times and postoperative complications are not significantly different in cases with residents as primary surgeon.

INTRODUCTION/BACKGROUND:Prior consensus meetings have addressed the relationship between phosphodiesterase type 5 (PDE5) inhibition and cardiac health. Given significant accumulation of new data in the past decade, a fourth consensus conference on this topic was convened in Pasadena, California, on March 10 and 11, 2023. OBJECTIVES/OBJECTIVE:Our meeting aimed to update existing knowledge, assess current guidelines, and make recommendations for future research and practice in this area. METHODS:An expert panel reviewed existing research and clinical practice guidelines. RESULTS:Key findings and clinical recommendations are the following: First, erectile dysfunction (ED) is a risk marker and enhancer for cardiovascular (CV) disease. For men with ED and intermediate levels of CV risk, coronary artery calcium (CAC) computed tomography should be considered in addition to previous management algorithms. Second, sexual activity is generally safe for men with ED, although stress testing should still be considered for men with reduced exercise tolerance or ischemia. Third, the safety of PDE5 inhibitor use with concomitant medications was reviewed in depth, particularly concomitant use with nitrates or alpha-blockers. With rare exceptions, PDE5 inhibitors can be safely used in men being treated for hypertension, lower urinary tract symptoms and other common male disorders. Fourth, for men unresponsive to oral therapy or with absolute contraindications for PDE5 inhibitor administration, multiple treatment options can be selected. These were reviewed in depth with clinical recommendations. Fifth, evidence from retrospective studies points strongly toward cardioprotective effects of chronic PDE5-inhibitor use in men. Decreased rates of adverse cardiac outcomes in men taking PDE-5 inhibitors has been consistently reported from multiple studies. Sixth, recommendations were made regarding over-the-counter access and potential risks of dietary supplement adulteration. Seventh, although limited data exist in women, PDE5 inhibitors are generally safe and are being tested for use in multiple new indications. CONCLUSION/CONCLUSIONS:Studies support the overall cardiovascular safety of the PDE5 inhibitors. New indications and applications were reviewed in depth.

The Princeton Consensus (Expert Panel) Conference is a multispecialty collaborative symposium dedicated to optimizing sexual function and preserving cardiovascular health. The Fourth Princeton Consensus Conference was convened on March 10-11, 2023, at the Huntington Medical Research Institutes in Pasadena, California. Princeton panels I to III addressed the clinical management of men with erectile dysfunction (ED) who also had cardiovascular disease. Thirteen years since Princeton III, Princeton IV builds on previous foundations in several key areas. Mounting evidence supports the need for providers to treat men with ED as being at risk for cardiac events until proven otherwise. Algorithms for the diagnosis and treatment of ED are updated with new recommendations for coronary artery calcium scoring for advanced cardiovascular risk stratification. Optimization of oral phosphodiesterase type 5 inhibitors in the treatment of men with ED and cardiovascular disease is thoroughly explored, including recent evidence of potential cardioprotective effects of these drugs.

PURPOSE/OBJECTIVE:The purpose of this white paper is to educate health care professionals about the evolution of telemedicine (TM) and to propose a hybrid model that leverages the strengths of traditional in-person medicine as well as virtual medicine while maximizing the safety and quality of men's sexual health care. LITERATURE SEARCH STRATEGY/UNASSIGNED:A literature search focused on the use of TM in urology and men's health was performed through PubMed/MEDLINE, Embase, and Web of Science (January 1, 2012-April 26, 2022). Keywords included all known permutations of the terminology used to refer to virtual health, care as well as the terminology used to refer to urologic diseases, issues specific to men's health, and men's sexual health concerns. Publications that emerged after the literature search that met this criterion also were incorporated. Opinion pieces, letters to the editor, meeting abstracts, and conference proceedings were excluded. Additional resources were retrieved, such as governmental technical reports, legislative updates and reviews, and blogs. This search strategy yielded 1684 records across databases after removal of duplicates. Abstracts from the retrieved records were reviewed for relevance. Relevant publications were defined as those that reported data on any aspect of TM use specific to urology, men's health, and/or men's sexual health. If relevance was unclear from the abstract, then the full text of the article was retrieved for a more detailed review. In addition, the published evidence-based practice guidelines relevant to care for erectile dysfunction, Peyronie's disease, ejaculatory dysfunction, and hypogonadism were retrieved. The most common reasons for article exclusions were a focus on TM use in disciplines other than urology and the absence of data (ie, opinion pieces). After exclusions, a total of 91 publications remained and constituted the evidence base for this paper.