Faculty Bibliography

PURPOSE/OBJECTIVE:American Urological Association (AUA) antibiotic prophylaxis recommendations may be insufficient for covering organisms commonly found in penile prosthesis infections. In this study we assess the difference between AUA recommended antibiotic prophylaxis and nonstandard prophylaxis in preventing device infections in penile prosthesis surgery performed in diabetic patients. MATERIALS AND METHODS/METHODS:A multicenter, retrospective cohort study of diabetic patients undergoing primary penile prosthesis surgery was performed between April 2003 and August 2018. Eighteen institutions from the United States, Europe and Korea contributed. The association between antibiotic prophylaxis type and postoperative penile prosthesis infections, device explantations and revision surgeries was assessed. RESULTS:Standard AUA antibiotic prophylaxis was followed in 48.6% (391) of cases while nonstandard prophylaxis was used in 51.4% (413). Common nonstandard antibiotic prophylaxis included vancomycin-gentamycin-fluoroquinolone, clindamycin-fluoroquinolone, and vancomycin-fluoroquinolone among other combinations. Patients who received AUA prophylaxis had significantly more postoperative device infections (5.6% vs 1.9%, p <0.01) and explantations (8.3% vs 2.0%, p <0.001) compared to those who received nonstandard prophylaxis. Patients who received AUA prophylaxis had significantly higher odds of a postoperative device infection (OR 2.8, 95% CI 1.1-7.3) and explantation (OR 3.6, 95% CI 1.4-9.1) compared to those who received nonstandard prophylaxis. CONCLUSIONS:Diabetic men with erectile dysfunction who received standard AUA prophylaxis for penile prosthesis surgery had significantly greater odds of experiencing a postoperative device infection and device explantation compared to patients who received nonstandard prophylaxis. Our study provides a strong rationale for a prospective investigation to establish the most appropriate prophylaxis strategy in penile prosthesis surgery.

INTRODUCTION:Infection remains a prominent concern following penile implantation. Recognition of the risk factors for infection may help to guide surgeons toward reducing the risk of prosthetic contamination. AIM:To gain a further understanding of infectious adverse events following penile prosthesis, we performed a systematic literature review. METHODS:As part of the 2018 American Urological Association Erectile Dysfunction Clinical Guidelines and with the support of the American Urological Association, we performed a comprehensive review of the PubMed, Embase, and Cochrane databases to search for eligible articles published between January 1, 1965, and July 20, 2016, to identify articles reporting infectious adverse events following prosthesis placement. MAIN OUTCOME MEASURE:The main outcome measure was infectious adverse events following penile prosthesis placement. RESULTS:Ninety-one articles reporting infectious adverse events representing 97 study arms were identified. Prosthetic infection rates ranged from 0% to 24.6% across all series. Inflatable penile prostheses displayed a wider range (0-24.6%) than malleable devices (0-9.1%); the most frequently reported infection rate for inflatable devices was 5% or less. With the advent of device coatings and improved surgical techniques, infectious adverse events have decreased. Infections among diabetic patients also decreased throughout the reviewed body of literature, with the most recent series reporting rates consistent with those of non-diabetic patients. Furthermore, no glycosylated hemoglobin cutoff was found to infer increased or decreased risk of prosthesis infection. CONCLUSION:Overall penile prosthetic infectious adverse events have decreased as surgical techniques have improved and the use of antimicrobial coating has gained in popularity. These advances have demonstrated significant benefits for all patients, particularly diabetic patients who experience infection rates similar to those of non-diabetic patients in recent reports. Further technological advancements for the prevention of biofilm formation is warranted. Mahon J, Dornbier R, Wegrzyn G, et al. Infectious Adverse Events Following the Placement of a Penile Prosthesis: A Systematic Review. Sex Med Rev 2020;8:348-354.

INTRODUCTION/BACKGROUND:Inadequate treatment of men with erectile dysfunction (ED) subjects them and their partners to lost quality of life, yet little is known about the cause and duration of symptoms that lead to penile prosthesis (PP) placement. AIM/OBJECTIVE:We performed a systematic review addressing cause and duration of symptoms before implantation. METHODS:We searched PubMed, Embase, and Cochrane for articles published between January 1, 1965-July 20, 2016, reporting on PP for ED. Studies were assessed for quality. Body of evidence strength was categorized in accordance to American Urological Association (AUA) categorization: grade A (well-conducted, highly-generalizable randomized controlled trials (RCTs) or exceptionally strong observational studies with consistent findings), grade B (RCTs with some weaknesses of procedure/generalizability or moderately strong observational studies with consistent findings), or grade C (RCTs with serious deficiencies of procedure/generalizability, have small sample sizes, or other problems that potentially confound interpretation). This review was performed as part of the 2018 AUA ED Clinical Guidelines, with the support of the AUA. MAIN OUTCOME MEASURES/METHODS:Cause and duration of symptoms before PP were assessed. RESULTS:We reviewed 113 articles constituting 150 study arms. All studies were observational (body of evidence strength grade C). Of these arms, only 19 reported on ED duration. Mean duration was 56 months for men undergoing inflatable penile prosthesis (IPP) placement (38.7 months for those after prostatectomy) and 72 months for those undergoing malleable penile prosthesis placement. Diabetic patients undergoing IPP had mean ED duration of 75 months. Among arms reporting on IPPs, causes of ED were vascular disease (47 arms; range 2.9-62.0%; mean 31.9%), diabetes (61 arms; range 12.8-77.8%; mean 28.3%), and pelvic surgery or trauma (49 arms; range 0.5-49.7%; mean 20.3%). CONCLUSION/CONCLUSIONS:Nearly all men undergoing PP have ED of organic causes, whereas diabetic patients and patients receiving malleable penile prosthesis have the longest ED duration. Factors driving this relative delay require additional investigation. Post-prostatectomy IPP placement is offered relatively late, on average. Bajic P, Mahon J, Faraday M, et al. Etiology of Erectile Dysfunction and Duration of Symptoms in Patients Undergoing Penile Prosthesis: A Systematic Review. Sex Med Rev 2020;8:333-337.

BACKGROUND:Prior to the coronavirus disease 2019 (COVID-19) pandemic, urology was one of the specialties with the lowest rates of telemedicine and videoconferencing use. Common barriers to the implementation of telemedicine included a lack of technological literacy, concerns with reimbursement, and resistance to changes in the workplace. In response to the COVID-19 pandemic declared in March 2020, the delivery of urological services globally has quickly shifted to telemedicine to account for the mass clinical, procedural, and operative cancellations, inadequate personal protective equipment, and shortage of personnel. OBJECTIVE:To investigate current telemedicine usage by urologists, urologist perceptions on the necessity of in-person clinic appointments, the usability of telemedicine, and the current barriers to its implementation. METHODS:We performed a global, cross-sectional web-based survey to investigate the use of telemedicine before and after the COVID-19 pandemic. Urologists' perceived usability of telemedicine was assessed using a modified Delphi approach to create questions based on a modified version of the validated Telehealth Usability Questionnaire (TUQ). For the purposes of this study, telemedicine was defined as video calls only. RESULTS:A total of 620 urologists from 58 different countries and 6 continents participated in the survey. Prior to COVID-19, 15.8% of urologists surveyed were using telemedicine in their clinical practices; during the pandemic, that proportion increased to 46.1%. Of the urologists without telemedicine experience, interest in usage of telemedicine increased from 43.7 to 80.8% during COVID-19. Among urologists that used telemedicine during the pandemic, 80.9% were interested in continuing to use it in their practice. The three most commonly used platforms were Zoom, Doxy.me, and Epic and the top three barriers to implementing telemedicine were patient lack of technological comprehension, patient lack of access to required technology, and reimbursement concerns. CONCLUSIONS:This is the first study to quantify the use, usability, and pervading interest in telemedicine amongst urologists during the COVID-19 pandemic. In the face of this pandemic, urologists' usage of telemedicine nearly tripled, demonstrating their ability to adopt and adapt telemedicine into their practices, but barriers involving the technology itself are still preventing many from utilizing it despite increasing interest.

BACKGROUND:The influence of serious mental illness (SMI) on the treatment and survival of patients with high-grade prostate cancer is not well understood. We compared the initial cancer treatment and cancer-specific mortality of SEER-Medicare patients with locoregional high-grade (nonmetastatic) prostate cancer with and without preexisting SMI. METHODS:We identified SEER-Medicare patients who were 67 years of age or older diagnosed between 2006 and 2013 with locoregional high-grade (nonmetastatic) prostate cancer. Preexisting SMI was identified by claims indicative of bipolar disorder, schizophrenia, and other psychotic disorder, during the 2 years before cancer diagnosis. We used multivariable binary logistic regression to examine associations between SMI and receipt of surgery or radiation concurrent with hormone therapy (definitive initial treatment) within 1 year after cancer diagnosis. We used Kaplan-Meier survival curves, as well as Cox proportional hazards and competing risk models to evaluate unadjusted and adjusted associations between SMI and 5-year cancer-specific survival. RESULTS:Among 49 985 patients with locoregional high-grade (nonmetastatic) prostate cancer, 523 (1.1%) had SMI and 49 462 (98.9%) had no SMI. Overall, SMI was associated with reduced odds of receiving surgery (OR = 0.66, 95% CI: 0.49-0.89) or radiation concurrent with hormone therapy (OR = 0.81, 95% CI: 0.67-0.98) as initial treatments in the year after cancer diagnosis. Additionally, SMI was associated with higher hazard of 5-year cancer-specific death (HR = 1.41, 95% CI: 1.06-1.89) after accounting for competing risks of non-cancer death. CONCLUSION:Among SEER-Medicare patients with locoregional high-grade (nonmetastatic) prostate cancer, those with preexisting SMI-relative to those without these conditions-were less likely to receive definitive initial treatment in the year after diagnosis and had poorer cancer-specific survival 5 years after diagnosis.