Ericson, Christian

Abstract Introduction Erectile dysfunction continues to be a concern for patients and physicians after surgical treatment of prostate pathology. Objective To analyze doppler diagnosis on patients who underwent prostate surgery for benign or malignant pathology of the prostate. Methods We retrospectively analyzed all patients who underwent either robotic assisted prostatectomy (RALP), open retropubic prostatectomy (RRP), endoscopic procedures such as greenlight procedure, laser resection of the prostate or transurethral resection of the prostate (TURP); and High Intensity Focused Ultrasound (HIFU) treatment for prostate pathology and who underwent intracavernous injection followed by Color Doppler Duplex Ultrasound (CDDU) at our institution between 2005 and 2019. CDDU findings were recorded following injection of low dose alprostadil (10-20 mcg) and again after a period of privacy and visual sexual stimulation. CCDU findings including peak systolic velocities (PSV), and resistive indices (RIs) were recorded. Arterial insufficiency (AI) was defined as either a post-stimulation PSV < 25 with any RI or a PSV 25-34.9 with RI≥0.9. Cavernous Venous Occlusion Disease (CVOD) was defined as post-stimulation PSV ≥35 with RI < 0.9. Mixed was defined as post-stimulation PSV 25-34.9 with RI < 0.9. Vascular normal was defined as post-stim PSV ≥ 35 with RI ≥ 0.9. Results 380/1917 (19.8%) patients had a past surgical history of prostate surgery. 111/380 (29.2%) underwent RRP, 168/380 (44.2%) patients underwent RALP, 85/380 (22.3%) underwent endourological resection of the prostate and 2/380 (0.5%) patients underwent HIFU. Median age for the RALP group was 60.5 (IQR 23.7-82.8), RRP group was 64.2 (29.7-87.7), endourological resection of the prostate 64.6 (30.8 – 85.6) and HIFU 65.0 (46.9-79.4). 87.1% of patients who had an endoscopic procedure were using phosphodiesterase-5 inhibitors at the time of CDDU. CVOD was the most common etiology of ED in patients who underwent RRP (28.8%) and Endourological procedures of the prostate (32.9%); In patient who underwent RALP the most common etiology of ED was noted to be AI (28.6%), however none of these values were statistically significant (p=0.428). Conclusions There is no difference in etiology of ED in patients who underwent open, robotic or endoscopic manipulation of the prostate as shown by CDDU. Disclosure No

ObjectiveTo validate a new baseline estimated glomerular filtration rate (NB‐GFR) formula in a cohort of robotic‐assisted partial nephrectomies (RAPN).MethodsNB‐GFR = 35 + preoperative GFR (× 0.65) – 18 (if radical nephrectomy) – age (× 0.25) + 3 (if tumor size >7 cm) – 2 (if diabetes). NB‐GFR was calculated in 464 consecutive RAPN from a single surgeon cohort. 143 patients were excluded secondary to insufficient eGFR follow up. We analyzed NB‐GFR accuracy utilizing the last observed eGFR 3–12 months post RAPN. Categorical variables were summarized with the frequency and percentage of patients. Numerical variables were summarized with the median, 25th percentile, and 75th percentile.ResultsThe mean difference between observed and predicted NB‐GFR was 4.6 ml/min/1.73m2 (95% CI −6.9 to 16.1 ml/min/1.73m2). There was a pattern of higher observed NB‐GFRs being underestimated by the NB‐GFR equation while lower observed NB‐GFRs were overestimated by the NB‐GFR equation. The NB‐GFR formula had a high level of accuracy with 98.8% of predicted NB‐GFRs falling within 30% of the observed NB‐GFR (95% CI 86.8% to 99.5%). The median and interquartile range of the difference between observed and predicted NB‐GFR was 3.9 ml/min/1.73m2 (IQR 0.7 to 8.2 ml/min/1.73m2). The sensitivity, specificity, positive predictive value, and negative predictive value for the ability of predicted NB‐GFR to identify those with an observed NB‐GFR <60 ml/min/1.73m2 after RAPN was 98%, 92%, 88%, and 99%, respectively.ConclusionThe NB‐GFR equation developed with partial and radical nephrectomy cohorts is accurate in predicting post‐operative eGFR 3–12 months following RAPN.

ABSTRACT Introduction Peyronie's Disease (PD) is a well described pathology affecting up to 5-10% of men. The presence and extent of penile calcifications is an important determinant in disease management. Calcifications have a variety of clinical presentations ranging from microcalcifications to calcified plaques. Calcified plaques were excluded from past Xiaflex clinical trials. Calcified plaques may necessitate plaque excision and grafting (E&G) sometimes combined with inflatable penile prosthesis (IPP) placement, which is more complex than plaque incision and grafting. Peyronie's Disease guidelines recommend color duplex Doppler ultrasound (CDDU) primarily to rule out Erectile Dysfunction. PD pathology such as corporal septal involvement, multifocal calcifications, and circumferential corporal calcification can be difficult to assess on penile ultrasound (PUS) due to acoustic shadowing and device limitations. We describe a series of patients in whom non-contrast CT scan was used to further define calcified or complicated pathology. Objective To describe the role of non-contrast CT scan of the penis for anatomic evaluation and surgical planning in patients with complicated calcified Peyronie's disease. Methods 23 male patients with a diagnosis of PD were evaluated by a single surgeon at a single academic institution between 2017 and 2021. All patients underwent color doppler ultrasound (CDDU) examination with artificial erection via intracavernosal alprostadil injection and were evaluated based on erectile function, plaque dimension, hourglass deformity, plaque septal involvement, and suspected calcification status. Patients with CDDU examination concerning for significant calcification or complexity proceeded to non-contrast CT scan for calcific confirmation and for 3-dimensional evaluation of their PD plaque prior to surgical discussion. Complexity was defined as concern for multifocal calcified plaques (&gt;2), partial/complete circumferential corpus cavernosum involvement, or septal involvement. Results All 23 patients had concerning findings on initial examination for calcified plaque. 9 of 23 (39.1%) patients had exam findings of an hourglass deformity. On CT evaluation, calcification was confirmed in 22 of 23 patients (95.7%). Plaque dimensions on CT scan ranged from 0.4 × 0.2 × 0.5 cm to 4.0 × 2.0 × 1.7 cm. Many of these measurements were approximations due to circumferential calcified plaque. This classic “gull-wing” appearance (Figure 1) was noted in 6 of 23 (26%) patients. 12 of 23 (52.2%) of patients had septal involvement on CT (Figure 2). 8 of 23 patients (34.8%) had significant multifocal disease (Figure 3). 8 of 23 patients (34.8%) decided to proceed with surgical correction via E&G (n = 3), IPP with E&G (n =1), or via IPP with manual remodeling via the Wilson technique (n = 4). Conclusions Non-contrast penile CT scan for evaluation of calcified Peyronie's disease allows for increased accuracy of surgical planning especially when evaluating for multifocal disease, circumferential plaque and/or septal involvement. These elements are critical in being able to provide accurate surgical recommendations and post operative discussions. Disclosure No

Abstract Objective: To analyze operating room (OR) efficiency by evaluating fixed and variable OR times for open (OPN) and robotic-assisted partial nephrectomies (RAPN).Methods: We analyzed consecutive OPN and RAPN performed by one surgeon over a 24-month period. All patients were placed in the lateral decubitus position and secured with a beanbag regardless of approach. Fixed (nonprocedural) OR times were prospectively collected and defined as: in room to anesthesia release time (IRAT), anesthesia release to cut time (ARCT), and close to wheels out time (CTWO). Variable OR time was procedural cut to close time (CTCT). Comparison of fixed and variable OR time points between OPN and RAPN were performed using the Wilcoxon rank sum test. Results: 146 RAPN and 31 OPN were evaluated from 2019-2020. Median IRAT was similar for RAPN versus OPN [20 min (IQR: 16-25) vs. 20 min (IQR: 16-26), P=0.57]. Median ARCT was longer for RAPN than it was for OPN [40 min (IQR: 36-46) vs. 34 min (IQR: 30-39), P<0.001]. Median CTWO was similar for OPN (12 min, IQR: 9-14) and RAPN (11 min, IQR: 7-15) (P=0.89). Median CTCT was longer for RAPN (202 min, IQR: 170-236) compared to OPN (164 min, IQR: 154-184) (P<0.001).Conclusions: In a single surgeon partial nephrectomy series with the same patient positioning, utilization of robotic technology was associated with longer surgeon operating time as well as less efficient fixed OR times, specifically ARCT.

ABSTRACTBackgroundIntracavernosal injections (ICI) are a well-established treatment option for men with erectile dysfunction (ED); however, the anticipation of pain with injection remains a significant barrier to the use of ICI.AimTo evaluate the patient-anticipated degree of pain versus the experienced degree of pain pre- and post-ICI in men undergoing their first injection with an erectile agent.MethodsWe studied 51 patients who underwent their first ICI in our men’s health clinic. Anticipated needle-associated pain was judged with a pre-injection score, and pain experienced during the injection was judged with a post-injection score. All patients graded their pre- and post-ICI pain using a standard 10-point scale (0–10).OutcomesPre- and post-ICI pain was defined with the visual analogue scale (0–10) in men undergoing their first penile injection.ResultsMedians and interquartile ranges (IQRs) of the patients’ age [65 years (54.5–68.0)], pre-injection pain [5 (4–7)], and post-injection pain [1 (1–2)] were recorded. Most men in the study had erectile dysfunction (68.6%) and/or Peyronie’s Disease (64.7%). The average pre-injection prediction pain score was 5.45 ± 2.15; the average post-injection perceived pain score was 1.20 ± 0.73. Thus, there was an average discrepancy of over 4 points in predicted pain vs perceived pain. A paired t-test was performed which showed a statistically significant difference between pre- and post-injection scores (P &lt; .05). A Wilcoxson Signed Rank Test showed statistical significance in the difference between pre- and post-injection pain scores (P &lt; .05).Clinical ImplicationsICI is a safe, effective treatment for patients with ED and is associated with significantly less pain than is anticipated by patients.Strengths & LimitationsThis is the first report to describe the discrepancy between pre-ICI anticipated pain and post-ICI experienced pain. Limitations include an overall small sample size.ConclusionPatients experience significantly less pain with ICI than they anticipate having. This represents an important factor to consider when counseling patients about available ED treatments.

Abstract Objective To present the pathologic analysis of female urethral strictures obtained during reconstructive urethroplasty. Methods Nine separate female urethral tissue specimens were obtained during dorsal vaginal graft urethroplasty by a single surgeon (S.P.P.). Samples were serially sectioned and fixed in 10% formalin 6 to 12 hours before routine processing in paraffin blocks. Serial 5-µm sections were subjected to H&E, Masson trichrome, and elastin staining. End point analysis included evaluation for epithelial hyperplasia and cell type, mucosal edema, degree of fibroblast/inflammatory cell infiltrate, and elastin fiber density and distribution. Results Nine specimens were examined. Six specimens had epithelial linings of stratified squamous epithelium overlying fibrosis (67%), 1 had mixed squamous and urothelial epithelium, and 2 had only urothelial epithelium. Two specimens (29%) showed acute injury with prominent squamous papillary hyperplasia, focal erosion, and patchy mucosal hemorrhage. Areas of urethral stricture were variably thickened, with increased, densely packed collagen fibers and associated mucosal lymphocytic inflammation ranging from mild and patchy to focally dense with lymphoid aggregates. The highest elastin fiber density appeared to be associated with vessels and overlying muscle bundles in the submucosa. Conclusions Further elucidation of histopathologic characteristics may illuminate more appropriate therapeutic pathways for female urethral stricture disease management.