Wajswol, Ethan

Abstract Introduction/ Background Holmium laser enucleation of the prostate (HoLEP) is an increasingly popular size-independent technique of treating male voiding dysfunction due to benign prostatic hypertrophy. Some patients after HoLEP may develop clinically significant prostate cancer and opt for definitive treatment with external beam radiation therapy (EBRT). Little is known about the safety of EBRT after HoLEP and how it may functionally impact voiding after HoLEP has altered the anatomy of the prostate. Our study aimed to assess patient-reported voiding outcomes following EBRT after HoLEP with a focus on incontinence related patient outcomes. Methods/ Materials This study was conducted with approval from our hospital’s institutional review board. Patients that underwent HoLEP followed by EBRT were identified and data was collected in a retrospective nature from a single surgeon HoLEP cohort over the past 4 years (2019–2023). Patient demographics, disease and radiation therapy characteristics, radiation therapy, and baseline voiding symptoms were recorded. Current functional voiding outcomes were also collected via phone-call or portal communication in a cross-sectional manner with questions pertaining to type of incontinence, IPSS quality of life score, and administration of the Michigan Incontinence Symptom Index (M-ISI). Adverse events encountered during follow-up were recorded. Results 24 patients were identified who received RT for prostate cancer after HoLEP with an average age of 73.6 (+/- 5.3). One third of patients reported no incontinence whatsoever after radiation and of those who experienced incontinence, the majority felt that it was not worsened after radiation. Median IPSS QoL score following radiation was 1 (range 0–6), median M-ISI Severity Score was 4 out of a maximum of 32, and median M-ISI Bother Score was 0 out of a maximum of 8. One patient developed a bladder neck contracture (BNC) approximately 1 year following his radiation therapy (approximately 18 months after HoLEP) causing bothersome incontinence and LUTS. Conclusions In our cohort most patients who received RT after HoLEP reported a high urinary-symptom related quality of life and a low rate of urinary incontinence. One patient who received SBRT suffered a BNC which is a known adverse event with RT but given our small sample size it remains unclear if the risk is higher in patients receiving RT after HoLEP. Larger studies should focus on examining the rate of bladder neck contracture in patients receiving RT after HoLEP, particularly focusing on whether the degree of dose fractionation may impact their development.

Abstract Introduction Vasectomy is a highly effective, permanent method of contraception. Poor compliance rates have been observed for patients in obtaining their post-vasectomy semen analyses (PVSA). Few studies have looked at associations with low compliance. Objective The objective of our study was to identify compliance rates of post-vasectomy semen analysis and to identify associations that may increase or decrease the rates of compliance. Methods We studied 111 patients between November 2018 and April 2022 who underwent vasectomy at a single institution. Only patients who underwent vasectomy for fertility-related reasons were included in our final analysis. We excluded any patients who had undergone previous vasectomy or vasectomy reversal. Variables analyzed included age, relationship status, presence of primary care provider, anxiety diagnosis, and race. Variables were obtained via chart review which included but was not limited to reviewing notes, summary diagnostic pages, problem lists, and medication lists. All analyses were performed using R version 4.1.2 (R Foundation for Statistical Computing, Vienna, Austria). Categorical data were described with the number and percentage of patients. Continuous data were described with the median, minimum, and maximum. Associations of race and anxiety diagnosis with PVSA were explored using Fisher’s exact test. All p-values were two-sided at the 5% significance level without adjustment for multiple testing. Results Our cohort included 111 men who underwent vasectomy with exclusion of 1 patient who underwent vasectomy for non-fertility reasons. The median age of vasectomy was 38 years (range 26-59 years). Of 110 patients, 83 (75%) returned for PVSA. There were 103 (94%) married patients. Additional cohort characteristics can be seen in Table 1. As shown in Table 2, African American patients were less likely to return for PVSA than either white patients (14% vs. 79%, p<0.001) or Hispanic patients (14% vs. 100%, p=0.015). we did not find evidence of difference between white and Hispanic patients (p=0.58). Patients with an anxiety diagnosis were more likely to undergo PVSA compared to patients without an anxiety diagnosis (p<0.001). Conclusions Patients in our cohort of African American race were significantly less likely to undergo PVSA compared to white and Hispanic patients. This suggests an opportunity for improved counseling in the African American population. We do recognize a disparity in the number of white patients studied (n=95) versus African American (n=7) and Hispanic (n=5) patients. Additionally, patients with an anxiety disorder were more likely to undergo PVSA compared to patients without an anxiety disorder. The prevalence of anxiety disorder in our cohort is somewhat high relative to the overall population in the United States. This could be due to questionnaires used at our institution and the timeliness of those questionnaires. Personality traits could also lead to confounding in anxiety diagnoses. Overall, a 75% rate of PVSA speaks to an opportunity for better counseling regarding PVSA, especially in particular populations such as the African American population. Disclosure No

Abstract Introduction The presence and extent of penile calcifications is an important factor in disease management of Peyronie’s Disease (PD). Calcified plaques may necessitate plaque excision and grafting (E&G) in addition to other therapies or surgeries. PD pathology such as corporal septal involvement, multifocal calcifications, and circumferential corporal calcification can be difficult to assess on color doppler ultrasound (CDDU) due to device limitations. Computed tomography (CT) can be utilized for further characterization of PD. Objective The objective of our study was to review patients who underwent CT imaging for characterization of their Peyronie's Disease. Methods Twenty-three patients with a diagnosis of PD were retrospectively evaluated between 2017 and 2021. Patients underwent CDDU examination with artificial erection and were evaluated based on erectile function, plaque dimension, hourglass deformity, plaque septal involvement, and suspected calcification status. Patients with CDDU examination suggestive of calcification or significant complexity underwent non-contrast CT scan for 3-dimensional evaluation of the plaque prior to surgical discussion. CT complexity was defined as concern for multifocal calcified plaques (>2), partial/complete circumferential corpus cavernosum involvement, or septal involvement. Results All 23 patients had concerning findings on initial examination for calcified plaque which led to their CT evaluation; 9 of 23 (39.1%) patients had exam findings with hourglass deformity. On CT evaluation, calcification was confirmed in 22 of 23 patients (95.7%). Plaque dimensions on CT scan ranged from 0.4 x 0.2 x 0.5 cm to 4.0 x 2.0 x1.7 cm. Many of these measurements were approximations due to circumferential calcified plaque. A classic “gull-wing” appearance was noted in 6 of 23 (26%) patients; 12 of 23 (52.2%) of patients had septal involvement on CT; 8 of 23 patients (34.8%) had significant multifocal disease; 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 Wilson technique (n = 4). Conclusions Non-contrast penile CT scan identifies calcification well in patients with Peyronie's Disease. CT allows for increased accuracy of surgical planning especially when evaluating for multifocal disease, circumferential plaque and/or septal involvement. These elements are critical for for providing accurate surgical recommendations and preoperative discussions. Disclosure No

Abstract Introduction Peyronie’s Disease (PD) is characterized by a fibrous scar of the tunica albuginea. PD is typically imaged with 2D ultrasound. We propose a classification system of these ultrasound findings in the evaluation of PD. Objective The purpose of this study is to establish a functional sonographic classification system for evaluating PD and to examine the relationship between PD grading and curvature, duration of PD, and vascular erectile status. Methods In our study, 395 patients with PD underwent intracavernosal injection with an erectile agent (ICI) followed by Color Doppler Duplex Ultrasound (CDDU). All CDDU studies were performed by a single examiner and all PD grading was done by two independent reviewers using saved images. Ultrasound findings including peak systolic velocities (PSV) and resistive indices (RIs) were recorded. PD grades of 2D images were classified into three grades: Grade 1 acoustic shadowing without calcification; Grade 2 focal microcalcifications of the tunica, pillars, or septal fibers; Grade 3 confluent calcification of the dorsal, septal, ventral tunica albuginea. Results There were 250 patients classified with Grade 1 (63%) sonographic changes, 75 with Grade 2 (19%), and 70 with Grade 3 (18%). All groups had similar median ages and body mass index (BMI): Grade 1 (59.3 yr), Grade 2 (59 yr) and Grade 3 (60.3 yr), p = 0.711; BMI 27.6, 28.2, 27.7, p = 0.813. Additionally, medical and surgical risk factors for erectile dysfunction were similar across the three groups; these included hypertension, heart disease, diabetes mellitus, hyperlipidemia, smoking history, and history of prostate surgery. Most patients had previously used PDE5-Inhibitors (293/395). History and/or physical findings of Dupuytren’s palmar contracture was noted in 30/395 (7.6%) of men. The median duration of PD was not significantly different across the three groups (12, 12, 14 months p = 0.639). Neither CDDU diagnoses (Table 1) nor curvature varied by sonographic grades (Table 2). Conclusions The scar resulting from PD seals together the outer longitudinal and inner circular layers of the tunica albuginea causing deformity of the erect shaft. PD plaques are usually palpable and associated with focal thickening of the tunica. On 2D ultrasound, the typical appearance is an acoustic shadow. Most of our patients presented with Grade I acoustic shadowing and no calcifications 250/395 (63%). On the other hand, 19% had acoustic plaque shadowing and additional findings of focal tunica or deep microcalcifications and 18% had confluent calcification of the dorsal, septal or ventral tunica. We propose a unique and reproducible classification system for Peyronie's Disease. This grading system is based on grayscale ultrasound of Peyronie’s plaques may serve the purpose of diagnostic evaluation, didactic teaching and integrated research. Disclosure No

Abstract Introduction Peyronie’s disease (PD) is characterized by penile pain, penile deformation and curvature, sexual dysfunction, and psychological implications. Fibrosis and plaque formation are often part of PD pathophysiology. Calcified plaques can alter treatment planning. Penile ultrasound with Doppler (PUS) is used to exclude erectile dysfunction and identify plaques. However, plaque extent and distribution can be obscured by acoustic shadowing, limiting complete plaque characterization. Non-contrast pelvis computed tomography (CT) provides a noninvasive method to identify plaques in 3 dimensions and quantify plaque Ca burden. Objective Our objective was to utilize Agatston Ca scoring measure Ca burden in patients with Peyronie's disease. Methods A retrospective database from 1/1/2017 and 6/30/2021 identified 25 men with calcified plaques on CT after PUS performed by a single urologist. Two abdominal radiologists reviewed CTs in consensus to measure calcified plaque size and distribution on Visage PACS. Semiautomated Agatston Ca scoring values were obtained with Syngo.via. Total Ca volume (mm3), total Ca score were correlated with hourglass deformity on clinical exam, plaque complexity on CT (>2 discrete calcified plaques, circumferential corpus cavernosum involvement, septal involvement), and surgical management using descriptive statistics and t-test. Results Mean Ca volume was 1417 mm3 (range 1.4-5425.7, standard deviation (SD) 1570); mean Ca score was 1691 (range 1.6-6048; SD 1862) with significantly higher Ca volume in patients with complex plaques (265 mm3 vs 472 mm3, p<0.05), and significantly longer plaque dimension for longest plaque dimension measured by CT vs US (31 vs 23, p<0.05). There was no significant difference in Ca volume for nonsurgical vs surgical (1791 vs 893, p=0.06) or for no hourglass vs hourglass deformity (1173 vs 1904, p=0.19). Conclusions CT scan and calcium scoring are useful tools in the assessment of PD. Semiautomated Ca scoring may help noninvasively identify complex calcified penile plaques to guide medical and surgical therapy for Peyronie’s disease. Disclosure No

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 < .05). A Wilcoxson Signed Rank Test showed statistical significance in the difference between pre- and post-injection pain scores (P < .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.