Ziegelmann, M

Abstract Background 0.05% Chlorhexidine gluconate (CHG) is now commonly used as an antiseptic irrigation for inflatable penile prosthesis (IPP) surgery. Limited in vitro data suggest compatibility of 0.05% CHG with antibiotic impregnated IPP devices; however, very little clinical research exists to guide use of 0.05% CHG in this population. Aim Assess the relationship of 0.05% CHG and antibiotic impregnated IPP infection in a large multi-institutional cohort. Methods We retrospectively reviewed a multi-institutional cohort of patients who underwent antibiotic impregnated IPP implantation. We identified cases using intraoperative 0.05% CHG and an equal number of consecutive control cases without 0.05% CHG use from each center for comparison. The primary outcome was IPP infection requiring explantation. Patient demographics and surgical variables were analyzed using chi-square tests and multivariable logistic regression to identify variables associated with infection. Outcomes The primary outcome was IPP infection requiring device explanation. Results Among 14 participating institutions, 761 cases using an antibiotic impregnated IPP were analyzed. Of these, 348 (45.7%) had 0.05% CHG used during the case. Median follow-up was 4 months (interquartile range 1-12) for the 0.05% CHG group and 8 months (interquartile range 2-21) for the control group. Intraoperative 0.05% CHG utilization was not associated with antibiotic impregnated IPP infection rate (1.9% vs. 2.0%, P = .9). On multivariable analysis, prior IPP infection (OR 6.32, 95% CI 1.32-30.2, P = .021) and prior priapism (OR 10.01, 95% CI 1.18-89.7, P = .039) were associated with increased infection risk. Clinical implications The use of 0.05% CHG irrigation with antibiotic impregnated IPPs was associated with similar infection rates compared to antibiotic irrigation. Strengths and limitations Limitations include the use of a historical comparator cohort which may introduce unknown confounders, practice variation between multiple sites, shorter follow-up in the 0.05% CHG cohort, and the low incidence of IPP infection which may limit statistical power despite a large sample. The major strengths include the large, multi-institutional cohort, and the use of consecutive patients to minimize selection bias. Conclusion 0.05% CHG utilization was not associated with infection rates in antibiotic impregnated IPPs.

Abstract Introduction Inflatable Penile Prostheses (IPPs) are a surgical implant used to treat erectile dysfunction in patients who do not respond to clinical treatments. IPP cylinder size often changes with cylinder exchange upon revision, but trends in these changes have not been formally assessed in the existing literature. Objective To analyze patient data for changes in implant size upon first revision. Methods Data included patients who underwent IPP surgical revision at Mayo Clinic Rochester between January 2021 and May 2024. Inclusion criteria specified cylinder exchange upon first revision of the IPP. A total of 48 patients were included in the analysis. A Bayesian regression was used to estimate the posterior probability of an increase in cylinder size upon first revision, after adjusting for patient age, revision service provider, and duration between implant and revision as covariates. Linear regression was used to assess the relationship between the extent of cylinder size increase and duration before revision. Results The median increase in cylinder size is 2 cm for the left cylinder and 1.75 cm for the right cylinder. The median increase for each patient’s average cylinder size is 1.625 cm. The median percentage increase in cylinder size is 9.76% for the left cylinder and 8.11% for the right cylinder. The median percentage increase for each patient’s average cylinder size is 8.13%. Posterior probabilities of increase were significant for the left cylinder, right cylinder, and the average cylinder size (Left PP: 97.53%; Right PP: 98.05%; Average PP: 98.05%). The extent of cylinder size increase is not significantly associated with duration before revision (Left p-value = 0.476; Right p-value = 0.500). Conclusions Patients and surgeons can expect about a 10% increase in cylinder size with their first revision. However, the extent of increase is not significantly associated with the duration between implant date and first revision. Future research efforts should focus on identifying where exactly this additional size is generated and what extent of size increase amounts to a noticeable difference for patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast

Abstract Introduction Chronic orchialgia is a common urologic complaint, and is estimated to make up 2.5 to 5% of urology clinic consultations. Hyperactive cremaster reflex is an often under-diagnosed source of chronic testicular pain, wherein patients experience vigorous muscular retraction of the testicles up to the external inguinal ring. This has been related to possible anatomic thickening of the cremaster muscles, or an attenuated external oblique aponeurosis. Objective To report a unique etiology and subsequent treatment of chronic orchialgia. Methods We present a case of an individual who developed new onset of hyperactive cremaster reflex after hamstring and rectus abdomonis tear during a sporting injury. Results Patient is a 37-year-old male who presented with new onset of bilateral testicular pain and chronic testicular retraction. 6 weeks prior to presentation, while playing soccer, he sustained a complete tear in the right hamstring, and partial tearing of the right rectus abdominis-adductor aponeurosis at the pubic symphysis. He completed conservative therapy with heat and ice, an extended course of anti- inflammatory medications, and physical therapy without relief. On exam, testicles were bilaterally high riding, and cremasteric muscles were noted to be in tonic spasm. Testicles would be brought into the scrotum, but were noted to rapidly ascend. He was offered injection of neuromodulator into the cremasteric muscles versus bilateral microsurgical cremaster release, and opted for the latter treatment. Bilateral cremasteric muscle fibers were ligated and excised from the external ring down to the testicle proper, and testicles were pexied in place. At follow-up, he reported complete resolution of pain and tonic retraction. Testicles were found to have normal anatomic lie within the dependent portion of the scrotum. Conclusions In patients with chronic testicular pain refractory to conservative measures, the cremasteric muscles may play a role in potentiating pain signaling through chronic, unprompted muscular spasm. This should especially be considered after regional musculoskeletal injuries affecting pelvic and inguinal muscle groups. In this select group of patients, excision of the cremasteric muscles to release cremasteric tension may be a viable treatment option for resolution of chronic pain. Disclosure No

Abstract Background Concerns exist regarding inflatable penile prosthesis (IPP) placement after transcorporal artificial urinary sphincter (TC-AUS) surgery due to potential risk of damaging the AUS cuff during corporal dilation and device placement. Aim To evaluate perioperative complications, infections, revision rates, and device longevity in patients undergoing IPP placement following prior TC-AUS surgery. Methods We present a case series of men who underwent IPP surgery with an existing TC-AUS in place. A retrospective review was conducted of all patients who underwent TC-AUS placement at a single tertiary institution between 2015 and 2025. Patients who subsequently received IPP surgery were identified. Standard IPP techniques were used with additional precautions to protect the AUS, including use of electrocautery instead of sharp dissection and contralateral reservoir placement. Demographics, operative details, complications, infections, revision events, and device survival were collected through review of operative notes and patient records. Outcomes Primary outcomes included intra-operative difficulties, perioperative complications, infection and erosion rates, and revision or failure rates for both the TC-AUS and IPP devices. Results Among 757 TC-AUS placements, 17 patients subsequently underwent IPP surgery. Seven patients (41%) had a history of pelvic irradiation. The median operative time for IPP placement was 83 minutes (interquartile range [IQR] 68-87), and median follow-up was 31.5 months (IQR 11.2-40.6). All reservoirs were positioned contralateral to the AUS reservoir. A 12 Fr catheter was left postoperatively in 10 patients (59%) for <24 hours. Proximal corporal dilation was noted to be challenging in 3 patients (18%) but dilation was completed without cuff injury or corporal perforation. One patient (6%) had TC-AUS cuff erosion 9.5 months after IPP surgery; one patient (6%) experienced TC-AUS device infection 11.5 months after IPP surgery when his AUD pump eroded through the scrotum. Four patients (24%) developed AUS mechanical failure due to cuff leak at a median of 31.9 months after IPP placement (39.9 months post-AUS). Clinical implications IPP implantation following TC-AUS can be performed safely using careful surgical technique, though vigilance for later AUS mechanical failure is warranted. Strengths and limitations This study represents one of the largest single-institution series evaluating IPP after TC-AUS and includes detailed operative and follow-up data. However, its retrospective design, small cohort size, and limited follow-up duration restrict generalizability. Conclusion IPP placement after TC-AUS appears safe, with low infection and erosion rates, though AUS cuff leaks may occur more frequently than when either device is implanted alone.

Abstract Introduction Resistance training by recreational sportspeople in fitness settings has become increasingly popular worldwide, moreover an increasing landscape of social media (SM) influencers in bodybuilding have arisen since 2021, specially on short-duration videos (clips). Some Image enhancer drug users, including anabolic androgenic steroids (AAS) are known to mistrust medical health professionals and seek out information and advice from online sources. Objective we aimed to quantitatively assess the quality of social media videos as an information source for AAS usage in the general population. Methods A search was performed on the most popular short-clips social media platforms in the US (TikTok, YouTube) with the most searched terms for AAS. The first 50 results with any search term listed by relevance were selected in each platform. Video features (views, likes, subscribers) and video sources were collected. Each video included in the study was assessed using DISCERN score to quantify the source quality. Results A total of 100 videos were included and analyzed. Most videos (84%) were from non-health professionals (influencers/clip source/podcasts), only 7% of the videos came from a health educator/physician. Most videos were rated as “very poor” (85%) and “poor” (7%) According to the DISCERN classification, there was a statistically significant difference (p < 0.001) by both content creator type, and platform with the highest scores among physicians [37 (33-41)] and YouTube [19(17.7-30.2]. [Fig]. Conclusions Image-centric social media use is positively associated with the use of AAS. Despite the increasing number of information, the overall quality was poor. The misleading, inaccurate and incomplete information may pose a health risk to the viewers. Further efforts in health policies are strongly encouraged to assess this problem. Disclosure No.

Abstract Introduction Peyronie’s disease is characterized by penile plaque or scar within the tunica albuginea. This results in penile deformity, most commonly penile curvature but also volume loss deformity such as hourglass or indentation. This volume loss occurs in up to 65% of men with Peyroine’s disease. Surgical management for patients with significant deformity includes plaque incision/partial excision and penile grafting with an absorbable grafting material. In the original description of extra-tunical grafting, the grafting material was placed over Buck’s fascia via a ventral longitudinal incision. In our modified technique, the grafting material is placed under Buck’s fascia and superficial to the tunica albuginea, which allows the grafting material to be less palpable in the flaccid condition. Objective To demonstrate a modified approach to Extra-Tunical Grafting for peyronie’s disease indentation deformity. Methods Intra-operative video of modified extra-tunical grafting was recorded with an overhead surgical camera. Results Successful modified extra-tunical grafting with excellent penile straightening and restoration of penile girth and minimal palpability of the graft. Conclusions Our modified extra-tunical grafting technique is a reasonable option compared to the standard grafting technique Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast.

Abstract Introduction Collagenase Clostridium Histolyticum (CCH) is an FDA-approved treatment for Peyronie’s Disease (PD). Based on phase-3 trials, the recommended treatment course consists of 8-injections over the course of roughly 18-20 weeks. While its efficacy has been established, less is known about patient-specific reasons for electing to discontinue CCH injection therapy. Objective To evaluate patient-reported factors associated with premature CCH discontinuation. Methods We queried a database of all patients (n=406) who underwent CCH at a single institution from 2014-2021. Patients who did not complete the recommended 8 injections were identified, and a detailed review was undertaken to determine causes of discontinuation. Patients were excluded from our analysis for the following reasons: deceased at the time of chart review, declined to participate, or could not be reached in 3 phone calls. Results Out of 406 patients who underwent Xiaflex treatment at our single institution, 133 did not complete 8 injections (32.8%). The mean number of CCH injections was 4.42 (SD 1.65). The most common reasons for discontinuing Xiaflex were satisfactory curve reduction (27%), unsatisfactory curve reduction (21%), bothersome side effect (15%), and decision to pursue surgery (12%) [Figure 1]. Other less common reasons included other health concerns, pausing treatments due to the Covid-19 pandemic, high treatment cost, transferring care elsewhere, and lack of awareness that more injections were indicated. Conclusions In our single institution study, we find that nearly 1/3 of patients who begin Xiaflex injections will not complete the full recommended treatment course. Understanding the reasons for discontinuation can help providers better stratify patients for Xiaflex treatment versus other modalities. In addition, given previous studies that indicate that 2/3 of men who fail to achieve a 20% curve reduction after their first 4 injections will go on to achieve this curve reduction after their final 4 injections, our data points to the potential impact of improved patient education for the 21% of individuals who discontinue due to unsatisfactory curve reduction (Alom et al 2021). Disclosure No

ABSTRACT Introduction Patient satisfaction after inflatable penile prosthesis (IPP) placement has been linked to preexisting curvature. Intraoperative findings such as curvature on artificial erection (AE) or asymmetric corporal measurements (ACM) are incompletely characterized in terms of impact on IPP outcome. Objective We sought to evaluate the clinical utility of AE and the significance of ACM during IPP surgery. Methods A single institution retrospective review of patients undergoing primary IPP placement between 7/2019-9/2020 was performed. Patient characteristics and intraoperative measurements were compared. Threshold for statistical significance was p≤0.05. Results A total of 130 patients underwent primary placement of penile prosthesis. Median age was 67 years (IQR 13). Comorbidities included prostatectomy in 33.8%, and known Peyronie's disease in 21.5%. Of the 27.7% (n=36) of patients who underwent intraoperative AE, 63.9% (n=23) had visible curvature. Of the patients with visible curvature, 70% (n=16) had a preoperative diagnosis of Peyronie's disease and 56.3% (n=9) underwent straightening procedures compared to 28.6% (n=2) of the 30% (n=7) with no known curvature. Incision and grafting was most frequently performed (6/11)- with a minority undergoing plication (2/11). Of the 72.3% (n=94) who did not undergo AE, only 2.1% (n=2) required additional measures for curvature correction. Median corporal measurement was 21 (IQR 2) bilaterally and median cylinder size 20 cm (IQR 4) bilaterally with 1cm rear tip extenders. Of the 18.5% (24/130) of patients with ACM, asymmetry was as follows: 20.8% (5/24) had less than 1 cm, 70.8% (17/24) had 1 to <2 cm, and 8.3% (2/24) had 2 cm or greater. Of these patients 87.5% (21/24) underwent placement of an asymmetric device, only 5% (1/21) of which had residual curvature less than 30 degrees. Despite ACMs, 12.5% (3/24) of patients had a symmetric device placed, one of which had residual curvature. Only 2 patients underwent straightening procedures including plication and incision/grafting. Conclusions Intraoperative AE is effective at revealing occult penile curvature at time of IPP placement, however most men with newly detected curvature do not require additional straightening measures. We also found that 1 in 5 patients undergoing IPP had ACM but this did not correspond to residual curvature following IPP or requirement for adjunct straightening. These findings may provide reassurance to urologists who do not routinely perform AE or those who encounter ACM during corporal dilation Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific, Coloplast

ABSTRACT Introduction Peyronie's disease (PD) is a connective tissue disorder of the penile tunica albuginea, that can often cause penile deformity, pain, sexual dysfunction, and shortening. Therapies available include penile traction, oral medications, intralesional therapy, and surgical management. Many patients undergo multiple therapies for this disease due to poor satisfaction or lack of subjective improvement. Objective We thus sought out to delineate which patients were more likely to undergo a second therapy. Methods A cohort of 385 men who underwent therapy for Peyronie's disease from 2014-2018 were analyzed. A univariate analysis of patient demographics, subjective complaints, IIEF score parameters, primary treatments, and secondary treatment approaches was conducted. Results Of the 385 men identified, 29 patients ultimately decided to undergo a secondary treatment approach with 14 patients undergoing penile traction therapy, 7 intralesional therapy (Xiaflex) and 9 surgical therapy (5 penile plication, 2 insertion of inflatable penile prosthesis, and 2 grafting). 17 patients initially underwent surgery for PD with 23.53% of these patients undergoing a second line therapy (p<0.0469). 148 patients initially underwent Xiaflex injections with 12.16% of these patients undergoing a second line therapy (p<0.0227). Patients with poor orgasmic function as determined by IIEF questionnaire (median scores 8 vs 2, p<0.0420), men with greater objective curvature (median curvature 45 vs 35, p<0.0220), and men with greater stretched penile length (13.5 cm vs 12 cm, p=0.0284) were also more likely to undergo secondary therapy. Table 1 shows all factors associated with increased likelihood for secondary therapy. Conclusions Peyronie's disease is often a complex condition to treat due to the mental, emotional, and physical toll this disease takes on patients. It is helpful to determine which patients could likely require secondary therapy as this may help guide patient counseling and further management. Disclosure No