Punjani, Nahid

AbstractDue to multiple medical advances over the past several years, angiographic investigation into arterial insufficiency as the cause of erectile dysfunction has decreased. Due to this, there is a general lack of familiarity with penile angiography technique and arterial anatomy, among current practicing interventional radiologists. Some potential indications for penile angiography include evaluation of penile trauma, high-flow priapism, further diagnostic evaluation of an abnormal penile Doppler ultrasound, or in the evaluation or treatment of erectile dysfunction with endovascular or surgical treatments. These indications, although relatively rare, still require practicing IRs to be familiar with angiographic anatomy of the penis. This article will briefly review angiographic technique in penile angiography with an emphasis on arterial anatomy.

Abstract Introduction Nonischemic priapism typically occurs secondary to penile trauma, resulting in increased blood flow into the penis without decreased outflow resulting in a clinically non-painful, partially rigid erection. Per the American Urologic Association guidelines, surgical treatment is discouraged, and following conservative management, first line treatment is arteriography with selective arterial embolization. This procedure is generally highly successful but it does carry a risk of erectile dysfunction as well as priapism recurrence. Objective Herein we present the first known case of ultrasound guided thrombin injection in an adult for nonischemic priapism treatment after persistent priapism and arterial blush following arterial embolization. Methods A 44-year-old male presented with an eight-month history of partial tumescence and erectile dysfunction after an episode of unwitnessed loss of consciousness resulting in the subsequent development of gross hematuria and dysuria. Physical examination revealed a semi-firm penis with suspected high-flow priapism. He initially presented to the emergency department, whereby a cystogram and cross sectional abdominal imaging were unrevealing. Initial outpatient cystoscopy revealed a urethral polyp which resolved on subsequent repeat testing. Following this an outpatient penile duplex doppler ultrasound was performed demonstrating a right pseudoaneurysm at the penile base measuring 13 mm in diameter with an arteriovenous fistulous communication to the corpus cavernosum. MRI demonstrates fibrotic changes within the right corpus cavernosum and tunica albuginea indicating prior traumatic penile injury. At the time the patient had approximately 25% tumescence at rest and was only able to obtain a slightly firmer erection, but was still able to achieve orgasm. After extensive conversation and given a trial of conservative management, the patient elected to proceed with angioembolization. An angiogram was completed which demonstrated a blush of contrast in the area of the bulbourethral artery. Despite successful deployment and coil embolization of the pseudoaneurysm, there was noted continued filling of the patent pseudoaneurysm from small branched collateral vessels. The patient tolerated the procedure well, and had reduction of his baseline penile tumescence and some erectile function recovery, requiring oral phosphodiesterase-5 inhibitors. There was concern for complete occlusion of the dorsal penile artery with repeat embolization, which may ultimately worsen erectile dysfunction. He remained incompletely satisfied with response to oral therapy. Results It was ultimately decided to pursue an ultrasound guided thrombin injection, which has been reported in a handful of cases as a primary intervention for priapism. During the procedure, 200 units of thrombin was injected into the pseudoaneurysm under ultrasound guidance resulting in immediate cessation of arterial flow. Post-procedure angiography demonstrated effective resolution. Conclusions High-flow priapism is a relatively uncommon condition, managed generally with embolization as first line treatment, with success rates reported at 89 to 100% and recurrence only occurring in 30% of patients. Recurrence is generally treated with repeat embolization which has been reported to cause erectile dysfunction in 15 to 22% of cases. Percutaneous ultrasound-guided thrombin injection has the potential to be an excellent second-line treatment option for pseudoaneurysm closure in correcting nonischemic priapism, albeit with limited data, but suspected high efficacy and potentially diminished rates of erectile dysfunction. Disclosure No.

Abstract Introduction Intracavernosal injections (ICI) is a well-established treatment for erectile dysfunction with common complications including priapism, penile ecchymosis and injection site pain. A rarer complication is breakage and retention of the needle inside the penis during self-injection, with only 16 cases reported in the literature from 1991 to 2023. Objective To report a case of needle breakage and retention as a complication of ICI and describe the optimal management of retained needle in the penis. Methods A 69-year-old male with a history of erectile dysfunction on TriMix presented to the Urology Department after half of his ICI needle broke off in the right side of his penis following self-injection. He denied having any pain or discomfort but reported that a small nodule had formed at the site. On physical examination, a nodule was palpated at the right base of his penis. He underwent pelvic X-ray and penile ultrasound, noting a 4-5 mm foreign body in the right base of the penis without gas in the soft tissue. As the retained needle was not significantly affecting him, he decided not to proceed with intervention and continued with ICI on the contralateral side. He began noticing burning pain at the site of injection, with development of a hard nodule that self-resolved each time. Due to worsening erectile function, he returned to clinic one year later to discuss inflatable penile prosthesis placement, where he inquired about removal of the retained needle. A small, nontender nodule was still noted at the right base of the penis. Results The patient underwent penile exploration in the operating room, revealing an obvious inflammatory fibrous nodule at the right base of the penis corresponding to the location of the needle on previous ultrasound. There was also a similar, smaller nodule contralaterally where the patient had continued ICI. Ultrasound guidance was used intraoperatively to identify the needle, then a spinal needle was used to triangulate with the needle fragment. The penis was sharply dissected along the spinal needle with iris scissors until the 4 mm needle fragment was identified and removed in its entirety. Dissection then began to excise the inflammatory nodule. However, despite attempts to completely mobilize Buck’s fascia and the nerves, the neurovascular bundles were quite adherent to the nodule from an inflammatory reaction and thus it was unable to be excised. A small possible corporotomy was then identified and repaired using 2-0 PDS. Injectable saline was then used to induce an erection and confirm no defects in the corpora. The patient recovered well post-operatively without any complications, and the nodules were noted to be much smaller at his one-month postoperative visit. Conclusions ICI needle breakage and entrapment in the penis is a rare complication. The diagnosis of needle retention includes imaging such as pelvic radiographs or penile ultrasound to locate the needle. While less invasive approaches can be attempted for removal, they may be less effective and cause further damage to surrounding tissue. Surgical exploration under ultrasound guidance is a safe and effective approach to needle removal. Disclosure No.

Abstract Introduction Recent literature suggests growing rates of malpractice claims against Urologists, with the incidence of being sued seeming to be unrelated to one’s professional reputation. These cases provide insight into errors that may lead to litigation. Given national trends of rising malpractice cases, estimates that a Urologist can expect to be sued at least twice in their careers are likely underestimates. Malpractice cases can give insight into the common medical errors rising to the level of litigation. Given the elective nature of procedures within sexual medicine, understanding litigation related to these cases is crucial. Objective We aim to analyze malpractice suits related to men’s health and highlight clinical presentations and legal outcomes. Methods Per STROBE guidelines, we searched the publicly available Thomson Reuters Westlaw legal database for “jury verdicts and settlements” from January 1970 to August 2023 to identify medical malpractice cases in Urology. Patient demographics, clinical presentation, alleged error, and legal outcomes were abstracted during full case review by an independent screener. Cases related to men’s sexual health or fertility that named a urologist as the defendant were fully analyzed. Results A total of 553 Urology cases were extracted, with 23 men’s health related cases subsequently analyzed and summarized in Table 1. The most common conditions associated with litigation were erectile dysfunction (penile prosthesis) (39%), epidydimal pathology (13%), and varicocele (13%). The most common allegations were misdiagnosis (26%), surgical complication (22%), lack of informed consent (22%), and violation of standard of care (22%). Of the 23 cases, 57% ruled “no liability” in favor of the urologist, 39% ruled in favor of the plaintiff with a median award of $335,000 (IQR = 100,000-450,000), and one was settled for $316,338. Among cases ruled as negligent, performing the incorrect procedure, surgical complications, and violating the standard of care were prominent allegations. Florida (26%) and Pennsylvania (17%) had the most cases in this sample. Of note, there were no cases for penile plication, plaque excision, microsurgical cord denervation, vasectomy reversal, or sperm retrieval, and only one for vasectomy. Conclusions This study characterizes malpractice cases related to men’s sexual health naming urologists as defendants. Despite fear of litigation, this review of the Westlaw database revealed only 23 cases related to men’s health since 1970. Moreover, the majority of cases ruled in favor of the Urologist. Obtaining comprehensive informed consent, following national guidelines, and responding appropriately to surgical complications may minimize likelihood of litigation and maximize patient outcomes. Disclosure No.

Abstract Introduction The Electronic Medical Record (EMR) has had a positive impact on healthcare but it has also increased administrative burden on physicians. One reason for this is the patient portal, which grants patients 24/7 access to ask their physician questions. Objective To characterize the patient message volume of urologists with a Men’s Health Practice by quantifying message volume per case, identifying procedures linked to high message volume, and examining demographics affecting patient portal use. We then assess the clinical utility of patient portal messages by examining their effect on Emergency Department (ED) utilization. Methods We queried the EMR of a health system spanning the southeast, midwest, and southwest using internal procedure and surgical codes for all office and operating room based urologic procedures from March 2017-November 2023. We identified procedures related to Men’s Health focusing on andrology, sexual medicine, and male reconstructive procedures. Patients identifying as women, those with multiple procedures within 6 months, and patients without research authorization were excluded. To identify factors associated with active portal users and message volume, we performed univariate and multivariable logistic and linear regression models. Multivariable models consisted of all statistically significant factors on univariate analysis. In models utilizing the procedure variable to compare message volume, vasectomy was chosen as the reference procedure due to it having the highest case volume. To assess the impact of active portal use (defined as sending at least 1 message within 6 months of their procedure) on risk of subsequent ED visit, we performed univariate Kaplan–Meier analysis and univariate and multivariable Cox Proportional Hazard models treating portal use as a time-dependent covariate. Results We examined 16,299 procedures which generated 49,422 messages within 6 months of their procedure (Table 1). Demographic data can be seen in table 2. On average, 3.04 ± 6.88 messages were generated after each procedure. The highest message generating procedures were testosterone Injection/pellets (5.83 ± 9.57), Itind (5.73 ± 14.18), and Transurethral Incision of the Prostate (5.19 ± 13.19). The lowest message generating procedures were vasectomy (1.30 ± 3.10), spermatocelectomy (1.67 ± 3.80), and circumcision (2.32 ± 5.26). The types of cases that generated the highest overall message burden were male reconstructive procedures (4.53 ± 8.57) and BPH procedures (4.07 ± 8.40) and. Slightly less than half of our cohort were active on the portal (45%) within 6 months of their procedure (Table 1). The procedures that were the most likely to have active portal users were microtese (OR 5.03 95% CI 2.38,10.67), testosterone injection/pellets (OR 4.86 95% CI 3.13, 7.54), and Itind (OR 3.02 95% CI 2.16, 4.24). On time to event analysis we found that portal usage decreased the risk of presenting to the Emergency Department (ED) by 15% within 90 days of their procedure [HR (95% CI) 0.65 0.85 (0.77, 0.93)] (Fig. 1). Conclusions Urologists practicing Men’s Health receive a high number of messages per procedure that they perform, however the use of the patient portal reduces ED utilization. Resources should be allocated to help urologists manage their patient messages as it lowers healthcare costs. Disclosure No.

ABSTRACT Background Large language model (LLM) chatbots, a form of artificial intelligence (AI) that excels at prompt‐based interactions and mimics human conversation, have emerged as a tool for providing patients with information about urologic conditions. We aimed to examine the quality of information related to benign prostatic hyperplasia surgery from four chatbots and how they would respond to sample patient messages. Methods We identified the top three queries in Google Trends related to “treatment for enlarged prostate.” These were entered into ChatGPT (OpenAI), Bard (Google), Bing AI (Microsoft), and Doximity GPT (Doximity), both unprompted and prompted for specific criteria (optimized). The chatbot‐provided answers to each query were evaluated for overall quality by three urologists using the DISCERN instrument. Readability was measured with the built‐in Flesch–Kincaid reading level tool in Microsoft Word. To assess the ability of chatbots to answer patient questions, we prompted the chatbots with a clinical scenario related to holmium laser enucleation of the prostate, followed by 10 questions that the National Institutes of Health recommends patients ask before surgery. Accuracy and completeness of responses were graded with Likert scales. Results Without prompting, the quality of information was moderate across all chatbots but improved significantly with prompting (mean [SD], 3.3 [1.2] vs. 4.4 [0.7] out of 5; p < 0.001). When answering simulated patient messages, the chatbots were accurate (mean [SD], 5.6 [0.4] out of 6) and complete (mean [SD], 2.8 [0.3] out of 3). Additionally, 98% (39/40) had a median score of 5 or higher for accuracy, which corresponds to “nearly all correct.” The readability was poor, with a mean (SD) Flesch–Kincaid reading level grade of 12.1 (1.3) (unprompted). Conclusions LLM chatbots hold promise for patient education, but their effectiveness is limited by the need for careful prompting from the user and by responding at a reading level higher than that of most Americans (grade 8). Educating patients and physicians on optimal LLM interaction is crucial to unlock the full potential of chatbots.

Abstract Introduction Despite direct access to clinicians through the electronic health record, patients are increasingly turning to the internet for information related to their health, especially with sensitive urologic conditions such as Peyronie’s disease (PD). Large language model (LLM) chatbots are a form of artificial intelligence that rely on user prompts to mimic conversation, and they have shown remarkable capabilities. The conversational nature of these chatbots has the potential to answer patient questions related to PD; however, the accuracy, comprehensiveness, and readability of these LLMs related to PD remain unknown. Aims To assess the quality and readability of information generated from 4 LLMs with searches related to PD; to see if users could improve responses; and to assess the accuracy, completeness, and readability of responses to artificial preoperative patient questions sent through the electronic health record prior to undergoing PD surgery. Methods The National Institutes of Health’s frequently asked questions related to PD were entered into 4 LLMs, unprompted and prompted. The responses were evaluated for overall quality by the previously validated DISCERN questionnaire. Accuracy and completeness of LLM responses to 11 presurgical patient messages were evaluated with previously accepted Likert scales. All evaluations were performed by 3 independent reviewers in October 2023, and all reviews were repeated in April 2024. Descriptive statistics and analysis were performed. Results Without prompting, the quality of information was moderate across all LLMs but improved to high quality with prompting. LLMs were accurate and complete, with an average score of 5.5 of 6.0 (SD, 0.8) and 2.8 of 3.0 (SD, 0.4), respectively. The average Flesch-Kincaid reading level was grade 12.9 (SD, 2.1). Chatbots were unable to communicate at a grade 8 reading level when prompted, and their citations were appropriate only 42.5% of the time. Conclusion LLMs may become a valuable tool for patient education for PD, but they currently rely on clinical context and appropriate prompting by humans to be useful. Unfortunately, their prerequisite reading level remains higher than that of the average patient, and their citations cannot be trusted. However, given their increasing uptake and accessibility, patients and physicians should be educated on how to interact with these LLMs to elicit the most appropriate responses. In the future, LLMs may reduce burnout by helping physicians respond to patient messages.

This study investigates the sex-specific role of the Hypothalamic–Pituitary–Gonadal axis in Alzheimer’s disease progression, utilizing ADNI1 data for 493 individuals, analyzing plasma levels of gonadotropic and sex hormones, and examining neurodegeneration-related brain structures. We assessed plasma levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), progesterone (P4), and testosterone (T), along with volumetric measures of the hippocampus, entorhinal cortex, and hypothalamic subunits, to explore their correlation with Alzheimer’s disease markers across different cognitive statuses and sexes. Significant cognitive status effects were observed for all volumetric measures, with a distinct sex-by-cognitive status interaction for hypothalamic volume, indicating a decrease in males but not in females across cognitive impairment stages. Regression analyses showed specific hypothalamic subunit volume related to hormone levels, accounting for up to approximately 40% of the variance (p < 0.05). The findings highlight sex differences in neurodegeneration and hormonal regulation, suggesting potential for personalized treatments and advancing the understanding of Alzheimer’s disease etiology.