Helo, Sevann

Abstract Introduction Inflatable penile prosthesis reservoir herniation or migration may occur with space of Retzius or submuscular placement. The dangers of high submuscular placement include bowel or bladder perforation (from blind instrument passage) and or bowel herniation (from unintentional peritoneal placement and stretching of small opening with reservoir filling). Even under direct vision submuscular placement, reservoirs can ultimately reside into the scrotum, retroperitoneum, and lateral abdominal wall. The Transfascial Fixation (TFF) technique was recently developed to prevent reservoir migration with placement either submuscularly or in the space of Retzius, but video of this technique has not been previously published. Objective To visually demonstrate the proper surgical technique of TFF during IPP reservoir placement. Methods An IPP surgical candidate at high risk of complications should reservoir migration occur was identified. Video of TFF technique performed during IPP surgery was recorded using an in-light overhead camera and a GoPro aseptically positioned on the lead surgeon. Results Successful demonstration of TFF technique during IPP placement. Conclusions TFF technique is a feasible option to aid prevention of penile implant reservoir herniation. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific, Metuchen Pharmaceuticals, Acerus Pharmaceuticals, Endo Pharmaceuticals, AbbVie Inc.

Abstract Introduction Inflatable penile prosthesis reservoir herniation or migration may occur with space of Retzius or submuscular placement. The dangers of high submuscular placement include bowel or bladder perforation (from blind instrument passage) and or bowel herniation (from unintentional peritoneal placement and stretching of small opening with reservoir filling). Even under direct vision submuscular placement, reservoirs can ultimately reside into the scrotum, retroperitoneum, and lateral abdominal wall. The Tubing, Hitch And Lasso, Intussusception Anchor (THALIA) technique was recently developed to prevent reservoir migration with placement either submuscularly or in the space of Retzius, but video of this technique has not been previously published. Objective To visually demonstrate the proper surgical technique of THALIA during IPP reservoir placement. Methods An IPP surgical candidate at high risk of complications should reservoir migration occur was identified. Video of THALIA technique performed during IPP surgery was recorded using an in-light overhead camera and a GoPro aseptically positioned on the lead surgeon. Results Successful demonstration of THALIA technique during IPP placement. Conclusions THALIA technique is a feasible option to aid prevention of penile implant reservoir herniation. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast

Abstract Introduction Penile duplex Doppler ultrasound (PDDU) is an important test to diagnose and guide treatment recommendations for peyronie’s Disease and erectile dysfunction. When patients do not achieve optimal rigidity during their evaluation we may be underestimating their degree of curvature and erection response which can impact treatment recommendations. Objective To evaluate specific examination conditions that may negatively impact the patient experience in men undergoing PDDU. Methods We developed a survey to evaluate patient experience during PDDU. Specific questions addressed preferences regarding the type of clinician performing the examination (physician versus advanced practice provider), provider gender, and specific modifiable conditions about the examination room. The survey was administered to thirty-five consecutive patients at a single academic practice. Patients were asked to complete portions of the survey before and after the examination to limit bias. Results 113 patients completed the survey. Prior to starting the testing, 48% of patients (n=54) had no provider preference, whereas 43% (n=49) preferred a physician as the performing clinician. 70% of patients (n=79) had no provider gender preference. All patients received at least a single dose of intracavernosal erectogenic medication at the start of their assessment. After completing PDDU, 40% of patients (n=45) reported that room conditions negatively impacted their ability achieve an adequate erectile response in the clinic. As shown in Figure 1, bright fluorescent overhead lighting (29%) and hallway noise (21%) were the most frequent contributing factors. When asked about opportunities to improve future patient experience, 38% (n=43) recommended dimming the room lights, 31% (n=35) would enjoy a warm blanket, and 36% (n=41) would favor gentle music or background sounds. 32% (n=36) felt that using call button, as opposed to routine staff checks to verify erectile response, would be desirable. Despite these preferences, the mean overall patient experience on a scale of 0-10 (0=poor, 10=excellent) was high at 9.3 (SD 1.2). Conclusions Despite high patient-reported satisfaction, we found that patients undergoing PDDU for PD and ED reported a preference towards (i) softer/dimmer lights, (ii) sound machine to drown out hallway noise, (iii) aa warm blanket, (iv) a call system to alert staff of a satisfactory erectile response. Further investigations are necessary to determine whether these simple modifications can improve the patient experience and exam efficiency. Disclosure No

Abstract Introduction Collagenase clostridium histolyticum (CCH, Xiaflex®; Endo Pharmaceuticals) is the only FDA-approved non-surgical therapy for Peyronie’s Disease (PD). CCH is an effective alternative to surgery for patients with PD who have a palpable plaque and a curvature deformity of ≥30°. Clinicians who administer CCH must complete risk mitigation training, and access to specialists varies by region across the US. Identifying areas with low provider availability may improve patient access to this and other treatments for PD. Objective To review the availability of clinicians offering CCH for the treatment of Peyronie’s Disease in the conterminous United States. Methods We utilized a publicly available search tool on a website provided by Endo Pharmaceuticals to identify certified providers offering CCH in the conterminous United States. We created a list of 23 zip codes that, when surrounded by a 500-mile radius, encompass the entire conterminous United States. We then utilized the search tool to identify providers within those radii. The data gathered included the provider’s name, specialty, and practice address. Duplicate addresses were removed, but a single provider offering CCH at 2 different locations was considered 2 different data points. We compared the data relative to the American Urological Association’s “The State of the Urology Workforce and Practice in the United States” and 2021 State Population Estimates from the US Census Bureau. Results In total, 1948 locations offering CCH were identified (Figure 1a). The mean number of locations offering CCH per 100,000 state residents was 0.61 [SD 0.27] (Figure 1b). Wyoming had the highest number of locations per 100k residents with 1.39. New Mexico had the lowest with 0.05. The 10 states with the highest ratio of clinicians/locations (from high-low) per capita were Wyoming, Georgia, Rhode Island, Nebraska, Maryland, New Jersey, Kansas, North Carolina, South Carolina, and Alabama. The 10 states with the lowest were New Mexico, Delaware, Maine, Mississippi, Minnesota, Vermont, Missouri, Indiana, New Hampshire, and Idaho. The mean proportion of urologists providing CCH to total urologists (Figure 1c) was 0.15 [SD 0.07]. Wyoming had the highest proportion of 0.40 and New Mexico had the lowest of 0.02. The 10 states with the highest proportion (from high-low) were Wyoming, Georgia, Utah, Nebraska, Kansas, Alabama, Nevada, Arizona, South Carolina, and Oklahoma. The 10 states with the lowest proportion (from low-high) were New Mexico, Delaware, Maine, Vermont, New Hampshire, Minnesota, Missouri, South Dakota, and Mississippi. Conclusions There are notable differences in the relative availability of CCH providers across the US. These discrepancies may impact access to care, supporting an opportunity to expand training efforts. States with low numbers of treatment locations offering CCH per 100k residents relative to other states also had a low total proportion of urologists offering CCH as a treatment. There is room for current practicing urologists in these states and others to expand their practice to offer CCH and improve patient access to this important non-surgical treatment option. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Endo Pharmaceuticals.

Abstract Introduction Epididymectomy is indicated for patients with focal epididymal pain and bothersome epididymal cysts or masses. Similarly, spermatocelectomy is indicated for spermatoceles that have becomes symptomatic due to size or pain. The majority of scrotal surgeries are performed in the operating room (OR) using general or monitored anesthesia. Here, we sought to evaluate our experience with office-based epididymectomy and spermatocelectomy using only local anesthesia. Objective To evaluate post-procedural complications and pain resolution following epididymectomy or spermatocelectomy, comparing procedures performed in the clinic with only local anesthesia, compared to the OR. Methods We identified patients who underwent epididymectomy or spermatocelectomy at our institution from 2018-2021. A chart review was performed to identify pertinent information including whether the procedure was performed in the OR under monitored/general anesthesia versus in the clinic using only local anesthesia. Post-procedural outcomes including pain resolution (if applicable) and 30-day complications were compared between those who underwent epididymectomy or spermatocelectomy in the OR versus the office. Statistical analysis was performed using the chi-squared test. Results A total of 112 patients were identified, including 23 (20.5%) who underwent epididymectomy and 89 (79.5%) who underwent spermatocelectomy. Mean patient follow-up was 14.8 months (SD 11.6). Indications for epididymectomy or spermatocelectomy included pain (n= 50, 44.6%), epididymal cyst/mass (n=6, 5.4%), and mass effect secondary to spermatocele (n=56, 50.0%). Fifty-seven procedures (50.9%) were performed in the office under local anesthesia. Nitrous oxide was used in 21 (36.8%) of these cases. Thirty-four patients (30.3%) were on anticoagulation/antiplatelet therapy prior to surgery including 22 (64.7%) who continued anticoagulation/antiplatelet therapy due to high-risk comorbidities. The adverse event rate within 30 days was similar between patients who underwent surgery in clinic versus OR (p=0.67). Specifically, adverse events occurred in 9 patients (8.0%), of whom 4 had their procedure performed in the clinic (7.0% of clinic procedures) and 5 had their procedure performed in the OR (9.1% of OR procedures). Specific adverse events included postoperative hematoma in 6 patients (66%) and a single case of each of the following: infection, inability to void postoperatively, and intestinal obstruction. Hematoma rates did not differ significantly between those who were or were not on anticoagulation perioperatively (p=0.057). In patients with reported adverse events, 3 (33.3%) required reoperation. Of the 50 patients who underwent epididymectomy or spermatocelectomy for scrotal content pain, 39 had sufficient documentation available to evaluate pain resolution. 82% (n=32) reported 50% improvement in pain. There was no statistically significant difference in the likelihood of reporting significant pain reduction based on the location of the procedure (OR versus clinic). Conclusions Epididymectomy and spermatocelectomy can be successfully carried out in the office using only local anesthesia, including in those patients who are high risk for general anesthesia or require maintenance of anticoagulation perioperatively. Pain improvement may be anticipated in the majority of appropriately selected patients following treatment in either the clinic or OR. Disclosure No

Abstract Introduction There is no agreed-upon definition for acute/chronic phases of Peyronie’s Disease (PD). Collagenase Clostridium histolyticum (CCH) is the only FDA-approved treatment for PD, but original phase-3 trials included patients with symptom duration > 12 months (“chronic phase”). Objective Here, we sought to evaluate the influence of time between symptom onset and starting CCH on treatment outcomes. Methods Men receiving CCH from 2014-2021 were included in an IRB-approved database. Pertinent data were reviewed, including demographics and curvature assessments. The duration between symptom onset and starting treatment with CCH was assessed to determine if the time from symptom onset to treatment impacted objective outcomes. Results One hundred forty-five patients completed the entire series of 8 injections and had complete data for review. Mean baseline curvature 53.2o (SD 18). The mean time between symptom onset and CCH was 14.8 months (SD 18). Mean absolute and percentage improvements were 20.3o (SD 16) and 39.4% (SD 35). Symptom duration did not significantly impact curvature improvement (Figure 1). Similarly, symptom duration did not significantly impact the risk for CCH-related side effects. Conclusions The time between symptom onset and treatment did not significantly impact outcomes with CCH. Our findings support the utility of using CCH early in the course of PD and emphasize the opportunity to delay if necessary without compromising efficacy. Disclosure No

Abstract Introduction Intralesional Collagenase Clostridium histolyticum (CCH) is approved for men with Peyronie’s Disease (PD). Most studies use curve improvement ≥ 20% to define treatment success. Objective Here, we sought to further characterize objective and subjective treatment outcomes with CCH. Methods We reviewed our prospectively maintained database for all patients who underwent CCH at our institution from 2013 through the present. We specifically identified those who completed four series of CCH (or elected to discontinue prior to completing four series due to satisfactory penile straightening or lack of results) and had available curvature assessment data. Treatment outcomes were broken down by level of curve improvement (0%, 10%, 20%, 30%, and > 40% improvement). Treatment success was also evaluated by improvements in the ability to engage in penetrative sexual intercourse and perceived surgery avoidance. Statistical analyses were performed using JMP Pro 14.1.0 (SAS Institute, Cary, NC). Results 127 patients had complete data available. The mean age was 57 years (SD 8.4). The mean PD duration was 27 months (SD 59). The mean baseline curvature was 66.1O, and the mean post-treatment curvature was 45.1O (p<0001). The mean curvature improvement was 32% (SD 33). 68% of patients achieved a 20% or greater improvement in penile curvature, including 38% who achieved ≥ 40% improvement. 72% (n=48/67) felt that CCH prevented the need for surgery, and 68% reported CCH restored the ability to penetrate. Stretched flaccid penile length (SPL) increased by ≥ 1 cm in 50% of patients who used concurrent penile traction (PTT) and CCH, including 28% of patients who experienced ≥ 2 cm of length gain. In contrast, only 16% of patients who did not perform concurrent PTT had a ≥ 1 cm increase in SPL (p<0.0001). Conclusions CCH may restore the ability to penetrate with intercourse, and most patients feel that CCH prevents the need for surgery. Almost 40% of patients experienced a 40% or greater curvature improvement. However, 13% of patients may go through the entire series with minimal improvement. Concurrent PTT allows for simultaneous penile length gain in some patients. These data are helpful when counseling patients on expected outcomes. Disclosure No

Abstract Introduction Women in healthcare are faced with unique challenges that may increase the risk of infertility including irregular work hours, occupational hazards due to radiation or chemicals, and advanced maternal age. Objective We therefore sought to investigate live birth rates of female healthcare workers presenting with infertility compared to their non-healthcare counterparts. Methods After obtaining IRB approval, a retrospective review of hospital employees and partners presenting for a fertility evaluation between 2013-2019 was conducted. Patient age, BMI, history of previous live birth, occupation, use of assisted reproductive technology and female fertility factor were recorded. Couples with at least 12 months of follow up from initial presentation as well as a documented semen analysis were included in the study. Normal semen parameters were defined by the World Health Organization 2010 criteria. Logistic regression analysis was conducted to identify factors associated with increased likelihood of live birth. Results Of the 934 female partners identified, 445 were healthcare workers and 489 non-healthcare workers. Female age, BMI, smoking status, and history of previous live birth were not statistically significant between groups. No differences in male partner age, BMI, semen parameters and presence of male factor were noted. As an overall group, female age, male age, and abnormal concentration were noted to impact live birth rates (p<0.016). Live birth rates were higher in female health care workers compared to non-healthcare workers, 76.1 vs. 69.6%, respectively, p=0.042. The cohort was then further analyzed to determine if there was a difference in between females holding a Doctor of Medicine (MD) and other medical occupations (91 MDs vs 357 other occupations). Live birth rates, pregnancy complications, and preterm labor were not statistically significant, however MDs were found to have higher rates of use of assisted reproductive technologies (IUI or IVF) and were more likely to be older at time of evaluation (p=0.0015). After controlling for age at delivery, female physicians were still more likely to utilize ARTs, but this was no longer statistically significant (p=0.0806). Conclusions In this cohort of hospital employees, female healthcare workers had a higher live birth rate despite no differences in age, BMI, female factor infertility, use of assisted reproductive technology, or male partner factors. However, when the subgroup of female hospital employees was further analyzed, MDs were noted to have higher use of assisted reproductive technologies and older age. This indicates increased difficulty achieving pregnancy, likely a reflection of advanced maternal age. Further research is needed to identify subgroups within the healthcare population that may be at greater risk for infertility. Disclosure No

Abstract Introduction Physicians may be subjected to grueling work hours, sleep deprivation, and a stressful work environment during their prime reproductive years. While attention to fertility among female physicians has garnered interest in recent years, little is known about the fertility of their male colleagues. Objective In this study we sought to compare semen parameters of male physicians presenting for a fertility evaluation compared to their non-physician counterparts. Methods Upon IRB approval, a retrospective review of all hospital employed individuals (or their partners) who underwent a semen analysis between 2013-2019 was performed. Post-vasectomy semen analysis patients were excluded. Baseline patient demographics including age, comorbidities, occupation, and BMI were recorded. Normal semen parameters were defined by the World Health Organization 2010 criteria. A comparison analysis of semen analysis parameters, baseline characteristics, and comorbidities was conducted with a significant p-value defined as <0.05. Results Of the 169 physicians and 438 non-physicians identified, physicians were more likely to have a lower BMI (median 25.8 vs. 28.0, p<0.0001) when compared to their non-physician counterparts. Physicians were less likely to have ADHD, depression, obstructive sleep apnea, malignancy, alcohol abuse, and history of smoking (p<0.05). Physicians had better semen parameters including pH, concentration, motility, volume, and morphology (p<0.05), with a greater sperm concentration (68.4 vs. 52.2 million/mL, p<0.0001) and higher total motile sperm count (125 vs. 86.4 million, p<0.0001) compared to non-physicians. However, male physicians were more likely to be older at time of semen analysis (33.8 versus 32.7 years, p<0.05), more likely to utilize assisted reproductive technology (IVF and IUI, p=0.0277), have older female partners (p=0.0053), and have older female partners at time of delivery (p=0.0124). Conclusions In this study we report, for the first time, semen parameters of physicians compared to non-physicians. Physicians had a significantly higher total motile sperm count and sperm concentration; however, they were older at time of semen analysis, more likely to utilize ART, and more likely to have older female partners. While physicians may be healthier, this may indicate increased difficulty achieving pregnancy. Patient care is directly impacted by the health and safety provided to their physicians. As the paradigm in the medical field shifts from caring only for our patients to caring for ourselves, fertility amongst male physicians warrants further investigation. Disclosure No

Abstract Introduction Obstructive azoospermia accounts for up to 14% of patients presenting for fertility evaluation. Fine-needle vasography (FNV) is a diagnostic procedure that can be performed to identify an obstruction proximal to the ejaculatory duct. Compared to traditional vasography, FNV utilizes a less-invasive method to perform imaging of the vas deferens and distal ejaculatory structures. Herein we report our experience performing FNV in a series of patients with suspected complete or near-complete obstruction. Objective To report our experience using FNV to identify a site of obstruction and determine candidacy for reconstructive procedures in patients presenting with suspected obstructive azoospermia or cryptozoospermia. Methods We report a multi-Institutional case series of patients with suspected complete or partial obstructive azoospermia. Patients that were included had azoospermia or severe oligoasthenospermia, presence of palpable vasa, testicles ≥12 ml, and FSH <7.6 IU/L. All patients underwent testicular biopsy prior to or at the time of FNV to confirm spermatogenesis. Fine-needle vasography was performed using a 25F angiocatheter, with radio-opaque dye visualized under fluoroscopy. Descriptive statistics are reported as median and interquartile range (IQR). Results A total of 16 patients underwent vasography between 2014 and 2022 with three surgeons. Twelve patients presented with azoospermia, and four with severe oligoasthenospermia. Median age at vasography was 35.0 (IQR 17) years. Median pre-vasography semen parameters were sperm concentration 0 million/mL (IQR 0.3), sperm motility 0% (IQR 1), semen volume 2.5 mL (IQR 2.5), and semen pH 8.0 (0.7). Median total testosterone was 445 ng/dL (IQR 433), and FSH 4.5 IU/L (IQR 3.6). Half of patients had a history of inguinal hernia repair, unilateral in two and bilateral in six cases. History of genitourinary infection was present in six (35.3%) patients. A total of 7 (44%) men were found to have distal obstruction on FNV, while 8 (50%) were offered epididymovasal reconstruction. Of the seven patients diagnosed with obstruction/atresia of the vas deferens within the inguinal canal and/or pelvis, only two were related to prior inguinal hernia repair. Of the eight men with prior inguinal hernia repairs, two were confirmed to have an obstruction at the level of the inguinal canal. Of the six patients with a history of genitourinary infection, four had an obstruction at the level of the epididymis (with normal FNV), while two had atresia of the vas deferens in the pelvis. Conclusions Fine-needle vasography is an effective, minimally-invasive way to identify the site of complete or partial obstruction in patients presenting with suspected obstructive azoospermia or severe oligoasthenospermia. It additionally permits identification of men who are candidates for epididymovasostomy reconstruction and helps to differentiate between ejaculatory duct obstruction and other causes of blockage. Disclosure No