Colquitt, John L.

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 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.

AbstractObjectivesFetal endoscopic tracheal occlusion (FETO) is offered to fetuses with congenital diaphragmatic hernia (CDH) and severe lung hypoplasia to promote lung growth and may secondarily affect left heart growth. The effects of FETO on left heart hypoplasia (LHH) are not described post‐CDH repair.MethodsA retrospective analysis was performed for fetuses with left‐sided CDH who underwent FETO and severity‐matched controls from 2007 to 2016 at our institution. Echocardiographic, ultrasound, and MRI data were reviewed. Left heart dimensions were assessed prenatally and postnatally. Primary clinical outcome evaluated was death.ResultsTwelve FETO patients and 18 controls were identified. Fetal LHH was noted in both groups and worsened after FETO. Postnatal mitral valve dimensions were larger in the FETO group pre‐CDH repair (P = .03). Post‐CDH repair, mitral valve and left ventricular dimensions were not significantly different between groups (P = .79 and P = .63 respectively) while FETO aortic valve dimensions were smaller (P = .04). Extracorporeal membrane oxygenation use was lower in the FETO group. No associations were found between left heart dimensions and outcomes.ConclusionAlthough increased lung growth was seen after FETO, fetal LHH persisted with relative normalization seen post‐repair. Persistent LHH post‐FETO could be secondary to a small contribution of pulmonary venous return to the fetal left heart and increased intrathoracic pressures post‐FETO.