Citations

Abstract Introduction Undergoing fertility testing can be a stressful event in a couple's life. This can impact multiple aspects of life, including sex. Objective To evaluate the relationship between stress and sexual function in men undergoing fertility testing. Methods We performed a review of a prospectively maintained database of men utilizing a mail-in semen analysis test system developed by Fellow Health, Inc. Those included consented to participate in research, were 18 or older, and completed survey questionnaires on both their quality of life and sexual function. Stress level (low, moderate, or high stress) was determined using the validated Perceived Stress Scale (PSS) 10-question survey. The sexual function survey assessed libido, orgasmic and ejaculatory dysfunction, intercourse frequency, Erection Hardness Score, and IIEF-5 score. Descriptive statistics were reported and chi-squared and t-tests were used to determine statistical significance at the 0.05 alpha level. Results A total of 2077 men undergoing fertility testing were included in this study. 50.2% reported moderate stress levels and 2.6% reported high stress levels. Those with low stress were older than those with moderate or high stress (average 35.4 vs. 34.3 and 34.0 years, respectively; p < 0.01). Men with high stress levels were more likely to report a “poor” or “terrible” libido (31.4%) compared to those with moderate or low stress, 17.2% and 9.5%, respectively (p < 0.01). Stress was highly associated with weekly intercourse frequency (p < 0.01): among men with high levels of stress, 25.5% reported having sex less than once a week compared to 6.0% of men with low stress. Likewise, no highly stressed men reported having sex more than six times per week compared to 2.8% of men with low stress. Whereas 80.4% of men with low stress were evaluated to have “No signs of ED” by the IIEF-5, the same was true for only 62.3% of moderately stressed men and 56.0% of highly stressed men (p < 0.01). Conclusions More than half of men undergoing fertility testing report increased levels of stress, which is negatively associated with libido and erectile function. In men seeking fertility evaluation, lifestyle factors such as stress levels should be assessed to identify patients who may benefit from stress management strategies. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow Health.

Abstract Introduction Depression is a common mental health disorder affecting men of reproductive age. Depression or depressive symptoms may impact a variety of health factors, including sexual function. Trying to conceive may contribute to additional stress and negative emotions for the couple. Objective To determine the rate of sexual dysfunction in men with depression who are undergoing fertility testing. Methods A review was performed of a prospectively maintained database of men utilizing a mail-in semen analysis test system developed by Fellow Health, Inc. Men ≥18 years were included if they consented to participate in research and completed survey questionnaires on both their quality of life and sexual function. Depression level (normal, mild, moderate, or severe) was derived via the short-form depression assessment developed by the Patient Reported Outcomes Measurement Information System (PROMIS). The sexual function survey assessed libido, orgasmic and ejaculatory dysfunction, intercourse frequency, Erection Hardness Score, and IIEF-5 score. Descriptive statistics were reported and chi-squared tests were used to determine statistical significance at the 0.05 alpha level. Results Of the 2125 men included, 15.2% reported mild depression and 12.8% moderate or severe depression. The presence of depression was negatively associated with libido, with 11.2% of men with normal levels of depression reporting terrible or poor libido compared to 18.7% with mild depression and 22.2% with moderate or severe depression, p < 0.001. Compared to men without depression, those with moderate or severe depression were nearly twice as likely to report ejaculatory dysfunction (17.2% vs. 29.7%) and three times as likely to report orgasmic dysfunction (3.9% vs. 13.0%), p < 0.001 for all. Severity of depression was also predictive of an erection sufficient for penetration: whereas 96.8% of those with normal levels of depression reported an erection sufficient for penetration, the same could be said for only 94.5% of those with mild depression and 92.5% of those with moderate or severe depression (p < 0.001). Only 53.1% of men with moderate or severe depression had an IIEF-5 score greater than 21 (i.e., “No signs of ED”), compared to 60.9% with mild depression and 75.8% without depression, p < 0.001. Importantly, men with moderate to severe depression were more than twice as likely to report intercourse frequency less than once weekly (18.0%) as opposed to men without depression (7.4%), p < 0.001. Conclusions The presence of depression in men undergoing fertility testing is negatively associated with libido, ejaculatory, orgasmic, and erectile function. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow Health.

Abstract Introduction Limited data exist on semen parameters post vasectomy reversal. Specifically, no studies have rigorously evaluated the likelihood of sperm return following discovery of azoospermia at some time point post vasectomy reversal. Objective To evaluate the rate of return of sperm among men who experience an azoospermia result post vasectomy-reversal. Methods A large, prospective dataset has been maintained of men undergoing vasectomy reversals at a single center from 2019 to the present. Men who had at least two post-operative semen analyses were included for review. The data were then analyzed in a manner to identify those who experienced a 0 count at varying time points and then either went on to continue to have 0’s beyond that point or who experienced a return of sperm. Results A total of 3414 men underwent a vasectomy reversal since 2019, with 2703 having semen analysis data available for review. Overall demographics demonstrated a mean age of 41, partner age 33, median time since vasectomy of 7 years, 92% first-time cases, and distribution of repair as noted: VV/VV (79%), VV/EV (12%), EV/EV (6%), VV/x (1%), EV/x (<1%), x/x (0%). Of men who had 0 sperm at varying time points, the percentages of those who experienced a return of sperm are noted as follows: 0 sperm at <2 months (52% experienced a return at some point, n = 349 used in calculation), 0 at 2-4 months (38% return, n = 210), 0 at 5-7 months (17% return, n = 206), 0 at 8-10 months (20% return, n = 133), 0 at 11-18 months (9% return, n = 107). The data are limited by the fact that relatively few men continued to send in semen analysis samples beyond 12 months (n = 403 with at least one result >12 months and n = 101 with results >24 months). Conclusions Men who experience azoospermia post-vasectomy reversal may experience a return of sperm over time, with the likelihood for return declining based on the duration of persistence of 0 sperm. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: PathRight Medical.

Abstract Introduction Microdissection testicular sperm extraction (microTESE) is performed in men with nonobstructive azoospermia who desire sperm retrieval for use in IVF. This procedure can be performed in the operating room or in the clinic with local analgesic. Objective To report office-based microTESE sperm retrieval, fertilization, and livebirth rates. Methods A review was conducted of all patients who underwent office-based microTESE for nonobstructive azoospermia with a partner that who underwent concurrent oocyte retrieval for an intended in-vitro fertilization (IVF) intracytoplasmic injection (ICSI) cycle 2022-2024. All male partners underwent Y chromosome microdeletion testing, karyotype analysis, and hormonal testing preoperatively. Patients with a diagnosis of hypogonadism were offered medical therapy and those diagnosed with a varicocele were offered varicocelectomy prior to microTESE. Office-based microTESE was performed using a surgical operating microscope, spermatic cord block, and oral anxiolytic. Female partners underwent oocyte retrieval with oocyte cryopreservation prior to microTESE. Oocyte warming and ICSI was performed only following the collection of motile sperm from the fresh microTESE samples. Relevant demographic and clinical data were collected for patients and their partners. Descriptive data analysis was performed and reported as mean ± standard deviation. Results Ten patients underwent 11 office-based microTESE procedures. One patient had repeat microTESE following an unsuccessful IVF/ICSI cycle. Overall sperm retrieval rate was 70% for first time microTESE with mean search time 197.2 ± 96.5 min. Amongst couples with successful sperm retrieval, normal fertilization rate was 42%. Early cleavage arrest was seen in 84% of normally fertilized oocytes with a 16% blastocyst rate. Embryo development arrested entirely in two couples, while the remaining five couples had at least one blastocyst on day 5 and underwent embryo transfer. Of these, four resulted in a clinical pregnancy (36%). Three couples had a successful live birth and one has an ongoing pregnancy with ultrasound-confirmed fetal heartbeat. Conclusions Our small series demonstrates high sperm retrieval rates from office-based microTESE. Fertilization rates, clinical pregnancies and live birth rates are comparable with those reported in the literature. Given the financial cost associated with microTESE and IVF/ICSI for nonobstructive azoospermia patients, office-based microTESE may be a solution to make the process more financially accessible for couples. Disclosure No.

Abstract Introduction Sleep disorders can negatively impact multiple facets of health including sexual function. In men undergoing fertility testing, optimization of general health is of utmost importance to maximize fertility outcomes. Objective To determine the relationship between sleep disturbance and sexual function in men undergoing fertility testing. Methods This study evaluated men undergoing fertility testing who completed an at-home semen analysis kit developed by Fellow Health, Inc. Men ≥18 years were included if they consented to participate in research and completed survey questionnaires on both their quality of life and sexual function. Sleep disturbance level (normal, mild, moderate, or severe) was derived using a validated survey assessment, developed by the Patient-Reported Outcomes Measurement Information System (PROMIS), which queried sleep quality, sleep depth, and restoration associated with sleep. The sexual function survey assessed libido, orgasmic and ejaculatory dysfunction, Erection Hardness Score, and IIEF-5 score. Descriptive statistics were reported and chi squared tests were used to test for independence of categorical variables with statistical significance reported at the 0.05 alpha level. Results Of the 1919 men included in this analysis, 7.7% were assessed to have a mild level of sleep disturbance and 4.4% had moderate to severe sleep disturbance. Compared to those with “normal” levels of sleep disturbance, those with mild to severe levels more often reported low libido (20.7% vs. 13.8%; p = 0.01), ejaculatory dysfunction (31.3% vs. 19.9%; p < 0.01), and orgasmic dysfunction (15.3% vs. 5.1%; p < 0.01). Of men with mild to severe sleep disturbance, 28.3% reported pursuing treatment for erectile dysfunction compared to those with normal levels of sleep disturbance (17.8%; p < 0.01). Further, only 57.2% of men with mild to severe sleep disturbance were assessed to have “No signs of ED” compared to 71.0% of men without elevated levels of sleep disturbance (p < 0.01). Conclusions Sleep disturbance is associated with reduced libido, ejaculatory, orgasmic, and erectile function in men undergoing fertility testing. Providers should assess for sleep-related symptoms during initial evaluation to optimize fertility potential. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow Health.

Abstract Introduction Transurethral bipolar enucleation of the prostate (TUBE) is an enucleation procedure with similar functional urinary outcomes to holmium laser enucleation of the prostate (HoLEP). In comparison to the steep learning curve associated with HoLEP, TUBE appears to be more easily reproductible likely due to pre-existing familiarity with instrumentation. Despite the significant benefits associated with TUBE, retrograde ejaculation has been shown to occur in approximately 44.3% of patients. Objective Patient perspectives have previously emphasized the importance of preserving erectile and ejaculatory function, however the lack of subjective and objective data after TUBE makes it difficult to determine the overall impact on sexual function. We therefore sought to assess the objective and subjective sexual outcomes in men undergoing TUBE. Methods After IRB approval, a retrospective review of 112 patients undergoing transurethral bipolar enucleation procedures with a single surgeon at a tertiary care center was analyzed. The database included patient demographics, prostate information, preoperative uroflow medication, preoperative bladder management, intraoperative characteristics, and pre- and post-operative IIEF scores. To evaluate subjective patient responses, a 21-question survey incorporating the IIEF score and subjective questions to determine ejaculatory, orgasmic, and erectile function was disseminated. Results On objective analysis, smaller prostate size was significantly associated with a lower post-operative sexual satisfaction (p < 0.023). Larger prostates (>125 g & 75-125 g) and the absence of a median lobe were significantly and independently associated with larger changes in post-operative intercourse satisfaction scores (p < 0.05). Intraoperative morcellation, medication usage, preoperative bladder management, and demographic characteristics were not associated with sexual satisfaction scores. On subjective analysis, twenty-seven percent of patients were not engaging in sexual activity post-procedurally. Of the patients that were sexually active, 24% were able to achieve an erection, 36% were almost always or always able to ejaculate, 57% continued to orgasm or climax, and 50% experienced sexual desire more than half of the time. However, 18% of men noted ejaculatory dysfunction contributed to diminished orgasmic function and sensation issues and 37% noted dissatisfaction with orgasms. Conclusions To our knowledge, this is the first study to analyze objective and subjective patient responses to sexual function post-TUBE surgery. On objective analysis, improvements in intercourse satisfaction following TUBE surgery were more common in patients with larger prostate sizes and presence of a median lobe. On subjective analysis, erectile satisfaction rates remained high, however patients endorsed issues with orgasm and ejaculatory function, often associated with retrograde ejaculation. This data will allow us to improve patient counseling preoperatively and potentially offer less aggressive operations in patients who prioritize sexual function. Disclosure No.

Abstract Introduction Treatment of patients with obstructive lower urinary tract symptoms has various side effects on their quality of sexual life. Objective This study aimed to compare the effects of Rezum and Rezurp (a combination of Rezum for lateral lobes and TURP for the median lobe) on erections, retrograde ejaculation, and subjective orgasm experience in patients with a significant median lobe. Methods This is a retrospective cohort study that includes patients who underwent Rezum and Rezurp between January 2021 and January 2024. Sexual outcomes were assessed at 3 months and a median follow up phone call was 33 months. Patients were queried: Any changes in erections (yes/no) and changes in ejaculation (yes/no). If yes to changes, patients were asked to further define and characterize their responses including specific effect on orgasm. The effect of surgery on sexual outcomes was explored by chi-square analysis with P ≤ 0.05 considered statistically significant. Results Sexual outcomes were obtained for 78/89 patients in the Rezurp and 97/107 patients in the Rezum group. There was no significant difference in baseline characteristics, including age, prostate volume, and medication regimens, between the two groups, as shown in Table 1. The results indicated that 78% (61/78) and 83% (86/97) of Rezurp and Rezum patients experienced no change in ejaculation. Total ejaculation loss was seen only in two Rezurp patients. Ejaculatory changes between the two groups were not significantly different, with 13.8% and 4.23% worsening for Rezurp and Rezum, respectively (P = 0.08). Changes in erections and orgasm satisfaction were not statistically significant between the two groups (P = 0.76 and 0.54, respectively). Subjective worsening in orgasm quality for Rezurp and Rezum was not different between groups (P = 0.54), with 6.4% and 4.1% worsening, respectively (Table 2). Conclusions Rezurp and Rezum have similar sexual function outcomes. Disclosure No.

Abstract Introduction Penile plication is an excellent approach for patients with congenital penile curvature and Peyronie’s disease. Beginning in March of 2023, patients who were candidates for penile plication were offered the procedure in the operating room under general anesthesia or in the office setting with no sedation. Fourteen patients opted for the procedure in the clinic. Objective We therefore sought to assess patient responses and experience after undergoing surgery in the clinic setting. Methods Fifteen patients, ages ranging from 21 to 74 were seen in clinic for penile plication surgery. Exclusion criteria included patients younger than 18 years and preoperative systolic blood pressure greater than 160. One patient was noted to have a systolic blood pressure over 200 and thus was unable to have the procedure. Five patients had a penile plication for congenital curvature, eight patients for Peyronie’s disease, and 1 patient had a release of a previously placed palpable plication suture. Degree of curvature, direction of curvature, presence of secondary curvature, presence of hinge defect, and indentation were not considerations in patient selection. Three patients were on anticoagulation, which was held prior to surgery. Twelve patients underwent a ventral approach and two a degloving approach. Results Patients are allowed and encouraged to eat and drink prior to the procedure. All patients were given a preoperative antibiotic, normally either Bactrim or ciprofloxacin prior to the procedure and 20 mg of oral versed. They were then taken to the in-office procedure room after consent was obtained. The procedure room contains a television for patients to watch. At the end of the procedure, an Exparel block was performed. Patients are then prepped and draped in standard sterile fashion. A dorsal penile nerve block and circumferential block were utilized at the beginning of the case. A catheter is not placed to help reduce patient discomfort. Alprostadil is injected to help identify curvature. Ten patients were noted to have dorsal, 2 patients’ ventral, and 2 patients’ lateral curvature with degree of curvature ranging from 30 to 60 degrees. Eight patients had a secondary curvature identified. Total number of plication sutures utilized ranged from 2 to 8. All procedures were successfully conducted, and patients discharged home. Patients were then contacted to determine their experiences with the procedure. Only seven patients were able to be reached. One patient did have a vasovagal response in the procedure room, but this resolved with a small snack. Average intraoperative discomfort was rated as a 2/10 and was mainly present during the initial block. All patients stated that they would choose this surgical approach again and have noted clinically significant improvement to their curvature. Conclusions Penile plication in the clinic setting reduces anesthetic risks as well as costs associated with the operating room. This study shows the safety and feasibility of this approach. Disclosure No.

Abstract Introduction Concerns exist when inflatable penile prosthesis (IPP) surgery is performed following transcorporal artificial urinary sphincter (TC-AUS) due to risk of damaging the AUS cuff during proximal corporal dilation and device placement. Aside from rare case reports, no data exists on outcomes and complications in patients who undergo IPP surgery with existing TC-AUS in place. Objective We aim to describe perioperative complications, infections, revision rates, and device longevity when IPP surgery is performed with existing TC-AUS in place. Methods A retrospective search was conducted to identify all patients who had undergone TC-AUS placement at a single institution from 2015-2023. Patients who had undergone IPP placement following TC-AUS at the same institution were identified. Operative technique for IPP placement was similar to standard IPP surgery with additional care taken to avoid the AUS device and preferential use of electrocautery over sharp dissection. Operatives notes and all patient encounters were reviewed, and data on demographics, operative details, perioperative complications, infections, revision rates, and device longevity were recorded. Results 727 patients underwent TC-AUS placement from 2015-2023. Of these, 13 patients underwent subsequent IPP placement (fig. 1). All patients had history of prostatectomy, and 6 (46%) patients had prior radiation. The median follow-up after IPP was 31.7 months and the time gap between AUS and IPP averaged 18.3 months (range 2.3 to 56.7 months). Average operative time for IPP was 85 minutes (range 53 to 202 minutes). Reservoirs were all placed contralateral to the AUS reservoir to minimize risk of injury to the AUS device. 8 patients had a 12 Fr catheter left post-operatively for less than 24 hours. Proximal dilation was noted to be difficult in 2 patients (15%), both of which were successfully dilated without perforation or damage to the AUS cuff. No infections or erosions occurred. 3 patients (23%) developed mechanical failure at a mean time of 28.7 months following IPP placement (36.5 months after AUS). Cuff leak was identified in 2 patients and the third has yet to undergo revision surgery to determine etiology. Conclusions IPP placement appears safe and effective in men who have previously undergone TC-AUS without increased risk of infection or device erosion. Care should be taken when dilating proximally, though proximal dilation was uneventful in most patients. Mechanical failure rates may be slightly higher compared to patients who have either device alone, and patients should be counseled accordingly. Disclosure No.

Abstract Introduction The utilization of rear tip extenders (RTE) is often imperative during Inflatable Penile Prosthesis (IPP) placement. The impact of RTE on perioperative morbidity of IPP surgery is underexplored. Objective In this study, we assess intraoperative and postoperative outcomes among patients undergoing primary IPP implantation with or without RTE. Methods We performed a multicenter, retrospective analysis of men undergoing primary IPP placement between July 2016 and July 2021. A total of 4308 patients were identified, of which 2963 had no RTE and 1345 had RTE. After 1:1 propensity score matching for all confounding variables, 840 patients without RTE were compared to patients with RTE for intraoperative and postoperative outcomes. Chi-square and Mann–Whitney tests were used for statistical analysis for categorial and continuous variables respectively. For multivariable analysis, we used a forward stepwise model and included significant variables found on preoperative characteristics of patients. Kaplan–Meier time to event analysis were compared with Mantel-Cox log-rank test. Results Patients with RTE use had more postoperative complications (9.6% vs 5.2%, p < 0.001). More specifically, RTE patients had more episodes of postoperative hematoma and bleeding (2.0% vs 0.7%, p = 0.033), device malfunction (2.7% vs 1.8%, p = 0.006), and glans-related complications (0.8% vs 0, p = 0.015). On multivariable analysis, use of RTE (OR 1.58, 95% CI 1.07-2.34, p = 0.021), AMS 700 series device (OR 1.93, 95% CI 1.27-2.94, p = 0.002), penoscrotal approach (OR 2.60, 95% CI 1.61-4.18, p < 0.001), and older age (OR 1.02, 95% CI 1.00-1.04, p = 0.035) were associated with increased risk of postoperative complications. Patients with RTE use had increased rate of postoperative IPP revision (5.0% vs 2.1%, p = 0.002). The use of RTE (OR 1.71, 95% CI 1.00-2.90, p = 0.046), AMS 700 series device (OR 1.73, 95% CI 1.01-2.97, p = 0.048), penoscrotal approach (OR 3.16, 95% CI 1.63-6.17, p < 0.001), and history of Peyronie’s disease (OR 2.24, 95% CI 1.31-3.82, p = 0.003) were associated with increased risk of postoperative IPP revision or explantation. On Kaplan–Meier analysis, use of RTE was associated with increased risk of postoperative complications and IPP revision or explantation within 48 months (log rank p = 0.001 and p = 0.002 respectively). Conclusions In this large multi-institutional cohort, patients with RTE experienced more hematoma, device malfunctioning, and glans related post operative complications. The use of RTE is an independent predictor of post-operative complications and IPP revision or explanation. Disclosure No.