Citations

Abstract Introduction Discrimination and sexual harassment within the workplace have a negative impact on well-being and productivity and are often underreported due to lack of comfortability in confronting the offender. Objective We aim to assess the prevalence of these abusive behaviors within a urology department and the impact of a dedicated training session on comfortability reporting/confronting discrimination and harassment. Methods Employees within a urology department at a single institution were invited to take a survey regarding discrimination and harassment both before and after a dedicated training session on reporting and confronting these behaviors. Statistical analyses were performed between pre- and post-survey groups, genders, and roles within the department. Results A total of 166 employees completed the pre-training survey, while 79 (47.6%) completed the post-training survey. 116 (69.9%) respondents identified as female. Roles within the department included physician (48/166, 28.9%), advanced practice provider (21/166, 12.7%), nurse (42/166, 25.3%), and nonclinical staff (51/166, 30.7%). The training demonstrated a positive impact in respondent comfort level with addressing gender discrimination, where 19/23 (82.6%) people who answered neutral/ disagree/strongly disagree changed their answer to agree/strongly agree compared to 7/56 (12.5%) who changed their answers in the opposite way (p=0.02). More women reported experiencing sexual harassment at least once a year compared to men (38.6% vs. 16.7%, p<0.0001). Patients were the most commonly reported offenders of abusive behaviors towards staff. Conclusions Specific training on strategies for addressing abusive behaviors can help employees feel empowered to confront gender discrimination by both patients and their peers. Disclosure No

Abstract Introduction Intralesional Collagenase Clostridium Histolyticum (CCH; Xiaflex; Endo Pharmaceuticals, Dublin, Ireland) is the only FDA-approved intralesional therapy to treat bothersome penile curvature in men with Peyronie’s Disease (PD). Clinicians who administer CCH must be certified through a risk evaluation and management strategy (REMS) program. However, provider availability is highly dependent on geography and many patients must travel great distances to undergo evaluation and treatment with CCH by an experienced injector. Objective The goal of the current study is to describe the landscape of certified CCH injectors with respect to location and clinical background/training. Methods Patients are currently able to use an online “locate a specialist” tool through Endo Pharmaceuticals to identify clinicians in their local geographic area who are certified to administer CCH. Using this tool, a list of all providers who offer CCH injections was compiled throughout the continental United States. Pertinent information that was gathered included geographic location, type of provider or level of training [Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Physician Assistant (PA), Nurse Practitioner (NP), and Registered Nurse (RN)], and gender of providers. This information was compared to state population data (United State Census Bureau) to determine per capita coverage. Results A total of 1947 Xiaflex providers were identified: 1749 Doctors of Medicine (MD; 90%), 115 Doctor of Osteopathic Medicine (DO; 6%), 60 Physician Assistants (PA; 3%), 21 Nurse Practitioners (NP; 1%), and 1 Registered Nurse (RN; 0.05%). Out of the 1947 providers, only 95 (4.9%) were women. Most women administering Xiaflex were MDs (73%), followed by PAs (12%), NP and DOs (7%), and RN (1%). Xiaflex providers were available in all states except for Hawaii and Alaska. Providers were distributed throughout the United States with the average provider per capita ratio of 230,240. Wyoming, Washington D.C., Rhode Island, and Georgia had the best provider per capita at <10,000 while New Mexico had the worst provider per capita ratio at 2,117,522. Conclusions Our results show significant variation in certified CCH injector availability for patients across the United States. < 5% of all certified clinicians are female and 4% were advanced practice providers. Further work is needed to characterize and remedy gender disparities amongst providers, and ensure greater access for patients who desire an FDA-approved non-surgical treatment for their PD-associated curvature. Disclosure No

Abstract Introduction Inflatable penile prostheses have favorable short-term results for men with refractory erectile dysfunction, but few studies have evaluated the long-term outcomes, including in a VA population. Objective This study aims to evaluate the outcomes and satisfaction rates using the novel validated survey, the Satisfaction Survey for Inflatable Penile Implant (SSIPI) of a long-term single-center VA practice. Methods Chart reviews were completed as a Quality Improvement project. All patients who underwent a primary inflatable penile prosthesis implantation from 1993-2021 were included. Demographics and data were collected; SSIPI was administered to men who could be reached. Statistical analyses were performed. Results 114 men were identified, 82 alive and 32 deceased. In the cohort we contacted, mean age at time of surgery was 62.6 years old and mean follow-up 78.2 months (5-234 months). Average SSIPI scores were 64.5/80 (26-80). Smokers were less satisfied with length of penis vs. non-smokers (SSIPI#8 = 2.89 vs 3.93, p=0.032). Men with diabetes were more likely to express regret about undergoing IPP surgery compared to men without (SSIPI#4 = 4.05 vs 4.38, p=0.0029). Men with an ASA score of 2 or less had higher total SSIPI scores compared to ASA score of 3+ (70.36 vs. 61.13, p=0.046). Conclusions Long-term satisfaction with IPP in a veteran population appears favorable. However, a significant number of these men still score poorly on SSIPI and/or have complications. The utility of this novel assessment instrument appears excellent. Men with smoking, diabetes, and higher overall comorbidities may find fewer positive results. Disclosure No

Abstract Introduction Vasectomy is a highly effective, permanent method of contraception. Poor compliance rates have been observed for patients in obtaining their post-vasectomy semen analyses (PVSA). Few studies have looked at associations with low compliance. Objective The objective of our study was to identify compliance rates of post-vasectomy semen analysis and to identify associations that may increase or decrease the rates of compliance. Methods We studied 111 patients between November 2018 and April 2022 who underwent vasectomy at a single institution. Only patients who underwent vasectomy for fertility-related reasons were included in our final analysis. We excluded any patients who had undergone previous vasectomy or vasectomy reversal. Variables analyzed included age, relationship status, presence of primary care provider, anxiety diagnosis, and race. Variables were obtained via chart review which included but was not limited to reviewing notes, summary diagnostic pages, problem lists, and medication lists. All analyses were performed using R version 4.1.2 (R Foundation for Statistical Computing, Vienna, Austria). Categorical data were described with the number and percentage of patients. Continuous data were described with the median, minimum, and maximum. Associations of race and anxiety diagnosis with PVSA were explored using Fisher’s exact test. All p-values were two-sided at the 5% significance level without adjustment for multiple testing. Results Our cohort included 111 men who underwent vasectomy with exclusion of 1 patient who underwent vasectomy for non-fertility reasons. The median age of vasectomy was 38 years (range 26-59 years). Of 110 patients, 83 (75%) returned for PVSA. There were 103 (94%) married patients. Additional cohort characteristics can be seen in Table 1. As shown in Table 2, African American patients were less likely to return for PVSA than either white patients (14% vs. 79%, p<0.001) or Hispanic patients (14% vs. 100%, p=0.015). we did not find evidence of difference between white and Hispanic patients (p=0.58). Patients with an anxiety diagnosis were more likely to undergo PVSA compared to patients without an anxiety diagnosis (p<0.001). Conclusions Patients in our cohort of African American race were significantly less likely to undergo PVSA compared to white and Hispanic patients. This suggests an opportunity for improved counseling in the African American population. We do recognize a disparity in the number of white patients studied (n=95) versus African American (n=7) and Hispanic (n=5) patients. Additionally, patients with an anxiety disorder were more likely to undergo PVSA compared to patients without an anxiety disorder. The prevalence of anxiety disorder in our cohort is somewhat high relative to the overall population in the United States. This could be due to questionnaires used at our institution and the timeliness of those questionnaires. Personality traits could also lead to confounding in anxiety diagnoses. Overall, a 75% rate of PVSA speaks to an opportunity for better counseling regarding PVSA, especially in particular populations such as the African American population. Disclosure No

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 Collagenase clostridium histolyticum (CCH) is the only food and drug administration (FDA) approved intralesional medication for Peyronies Disease (PD). The manufacture instructions recommend a single injection into the plaque at the point of maximal curvature. However, a 2019 survey of the Sexual Medicine Society of North America (SMSNA) found that physicians were utilizing many different injection techniques. It is unknown if one technique is superior. Objective To assess delivery of medication into PD plaques using an invitro model. Methods We obtained PD plaques from men undergoing plaque excision and grafting. Plaques were stored at -80C until ready for use in the lab. We injected the plaques with 0.25ml of Eosin Y, 5 wt. 5% solution in water because this solution is visibly red and similar to the density of CCH. We assess how the dye spread through the plaque in four different injection techniques: single injection, single injection with slow pull back, multiple site injection and lateral injection. All injections were video recorded in real time. Results Dye was retained inside the plaques will all injection techniques, however in all conditions, a significant amount of dye leaked out of the plaques. Multiple injection technique appeared to have the least about of dye leak out of the plaque. Conclusions In all conditions, dye leaked out of the plaques, however the multiple injection technique appears to have deliver the greatest amount Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Endo Pharmaceuticals

AbstractBackgroundStiff person spectrum disorder (SPSD) is heterogeneous, and accurate diagnosis can be challenging.MethodsPatients referred for diagnosis/suspicion of SPSD at the Mayo Autoimmune Neurology Clinic from July 01, 2016, to June 30, 2021, were retrospectively identified. SPSD diagnosis was defined as clinical SPSD manifestations confirmed by an autoimmune neurologist and seropositivity for high‐titer GAD65‐IgG (>20.0 nmol/L), glycine‐receptor‐IgG or amphiphysin‐IgG, and/or confirmatory electrodiagnostic studies (essential if seronegative). Clinical presentation, examination, and ancillary testing were compared to differentiate SPSD from non‐SPSD.ResultsOf 173 cases, 48 (28%) were diagnosed with SPSD and 125 (72%) with non‐SPSD. Most SPSD were seropositive (41/48: GAD65‐IgG 28/41, glycine‐receptor‐IgG 12/41, amphiphysin‐IgG 2/41). Pain syndromes or functional neurologic disorder were the most common non‐SPSD diagnoses (81/125, 65%). SPSD patients more commonly reported exaggerated startle (81% vs. 56%, p = 0.02), unexplained falls (76% vs. 46%, p = 0.001), and other associated autoimmunity (50% vs. 27%, p = 0.005). SPSD more often had hypertonia (60% vs. 24%, p < 0.001), hyperreflexia (71% vs. 43%, p = 0.001), and lumbar hyperlordosis (67% vs. 9%, p < 0.001) and less likely functional neurologic signs (6% vs. 33%, p = 0.001). SPSD patients more frequently had electrodiagnostic abnormalities (74% vs. 17%, p < 0.001), and at least moderate symptomatic improvement with benzodiazepines (51% vs. 16%, p < 0.001) or immunotherapy (45% vs. 13% p < 0.001). Only 4/78 non‐SPSD patients who received immunotherapy had alternative neurologic autoimmunity.InterpretationMisdiagnosis was threefold more common than confirmed SPSD. Functional or non‐neurologic disorders accounted for most misdiagnoses. Clinical and ancillary testing factors can reduce misdiagnosis and exposure to unnecessary treatments. SPSD diagnostic criteria are suggested.

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.