Citations

Abstract Background While the rate of physician burnout has been characterized as relatively high among urologists compared to other specialties, a specific examination of burnout and predictors of burnout among urologists specializing in sexual medicine has not been conducted. Aim The aim of this study was to collect demographic characteristics of urologists specializing in sexual medicine, assess the occurrence of and risk factors for burnout, and characterize satisfaction with career, compensation and work-life balance. Methods We surveyed 96 urologists specializing in sexual medicine to characterize demographic and practice characteristics and assess their satisfaction with career aspects and levels of burnout. Univariable and multivariable modeling with stepwise variable selection was utilized to identify predictive variables of burnout. Outcomes The Copenhagen Burnout Inventory was used to assess personal burnout, work-related burnout, patient-related burnout, and overall burnout. Results Twenty-four percent (n = 23) of participants reported burnout with 35.4% (n = 34) reporting personal burnout, 38.5% (n = 37) reporting work-related burnout, and 24.0% (n = 23) reporting patient-related burnout. Younger age (P = 0.051), Black/African American or multiracial race compared to white race (P < 0.0001), Latino or Hispanic background (P = 0.034), female sex (P = 0.059), being unmarried (P = 0.047), and increased educational debt (0.030) were identified as predictive of overall burnout in adjusted analysis. Dissatisfaction with work-life balance was significantly related to an increase in all categories of burnout (P < 0.01). Clinical implications These findings may guide practice patterns and initiatives to support groups identified at increased risk of burnout, as well as function as a benchmark for future studies of burnout in the sexual medicine urology community. Strengths and limitations While this is the first study of burnout specifically among sexual medicine urologists and findings are consistent with the overall urology community, the small sample size may lead to a biased sample. Conclusion Several demographic and personal characteristics were identified to be predictive of burnout among the sexual medicine urology community, indicating opportunities for additional support.

Abstract Introduction Selective angioembolization for high flow priapism (Step-by-step guide). Aim Describe the indications and techniques of angioembolization for high flow priapism. Methods We outline patient selection, preparation, technique, outcomes, and potential complications of angioembolization for high flow priapism as supported by the literature. Main outcome measure The effectiveness of embolization for treating high flow priapism. Results Transarterial embolization is minimally invasive, low risk, and effective method from managing high flow priapism. Success rates range from 70% to 87% depending on the type of agent used for embolization. Side effects include erectile dysfunction with a reported rate of 7%-19%. Complications may be mitigated by embolizing as selectively as possible and using temporary embolic agents. Conclusion Embolization is a safe and effective treatment for nonischemic, high flow priapism in patients who have not responded to conservative management.

Abstract Background Chlorhexidine gluconate (CHG) (0.05%) has recently been suggested as a dip and irrigation solution at time of inflatable penile prosthesis (IPP) surgery. Aim This study evaluated infection rates before and after implementing CHG protocol while investigating concurrent risk factors contributing to post operative infections. Methods A retrospective, consecutive cohort study was performed that included patients who underwent insertion of a Coloplast Titan IPP including both virgin and revision cases between 2021 and 2024. Cases performed from January 2021 to August 2022 utilized rifampin/gentamicin for dip and vancomycin/gentamicin for irrigation (ABX), whereas those from October 2022 to May 2024 utilized CHG for both dip and irrigation. Perioperative risk factors including dip and irrigation solution used at time of surgery were compared between groups. Outcomes We defined the incidence of postoperative infection and risk factors associated with infection in each group. Results The incidence of infection was significantly higher in the 0.05% CHG group (13/377) compared to the ABX group (0/320) (P < .001). When analyzed separately by subgroup, virgin cases treated with CHG for dip and irrigation demonstrated a significantly higher infection rate (7/315) compared to those in the ABX group (0/280) (P = .012). Similarly, in revision cases, the CHG group also exhibited a significantly higher infection rate (0/40) than the ABX group (6/62) (P = .043). Univariable analysis of the CHG cohort identified three significant risk factors for infection: diabetes mellitus (DM), extended operative time (OP), and revision surgery (P = .003, .001, and < .001, respectively). Multivariable regression analysis revealed that patients with DM had a 5.7-fold increased risk of infection (OR: 5.70, P = .004), while those undergoing revision surgery faced a 5.3-fold higher risk (OR: 5.26, P = .004). Additionally, each minute increase in OP was associated with a 1% higher infection risk (OR: 1.01 per minute, P = .007). These associations remained significant after adjusting for all variables in the model. Clinical Implications Prosthetic surgeons should be cautious about adopting 0.05% CHG for both dip and irrigation in the absence of strong clinical evidence demonstrating its non-inferiority to antibiotic solutions. Strengths and Limitations This is the first clinical study reporting infection rates after IPP surgery using 0.05% CHG for both dip and irrigation. While retrospective and non-randomized, we present a relatively large sample size of patients. Conclusions Our findings identify four risk factors for penile prosthesis infection: usage of the 0.05% CHG solution for dip and irrigation solution of Coloplast hydrophilic-coated devices, DM, revision surgery, and extended OP.

Purpose of review Peyronie's disease characterizes a condition in which there is angular curvature of the penis. We know that the most patients with Peyronie's disease will not have spontaneous resolution of their penile curvature. As such, patients who desire treatment can elect for either surgical or nonsurgical therapy. Herein, we discuss the contemporary nonsurgical management options for Peyronie's disease. Recent findings Nonsurgical management options for Peyronie's disease include oral therapy, intra-lesional injections, and penile traction therapy. At the time of this review, there is essentially no high-level evidence demonstrating any benefit for oral therapy. Penile traction therapy has evolved over the past decade with second-generation devices demonstrating strong efficacy and more convenient treatment regimens. Intra-lesional options include collagenase Clostridium histolyticum (CCH), verapamil, and interferon alpha-2b. The IMPRESS trial garnered the strongest level of evidence (two randomized, double-blind, placebo-controlled trials) to support the safety and efficacy of CCH. Verapamil is an option supported by several urological societies; however, the evidence supporting its efficacy is inconsistent between several notable series and randomized studies. IFN alpha 2b can produce modest improvement in curvature, however, is not available for use in North America. Summary Herein, we will discuss notable advances in nonsurgical management of Peyronie's disease.

Abstract Introduction Obesity, defined as an elevated Body Mass Index (BMI) >30, is a prevalent public health concern with far-reaching implications for various medical procedures and outcomes. In the context of inflatable penile prosthesis placement (IPP), where patient well-being and surgical success are of paramount importance, the impact of obesity on postoperative and intraoperative complications warrants thorough investigation. Objective We aimed to investigate the impact of BMI on both postoperative and intraoperative complications in an international, multi-institutional cohort of patients who underwent IPP placement. Methods We performed a retrospective chart review of 4,398 cases. These cases were divided into two distinct groups based on BMI: less than 30 (n = 2,260) and greater than or equal to 30 (n = 2,138). The study assessed various surgical factors as well as complications, including overall complications, corporal scarring, incontinence, intraoperative complications, proximal perforation, distal perforation, proximal crossover, distal crossover, and urethral injury. Results Our analysis revealed that there were no statistically significant differences in intraoperative or postoperative complications between the two BMI categories. Notably, proximal corporal measurement was significantly higher for >30 BMI group with 1858 (86.9%) compared to 1919 (84.9%) for <30 BMI group, (p = < 0.001). The incidence rates for overall complications (30.2% vs. 28.7%; p = 0.164), corporal scarring (18.2% vs. 16.7%; p = 0.36), incontinence (3.53% vs. 3.13%; p = 0.076), intraoperative complications (1.94% vs. 1.68%; p = 0.253), and specific complications all exhibited no significant differences. Similarly, post-operative complications, including both non-infectious (6.99% vs. 6.22%; p = 0.215) and infectious (2.61% vs. 1.87%; p = 0.165) complications, did not significantly vary between BMI categories. Conclusions Our findings indicate that BMI does not exert a statistically significant influence on postoperative and intraoperative complications in the context of high-volume prosthetic urology. In the absence of any other differences between patients of differing BMIs, the IPP industry may need to consider device specific alterations with pump tubing length in obese patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Clarus Therapeutics, Antares Pharma, Acerus.

Abstract Introduction Penile prosthesis (PP) implantation is associated with high patient satisfaction in patients with medically refractory erectile dysfunction (ED). There remains a paucity in the literature regarding the temporal evolution of patient following PP surgery. Objective We sought to evaluate mechanical-associated outcomes in our Penile prosthesis (PP) cohort. Methods We analyzed our prospective penile registry that includes patient-completed surveys regarding device outcomes administered at 6 and 12-months after PP placement. We specifically examined the questions: “Have you had another [prosthesis] surgery since your first operation?”; and, “Does the device ever inflate or deflate on its own, if Yes how bothersome is this for you on a scale of 1-10 (1- very bothersome, 10 no bother)?”. Chart review was performed to identify pertinent variables including reservoir location (retropubic vs submuscular) and need for prosthesis revision for survey respondents. Results A total of 304 patients were enrolled in the registry. Of these, 101 completed the 6-month assessment and 79 completed the 1-year survey. The vast majority of PP were Coloplast (91.4%) utilizing the “classic” pump. Mean chart review follow up was approximately 3 years. One device was explanted for implant infection. No additional operations were reported for mechanical failure. Auto-inflation (AI) was reported in 38 patients at 6 months and 21 patients at 12 months. AI was most common in patients with submuscular reservoir placement (75.9% of those who reported AI at 6 months and 50% at 12 months respectively). The relative risk of developing AI was doubled in patients with a submuscular reservoir [2.2 (1.05-3.44); p < 0.001)]. Degree of bother had a reported median of 5 (3.75-9) at 6 months and became less bothersome after 12-months year with a reported median of 7 (5-9) (p = 0.230) [Fig. 1]. Conclusions Early Penile prosthesis mechanical failure requiring revision surgery did not occur in our cohort but patient-reported auto-inflation was identified more frequently than previously reported. Further study is warranted, but patients may benefit from pre-operative counseling regarding the incidence of auto-inflation. Disclosure Yes, this is sponsored by industry/sponsor: Coloplast. Clarification: Industry funding only - investigator initiated and executed study.

Abstract Introduction Clostridium Collagenase Histolyticum (CCH) is the only-FDA approved non-surgical, intralesional option for men with Peyronie’s disease. However, little is known regarding practice patterns of CCH providers due to lack of standardized protocols. Objective To evaluate practice patterns for providers approved to administer CCH to treat Peyronie’s disease (PD), this study was conducted. Methods The “Find a Xiaflex-Trained Urologist” search tool on the Endo International patient-facing website was utilized to identify clinicians offering CCH injections in the United States. A 24-question survey was mailed to these providers with topics including provider type, years in practice, therapies offered, and patient evaluation was distributed to providers on patient-facing Endo International Xiaflex Find a Provider web-based tool. Results 63 responses were obtained, including 41% fellowship-trained urologists (FTU), 40% non-fellowship-trained urologists (NFTU), 14% advanced practice providers, and 5% un-specified. Prior to therapy, over 63% of providers performed in-office assessment of an erect penis while only 35% obtained ultrasound. 32% always and 36% never performed an artificial erection prior to administering CCH. Plaques were most identified by palpation or patient-provided direction with penile modeling and traction the most common adjuncts. When comparing NFTU to FTU, there was no difference in volume of PD patients with 60% examining fewer than 10 per month. FTU were more likely to offer traction (p = 0.002), plaque incision/excision and grafting (p = 0.005), increase time between injections (p = 0.012), and less likely to encourage penetrative intercourse between cycles (p = 0.016). The incidence of post-operative hematomas or suspected corporal rupture was not significantly different, although FTUs were more likely to conservatively manage rupture. Conclusions Variability exists in provider practice patterns surrounding CCH injections with most evaluating less than 10 patients with PD per month. This calls to attention the need for evaluation of techniques, patient outcomes, and standardization of care. Disclosure Yes, this is sponsored by industry/sponsor: Endo Pharmaceuticals. Clarification: Industry funding only - investigator initiated and executed study. Any of the authors act as a consultant, employee or shareholder of an industry for: Endo Pharmaceuticals.

Abstract Introduction Surgical treatment options for Peyronie’s disease (PD) include penile plication, plaque excision with grafting, and penile prosthesis placement with straightening maneuvers. Choice of surgical incision depends on location and severity of curve, concomitant procedures, and surgeon preference. Objective To assess risk of wound complications after PD surgery stratified by ventral versus subcoronal incision type. Methods A single surgeon retrospective chart review was conducted for all patients undergoing PD tunica albuginea plication (TA) or plaque excision with grafting (PEG) from Aug 2019 to June 2023. Wound complication was classified as any dehiscence or physical examination finding suspicious for infection within 30d of surgery. A Mann–Whitney U Test was used to compare demographic variables and wound complication rate based on ventral and subcoronal approaches. Results Of the 161 patients included, 105 underwent TAP and 56 underwent PEG. All patients who underwent PEG had at least one plication suture performed to correct mild residual curvature after grafting. A ventral midline penile incision was used in 81 patients (50%) and subcoronal in 80 patients (50%). Wound complications within 30d of surgery were found in 10 patients (6%), including 8 (10%) with ventral incisions versus only 2 (3%) subcoronal (OR 4.27; 95% CI 0.87-20.79; p = 0.09). There was no significant difference in wound complications between TAP and PEG cohorts. Wound complications included dehiscence requiring repeat closure (n = 1) and superficial wound infection necessitating antibiotic therapy (n = 9). In a subgroup analysis of patients who underwent TAP only, 8 patients (7.6%) with a ventral approach experienced a 30d wound complication compared with 1 patient (3.4%) with a subcoronal approach. Conclusions Penile straightening surgeries are associated with a low rate of significant wound infections. While not statistically significant, a ventral incision may have a slightly higher risk than subcoronal for wound complications within the first 30d of surgery. Both ventral and subcoronal incisions can offer excellent exposure and may be considered for patients requiring plication and/or grafting approaches. Disclosure No.