Citations

Abstract Introduction Inflatable Penile Prostheses (IPPs) are a surgical implant used to treat erectile dysfunction in patients who do not respond to clinical treatments. IPP cylinder size often changes with cylinder exchange upon revision, but trends in these changes have not been formally assessed in the existing literature. Objective To analyze patient data for changes in implant size upon first revision. Methods Data included patients who underwent IPP surgical revision at Mayo Clinic Rochester between January 2021 and May 2024. Inclusion criteria specified cylinder exchange upon first revision of the IPP. A total of 48 patients were included in the analysis. A Bayesian regression was used to estimate the posterior probability of an increase in cylinder size upon first revision, after adjusting for patient age, revision service provider, and duration between implant and revision as covariates. Linear regression was used to assess the relationship between the extent of cylinder size increase and duration before revision. Results The median increase in cylinder size is 2 cm for the left cylinder and 1.75 cm for the right cylinder. The median increase for each patient’s average cylinder size is 1.625 cm. The median percentage increase in cylinder size is 9.76% for the left cylinder and 8.11% for the right cylinder. The median percentage increase for each patient’s average cylinder size is 8.13%. Posterior probabilities of increase were significant for the left cylinder, right cylinder, and the average cylinder size (Left PP: 97.53%; Right PP: 98.05%; Average PP: 98.05%). The extent of cylinder size increase is not significantly associated with duration before revision (Left p-value = 0.476; Right p-value = 0.500). Conclusions Patients and surgeons can expect about a 10% increase in cylinder size with their first revision. However, the extent of increase is not significantly associated with the duration between implant date and first revision. Future research efforts should focus on identifying where exactly this additional size is generated and what extent of size increase amounts to a noticeable difference for patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast

Abstract Introduction Proximal perforation in complex penile prosthesis placement is well recognized. If recognized, suture sling repair amongst other techniques is our favored approach. Unrecognized proximal perforation often results in unilateral or bilateral perineal bruising, often with eventual proximal device migration and palpability of the proximal device in the buttock. Objective We present a series of 5 cases in which the suture sling technique was utilized for known proximal perforation, with subsequent need for immediate or delayed revision. Methods We assessed all cases performed at Mayo Clinic since 2018 that resulted in a known suture sling complication amongst 3 high volume implanters. We identified 5 cases in which the suture sling technique required revision surgery. All patients underwent cross sectional imaging for further evaluation. Results Patients were males aged 59 to 89 with erectile dysfunction. There were no consistent factors amongst the 5 cases that may have predicted suture sling complication. The majority of cases were inflatable penile prostheses (4/5), were prosthesis revision cases (3/5), utilized the penoscrotal approach (4/5), were Coloplast devices (4/5), utilized rear tip extenders (3/5), utilized Prolene suture sling (3/5), and returned to OR within 2 days for revision (3/5). The majority of the complications (4/5) involved excessive proximal cylinder length that were palpable on examination of the buttocks or near the rectum (one felt on rectal exam). One case demonstrated improper anchoring of the device not allowing proximal seating and thus S shaped deformity. We noted medial cylinder deviation on all imaging, as corporal perforation was always medial to the true corporal path. Conclusions When performing suture slings, surgeons should be very wary of oversizing. The medial cylinder path and prior surgical capsule may mislead surgeons when choosing appropriate cylinder length. If perforated, we advocate against rear tips and for under sizing in general, as proximal anchoring is reliant upon the suture, not a true corporal boundary. Similarly, the device should be fully inflated and proximally seated on palpation prior to tying down the sling to avoid S deformities. Disclosure No

Abstract Introduction The U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization (June 2022), which overturned Roe v. Wade, has prompted significant shifts in reproductive health behavior, particularly among men. Several studies have reported trends in vasectomy-related interest and procedural volume following the decision, suggesting a growing inclination to pursue vasectomy as a long-term contraceptive option amid changing abortion access on national and statewide levels. Emerging research has also begun to explore the motivations behind this trend, pointing to a complex interplay of personal, social, and policy-related factors. However, the current body of evidence is fragmented, spanning various settings and study designs. Thus, there is a need to map the breadth and scope of this literature, identify key themes, and highlight gaps in knowledge. Objective To review the published literature assessing changes in vasectomy interest and utilization following the Dobbs decision. Methods This scoping review was conducted in accordance with established methodological frameworks to systematically map the existing literature on vasectomy trends in the United States following the Dobbs decision. A scoping review was chosen rather than a systematic review or meta-analysis due to the heterogeneity in study designs, populations, and outcome measures. Eligible studies included peer-reviewed articles examining adult patients concerning vasectomy in U.S. settings, with a focus on changes in utilization, interest, or related behaviors in response to abortion policy shifts. A comprehensive search strategy was developed to capture English-language peer-reviewed literature from 2010 onward. Searches were conducted in January 2025 across six databases: PubMed (n=207), Embase (n=243), Scopus (n=195), Web of Science (n=48), Cochrane Library (n=17), and ClinicalTrials.gov (n=0). Search terms included variations of “vasectomy” and “abortion.” Two independent reviewers screened articles and extracted data using a piloted form on the Covidence platform, collecting information on study characteristics, population demographics, outcomes related to vasectomy trends, patient motivations, and contextual policy factors. Results A total of 405 unique records were identified through the literature search, with 34 articles reviewed in full text. Seventeen studies met final inclusion criteria. Internet search analyses (29%, n=5) demonstrated increased interest in both vasectomy and tubal ligation following the Dobbs decision, with all reporting greater relative increases for “vasectomy” across short-, mid-, and long-term timeframes. Procedural trend analyses (29%, n=5) showed overall increases in vasectomy volume compared with 6-month to 5-year pre-Dobbs baselines. Six studies found that men undergoing or seeking vasectomy post-Dobbs were significantly younger. Five studies reported higher proportions of childless or fewer-child patients. Additionally, five studies identified shifts in marital or partner status, with increased rates of single, unpartnered, or nonmarried patients post-Dobbs. Geographic differences were observed across 47% of studies (n=8), with greater vasectomy and tubal ligation interest reported in states with abortion trigger laws or more restrictive abortion environments. Conclusions This scoping review identified key demographic and geographic patterns in vasectomy trends following the Dobbs decision. Findings underscore increased interest and utilization, particularly among younger, childless, and unpartnered men, and highlight regional variation aligned with abortion policy restrictiveness. These results warrant further prospective study on patient-level motivations for permanent sterilization. Disclosure No

Abstract Introduction Infection following inflatable penile prosthesis (IPP) placement is an uncommon yet serious complication, and its management poses significant clinical challenges. IPP infection management strategies continue to evolve, however, multicenter and robust studies evaluating and describing current practice patterns are lacking. Objective Using a large cohort from tertiary IPP referral centers in the United States to evaluate current infection management practice patterns and to identify factors that could predict the approach to managing IPP infections. Methods We queried a retrospective 14-center multi-institutional database for patients with IPP infections between April 2017 and January 1/2025. Patients were categorized by infection management strategy, which included device explant, malleable salvage, and 3-piece IPP salvage. Patient characteristics were compared using chi-square and independent t-tests. Multinomial analysis was performed to investigate patient and perioperative factors associated with management strategy at the time of infection. Results Among 2,934 cases, 85 (2.9%) patients developed IPP infection at a median of 40 (22-78) days after IPP implantation. Infections occurred after primary IPP surgery in 59 (69%), revision in 25 (29%), and after infection salvaged with IPP in 1 (1%). Infections were managed with device explant in 32 (38%), malleable salvage in 43 (51%), and IPP salvage in 10 (12%). A significantly higher proportion of non-White patients underwent salvage (either with malleable or IPP) compared to White patients (p=0.01). Multinomial regression showed no association between patient and perioperative characteristics and infection management (p>0.05). Conclusions In this multi-institutional cohort of experienced implanters, infections were most commonly managed with malleable salvage. Patient and perioperative factors did not predict management approach, suggesting that the decision between explanation and salvage is primarily driven by individual surgeon preference. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston scientific

Abstract Introduction With the growing use of 0.05% Chlorhexidine Gluconate (CHG) as irrigation and dip for inflatable penile prosthesis (IPP) surgery, understanding the possible relationship between CHG use and non-infectious complications is imperative. Such information may guide provider decision-making during implant surgery. Objective We therefore sought to determine whether the use of 0.05% Chlorhexidine Gluconate (CHG) during inflatable penile prosthesis (IPP) surgery was associated with non-infectious wound complications. Methods We performed a multi-institutional retrospective cohort study of patients undergoing IPP surgery from January 2017 to March 2024. The primary outcome was wound complications (ex. rash, wound dehiscence, edema). Secondary outcomes included other non-infectious complications (Table 1). The primary exposure was whether patients received intraoperative CHG either as irrigation or dip. Descriptive comparisons were used to compare CHG and non-CHG cohorts. Univariable logistic regression was utilized to assess if CHG use was associated with any non-infectious complication. Multivariable logistic regression was subsequently performed to assess factors associated with certain non-infectious complications after IPP surgery – controlling for age, body mass index, race, diabetes, and hypertension as covariables. Results Across 2,933 patients, there were 1,573 non-CHG and 1,359 CHG patients. Non-infectious complications occurred in 83 (5%) non-CHG patients and in 65 (5%) CHG patients. Median follow-up was 22 months (IQR 7-59) for non-CHG patients and 8 months (IQR 3-16) for CHG patients. The incidence of wound complications was greater among CHG patients than non-CHG patients (1.0% vs. 0.1%, p<0.01). On univariable logistic regression, CHG use was associated with increased odds of wound complications (OR 7.34, 95% CI 1.65-32.71) but was not associated with any other non-infectious complication (Table 2). On multivariable logistic regression, CHG use remained associated with an increased odds of wound complications (OR 13.86, 95% CI 1.80-106.44). Conclusions Among patients experiencing non-infectious complications after IPP, CHG use during IPP surgery appears to be associated with an increased odds of wound complications. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast Corporation and Boston Scientific

Abstract Introduction Erectile Dysfunction (ED) is becoming increasingly recognized as a potential marker of chronic medical conditions. Recent research has examined the association between ED and Parkinson’s disease. In fact, recent findings indicate that men with ED have upwards of a fourfold higher risk of developing Parkinson’s disease compared to those without a diagnosis of ED. Objective Our research investigates associations between self-reported ED severity and neurobiological factors, including measures of cognitive function and neuroimaging of dopaminergic integrity. Methods We performed a retrospective analysis of 93 male research participants with ED extracted from an observational cohort study of aging and Parkinson’s disease biomarkers. Though some patients experienced some age-related mild cognitive changes, all participants were classified as clinically neurologically healthy. Patients received cognitive testing through the Montreal Cognitive Assessment (MoCA), with scores ranging from 0-30. Neuroimaging of the bilateral caudate and putamen, components of the striatum implicated in Parkinson’s disease pathology and dopaminergic binding, was measured through dopamine transporter SPECT imaging (DaTScan) binding ratios. ED was self-reported using questions 22-23 on the Scales for Outcomes in Parkinson’s Disease – Autonomic Dysfunction (SCOPA-AUT). Question 22 stated “In the past month, have you been impotent (unable to have or maintain an erection?)” and question 23 stated “In the past month, how often have you been unable to ejaculate?”. SCOPA-AUT scores ranged from 0 (sometimes) to 3 (often) and were averaged across both questions. Patients taking dopaminergic Parkinson’s disease medications or PDE5 inhibitors at baseline were excluded due to potential confounding. Due to violations of normality assumption, numerical associations utilized an age-adjusted partial spearman correlation coefficient. Descriptive statistics are displayed as median (IQR). Results Of the 93 selected participants, one individual was excluded due to incomplete neuroimaging DaTScan data. Therefore, 92 patients were included in our analysis. The median age of participants was 67.3 years (61.4 – 73.0) and the median MoCA score was 27.2 (26.0, 28.7) which represents minimal cognitive impairment. Age-adjusted spearmen correlation coefficient showed no association between MoCA measured cognitive performance and ED severity (r = -0.116, p = 0.275). Age-adjusted associations of striatal DaTScan showed a significant, mild relationship between ED severity and both right caudate dopamine binding ratios (r = 0.236, p=0.0242) and left putamen dopamine binding ratios (r = 0.262, p = 0.0121). However, associations between ED severity and both left caudate (r = 0.150, p = 0.155) and right putamen (r = 0.143, p = 0.176) dopamine binding ratios did not reach statistical significance. Conclusions Although no association was observed between ED severity and cognitive function, greater ED severity was significantly associated with increased striatal dopaminergic binding. This positive, age-adjusted association may reflect a compensatory dopaminergic response similar to that seen in the early stages of Parkinson’s disease. Overall, our findings suggest that ED could serve as a potential marker of central dopaminergic and autonomic alterations, even in the absence of clinically evident neurological disease. Disclosure No

Abstract Introduction Penile plication is the gold standard operation for Peyronie’s disease with preserved erectile function but is associated with persistence of hourglass shaft deformity and palpable, permanent plication sutures that may be bothersome in some patients. A novel technique utilizing extratunical grafting overlying plication sutures in the tunica albuginea may improve patient discomfort, increase penile girth, and improve overall satisfaction. Objective We aim to analyze patient centered outcomes and satisfaction scores associated with this operation. Methods We retrospectively evaluated 13 patients who underwent Peyronie’s correction with penile plication with extratunical onlay grafting with biological Dura substitute graft performed by a single surgeon at a tertiary academic center. The graft was placed over 2-0 Ethibond Lue plication sutures in a circumferential fashion sparing the neurovascular bundle and secured with chromic suture. Primary endpoints of interest were patient satisfaction scores (1-10), presence of hourglass, palpability of sutures as well as associated discomfort, and sexual activity. Results Median follow up was 15.4 months. 100% of patient were sexually active at time of follow up. Mean patient reported post operative satisfaction was 8.9 out of 10. No patients endorsed palpability of plication sutures, coital discomfort at site of repair, or persistence of hourglass or concavity deformity. In patients who reported less than a 10 in satisfaction, areas of dissatisfaction include persistence of curvature, albeit decreased pre-operatively, as well as enhanced girth associated with dyspareunia of the receptive partner during intercourse in a single patient. Conclusions We present excellent post operative satisfaction and patient centered outcomes utilizing extratunical grafting overlying penile plication sutures in Peyronie’s disease repair. This novel technique may meaningfully improve patient satisfaction is patients with Peyronie’s disease undergoing plication alone. Disclosure No

Abstract Introduction Peyronie’s disease (PD) and ED can coexist, affecting the patient’s perception of erectile function. The AUA guidelines recommend intracavernosal injection, with or without doppler ultrasound, prior to invasive interventions. Our objective was to assess vascular erectile integrity in patients with PD. Objective The objective of our study was to assess vascular erectile integrity in patients with PD. Methods We retrospectively reviewed 2309 patients who underwent color doppler duplex ultrasound (CDDU) at our institution. CDDU findings such as peak systolic velocities and resistive indices were recorded following injection of low dose Alprostadil and again after a period of privacy and visual sexual stimulation. Among patients diagnosed with PD, comparisons of patient characteristics between those with PD only and those with PD and ED were made using ANOVA (continuous characteristics) or Chi-squared test (categorical characteristics). Results Of men that underwent CDDU, 1468/2452 (63%) were diagnosed with PD. Among those with PD, 327 (14%) were diagnosed with PD only and 1141 (49.4%) were diagnosed with both PD and ED. Those with PD only had lower BMI (27.1 vs 28.4), were less likely to have hypertension (37% vs 46%), less likely to have Diabetes Type 2 (16% vs 31%), less likely to have used PDE-5 inhibitor (39% vs 82%), and less likely to have failed to a PDE-5 inhibitor (30% vs 73%) compared to men with both PD and ED, all p<0.005. Average SHIM scores were higher among those with PD only compared to PD and ED (18 vs 12). CDDU diagnoses for men with PD and ED were: AI (32%), CVOD (43%), mixed vascular ED (26%). Conclusions In a large cohort of men with PD we identified multiple potential risk factors for erectile dysfunction. CDDU of men with PD demonstrates that three-quarters of patients have some form of vascular erectile dysfunction. Counselling for surgical interventions should include a Doppler assessment to ensure patients are appropriately triaged to PD-corrective surgery versus penile implant. Future AUA Guidelines should reclassify the recommendation for evidence-based testing prior to surgical interventions from ‘Expert Opinion’ to ‘Clinical Principle’. Disclosure No

Abstract Introduction Chronic orchialgia is a common urologic complaint, and is estimated to make up 2.5 to 5% of urology clinic consultations. Hyperactive cremaster reflex is an often under-diagnosed source of chronic testicular pain, wherein patients experience vigorous muscular retraction of the testicles up to the external inguinal ring. This has been related to possible anatomic thickening of the cremaster muscles, or an attenuated external oblique aponeurosis. Objective To report a unique etiology and subsequent treatment of chronic orchialgia. Methods We present a case of an individual who developed new onset of hyperactive cremaster reflex after hamstring and rectus abdomonis tear during a sporting injury. Results Patient is a 37-year-old male who presented with new onset of bilateral testicular pain and chronic testicular retraction. 6 weeks prior to presentation, while playing soccer, he sustained a complete tear in the right hamstring, and partial tearing of the right rectus abdominis-adductor aponeurosis at the pubic symphysis. He completed conservative therapy with heat and ice, an extended course of anti- inflammatory medications, and physical therapy without relief. On exam, testicles were bilaterally high riding, and cremasteric muscles were noted to be in tonic spasm. Testicles would be brought into the scrotum, but were noted to rapidly ascend. He was offered injection of neuromodulator into the cremasteric muscles versus bilateral microsurgical cremaster release, and opted for the latter treatment. Bilateral cremasteric muscle fibers were ligated and excised from the external ring down to the testicle proper, and testicles were pexied in place. At follow-up, he reported complete resolution of pain and tonic retraction. Testicles were found to have normal anatomic lie within the dependent portion of the scrotum. Conclusions In patients with chronic testicular pain refractory to conservative measures, the cremasteric muscles may play a role in potentiating pain signaling through chronic, unprompted muscular spasm. This should especially be considered after regional musculoskeletal injuries affecting pelvic and inguinal muscle groups. In this select group of patients, excision of the cremasteric muscles to release cremasteric tension may be a viable treatment option for resolution of chronic pain. Disclosure No

Abstract Introduction Vasectomy is a highly effective, permanent method of contraception. Vasectomy is commonly performed in the outpatient urology clinic with the patient awake. There is clearly anticipation of pain as well as anxiety associated with the procedure. Objective The objective of our study was to evaluate anticipated versus experienced pain associated with office-based vasectomy. Methods We studied men who underwent vasectomy in May and June of 2022. Men who had no history of scrotal surgery of any kind were asked to score the anticipated pain associated with an office based vasectomy with a score of 0-10. After the vasectomy, patients were asked to rate the pain they perceived with the vasectomy on the same scale (0-10). Results A total of 17 men were asked to rate their pain as discussed in the method section. The median age of men sampled was 38 years of age. All men we treated were given 15 mg of Valium before the procedure and instructed to take the medication 30 minutes prior to their procedure. The average pre vasectomy prediction pain score was 7.5+/- 1.9; the average post-injection perceived pain score was 2.9+/- 1.9. Thus there was an average decrease of over 4 points in the predicted pain versus perceived pain. A two-sample T test was performed; in addition Wilcoxson Signed Rank Test was performed. Both tests showed a statistical significance in the difference between pre and post vasectomy pain scores (p<0.001). Conclusions We found that patients who are undergoing office based vasectomy for the first time have a significantly higher perception of pain versus perception of pain after the injection. We have utilized this data in our clinic to explain to patients that while most patients will predict a high pain score associated with the vasectomy, the vast majority of patients report minimal pain after the procedure. Our study can be particularly helpful in patients who have had significant anxiety about office based vasectomy and for those patients who are deciding between office based vasectomy and vasectomy performed under general anesthesia. Disclosure No