Citations

Background: Disparities in postoperative nausea and vomiting and its prophylaxis may exist based on race, ethnicity, and socioeconomic status. The objective was to evaluate whether patients from racial and ethnic minority groups and patients from lower socioeconomic status backgrounds received less appropriate postoperative nausea and vomiting prophylaxis and experienced higher rates of postoperative and postdischarge nausea and vomiting. Methods: This retrospective cohort study included 23,333 adults who underwent major surgeries (total knee arthroplasty, cholecystectomy, hysterectomy, and prostatectomy) from 2017 to 2022 in a single, multistate hospital system. Outcomes included prophylactic antiemetic administration according to consensus guidelines, as well as the occurrence of postoperative and postdischarge nausea and vomiting, with predictors being patient race and ethnicity, payor type, and community-level socioeconomic status. Results: About 45% (n = 10,407) of patients received guideline-recommended postoperative nausea and vomiting prophylaxis. Regression models showed statistically significant differences in appropriate postoperative nausea and vomiting prophylaxis by race and ethnicity, as well as community-level socioeconomic status, with Black (odds ratio, 0.76; 95% CI, 0.63 to 0.92) and Hispanic (odds ratio, 0.82; 95% CI, 0.70 to 0.96) patients having lower odds of receiving appropriate antiemetic prophylaxis compared to non-Hispanic White patients. Approximately 11% of patients (n = 2,522) experienced postoperative nausea and vomiting in the postanesthesia care unit, and about 19.5% of patients (n = 4,540) experienced postdischarge nausea and vomiting. No significant differences in postoperative nausea and vomiting were observed in the postanesthesia care unit among different groups; however, Black, Hispanic, other races and ethnicities, and patients with Medicaid had higher odds of postdischarge nausea and vomiting. Conclusions: The study identified differences in appropriate postoperative nausea and vomiting prophylaxis by race and ethnicity, as well as community-level socioeconomic status. There were no differences in postoperative nausea and vomiting by the predictors, but there were higher odds of postdischarge nausea and vomiting by race and ethnicity and payor. This study underscores the importance of data stratification in quality measures to identify disparities in perioperative care; it can lead to changes in perioperative anesthetic management. Further research should explore these associations in a broader cohort and address potential confounding sources.

Objective: To describe a step-by-step guide for successful implementation of transmeatal urethral surgery for obliterated membranous urethral strictures. Patient and Methods: The patient is placed in the dorsal lithotomy position. Cystoscopy will be performed through both the suprapubic tube above and transmeatally from below. A Libri rigid endoscopic needle will be passed under guidance, with placement of a 0.38 wire through the inner lumen. Subsequently, over the wire, a tiger tail catheter will be placed and the wire exchanged for a rigid sensor wire, over which a charger balloon will be passed and used for dilation. The Olympus resectoscope will be used to resect the area of the stricture. The RD180 from LSI solutions will be used to situate the graft over the area of the stricture. Results: Our number of cases is five, of which 4 have had no recurrence. The median follow-up is 6 months. We have three from radiation and two from pelvic fractures. In the radiation population, one patient did recur. However, he was not obliterated and has been voiding even though he has a 14 French urethra. Conclusion: This technique appears to be a safe and effective repair option for management of obliterated membranous urethra strictures. Author disclosure statement: J.N.W. is a consultant for Olympus. The other authors have no conflicts of interest to disclose. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure . Runtime of video: 7 min 38 sec.

Abstract Objective Data extraction from the published literature is the most laborious step in conducting living systematic reviews (LSRs). We aim to build a generalizable, automated data extraction workflow leveraging large language models (LLMs) that mimics the real-world 2-reviewer process. Materials and Methods A dataset of 10 trials (22 publications) from a published LSR was used, focusing on 23 variables related to trial, population, and outcomes data. The dataset was split into prompt development (n = 5) and held-out test sets (n = 17). GPT-4-turbo and Claude-3-Opus were used for data extraction. Responses from the 2 LLMs were considered concordant if they were the same for a given variable. The discordant responses from each LLM were provided to the other LLM for cross-critique. Accuracy, ie, the total number of correct responses divided by the total number of responses, was computed to assess performance. Results In the prompt development set, 110 (96%) responses were concordant, achieving an accuracy of 0.99 against the gold standard. In the test set, 342 (87%) responses were concordant. The accuracy of the concordant responses was 0.94. The accuracy of the discordant responses was 0.41 for GPT-4-turbo and 0.50 for Claude-3-Opus. Of the 49 discordant responses, 25 (51%) became concordant after cross-critique, increasing accuracy to 0.76. Discussion Concordant responses by the LLMs are likely to be accurate. In instances of discordant responses, cross-critique can further increase the accuracy. Conclusion Large language models, when simulated in a collaborative, 2-reviewer workflow, can extract data with reasonable performance, enabling truly “living” systematic reviews.

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 Inflatable penile prosthesis (IPP) surgery is a well-established treatment for erectile dysfunction (ED). There is little information in the literature regarding the utilization of perioperative antimicrobial prophylaxis in primary and revision IPP surgeries. Objective We investigated the patterns of perioperative antimicrobial prophylaxis among a large multinational cohort of primary and revision IPP surgeries. Methods We conducted a retrospective analysis of 5,400 patients (4,187 primary IPP patients and 849 revision IPP patients) from our Prosthetic Urology Multi-Institutional Partnership (PUMP) institutions. Usage data for intravenous (IV), preoperative oral, and postoperative oral antimicrobials were analyzed. We specifically assessed patient profiles, antimicrobial selection, and antimicrobial duration. Multivariate statistical analyses were conducted to identify significant variations between primary and revision surgeries. Results For patients undergoing primary IPP placement, 81.9% received IV antibiotics for <24 hours whereas 18.1% received IV antibiotics for >24 hours. Preoperative oral antimicrobials were used in 59.4% of patients and 99.4% received postoperative oral antimicrobials. The overall infection rate for primary implants was 2%. Notably, quinolone administration shows a higher postoperative infection rate (11.4%) compared to gentamicin (1.9%), cephalosporin (0%), and vancomycin (1.0%). Multivariable regression analysis identifies factors such as a history of infection, diabetes, and priapism as predictors for postoperative infections. Furthermore, the study finds that perioperative antifungal use is associated with a decreased risk of infection. Conclusions This study provides valuable insights into the patterns of perioperative antimicrobial prophylaxis. Duration, type, and route of antibiotics given preoperatively or postoperatively do not affect postoperative infection rates among high volume prosthetic urologists. Giving IV antibiotics for more than 24 hours does not affect postoperative infection. Perioperative antifungals are a protective factor. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Clarus Therapeutics, Antares Pharma, Acerus.

Abstract Introduction Since FDA approval of Collagenase Clostridium Histolyticum (CCH) for the treatment of Peyronie’s Disease (PD), there has been significant debate as to its role and comparable efficacy in relation to surgical therapies. We therefore sought to compare key outcomes between the two therapies. Objective To compare the satisfaction and adverse event profiles between surgery and CCH injections for the treatment of PD. Methods A randomized, controlled trial is ongoing. Participants were randomized 1:1 to receive either CCH + traction (RestoreX) + sildenafil (CCH) or penile surgery (plication and/or incision and grafting) + traction + sildenafil for PD (Surgery). Objective, standardized, and non-standardized assessments were obtained at baseline and 3, 6, 12, 24, 36, 48, and 60 months post-treatment. Key outcomes included differences in standardized questionnaires, penile curvature, penile length, subsequent interventions, and non-standardized questionnaire responses. Results A total of 40 men were randomized with 24-month data available in 29. Mean age was 54.7 years, PD duration 37.4 months (mo), composite curvature 73.1 degrees (deg), and penile length 12.7 cm. All baseline variables were similar between cohorts. Regarding primary outcomes, at 24-months post-treatment, CCH men were more likely to report being very satisfied with treatment (62% vs 25%, p < 0.05). For secondary outcomes, only questionnaire data were captured at two years without objective measurements obtained. No differences were noted between groups regarding subscales of the IIEF, PDQ, Beck’s Depression Inventory, or SEP-2, however CCH men had better SEP-3 positive responses (62% vs 19%, p = 0.02), indicating improved ability to maintain erections sufficient for intercourse. Surgery men reported higher subjective rates of length loss compared to CCH (81% vs 15%, p < 0.001) and curvature recurrence (56% vs 8%, p < 0.01), but similar rates with changes in sensation, indentation/hourglass, and erectile function. Both groups indicated similar willingness to undergo the therapy again. Interestingly, at 2-years, the majority of men in the Surgery arm said that their initial preference for treatment was surgery (56%), which decreased from a peak 86% at 1-year. However, in reviewing baseline information, 72% of Surgery men actually preferred CCH at study onset, highlighting a significant recall bias towards whatever treatment one actually ended up receiving. Conclusions Preliminary data suggests that when compared to surgery at 24-months, CCH men were more likely to be very satisfied with therapy, have greater subjective length improvements and lower curvature recurrence rates. 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: PathRight Medical.

Abstract Introduction Limited data currently exist on the role and efficacy of additional series of collagenase clostridium histolyticum (CCH) injections among Peyronie’s disease (PD) men who have previously failed a first series of injections. We sought to evaluate outcomes of a novel protocol for CCH injections among men who had previously failed 6-8 CCH injections using a traditional approach. Objective To evaluate whether additional rounds of CCH using a novel protocol in men previously unresponsive results in greater curve improvements. Methods A randomized, controlled trial (NCT05108558) is ongoing. All participants previously failed to achieve ≥20% curvature improvement with 6-8 prior CCH injections. Men were randomized 3:1 to receive either CCH + traction (RestoreX) + sildenafil (treatment) up front or initial observation followed by treatment (controls). Outcomes were compared between treatment and control groups. Key measures included objective curve improvements and standardized/non-standardized questionnaires, with assessments obtained at baseline, 6-weeks after completion of CCH (treatment arm), after the no treatment period (controls), and at 1 year. Results A total of 38/40 men have been randomized to date, with 22 having fully completed treatment. Mean age was 57 years, with a median PD duration of 22 months. Median composite baseline curvature was 65 degrees, with 40% having hourglass or indentation deformities, 8% calcification, median baseline IIEF-EFD 20, and 58% able to have penetrative intercourse. Median estimated improvement with the prior CCH series was 0% (IQR 0, 18.8), and the median number of prior injections was 8. The majority of men were dissatisfied with their prior series of CCH (58% vs 35% satisfied, 8% neutral). Of the 22 men who had completed the study protocol, 50% required 1 series, 14% 2 series, 29% 3 series, and 7% 4 series. Compared to the no treatment arm, treated men experienced significantly greater improvements (median 60 degrees vs 0, p = 0.01). IIEF-EFD was non-statistically higher in treated men (0 vs -5, p = 0.17). 92% of men reported a subjective major improvement in curvature, with the median subjectively estimated improvement 90%. 42% reported improved sensitivity (58% no change), while 63% reported improved or no change in erectile function, with 9% unsure, and 27% worse. Post-treatment, 92% of men were very satisfied with CCH as a treatment and 8% neutral. Conclusions Repeating CCH using a novel protocol after an initially unsuccessful course of CCH achieves significant improvements in curvature and patient satisfaction. Additional data, including external validation, are warranted. 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: PathRight Medical.

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.