bluuebunny/crossref_metadata_2025 huggingface dataset:
185 Preventing Urinary Fistulae After Artificial Urinary Sphincter Removal: Outcomes of a Standardized Protocol
Authors: Lin J. , Ginsberg D. , Doumanian L. , Boyd S. , Loh-Doyle J.
Published: April 2022

Introduction

The artificial urinary sphincter (AUS) is the standard treatment for moderate to severe stress urinary incontinence in male patients. Despite their efficacy, the AUS is not without risk. Patients with an AUS are susceptible to complications such as mechanical failure, device infection, and urethral erosion. Erosion of the urethra can result in negative sequelae such as urethral stricture disease and urinary fistulae.

Objective

While there is no debate that patients presenting with urethral erosion require removal of the AUS, there is a lack of consensus on how to manage the patient in the perioperative period. We present our experience using a standardized surgical technique and perioperative protocol used at our institution to manage patients with an AUS presenting with urethral erosion.

Methods

Using an IRB-approved prosthetic database we completed a retrospective review of 97 patients who underwent AUS explantation between 2009 and 2020. Indications for removal, patient demographics, AUS component characteristics, and post-operative outcomes were analyzed. Patients undergoing AUS removal in the setting of urethral erosion were treated with a standardized protocol. Upon presentation, cystourethroscopy is performed to confirm erosion and to facilitate safe passage of a urethral catheter. With the urethral catheter in place, all AUS components are removed. After urethral cuff removal, urethrorraphy is performed. A 10-French surgical drain is placed through a separate stab incision and made to lie in the perineum and the wounds are closed in multiple layers. The urethral catheter is left in place for 4 weeks. After 4 weeks, physical examination and cystourethroscopy is performed to confirm repair of the urethra and the absence of fistula. Patients are seen monthly and are deemed eligible for reimplantation only after a minimum of 3 months have elapsed after explantation and the patient is deemed to have sufficient healthy urethra.

Results

No intraoperative complications occurred during AUS explantation. 117 patients underwent AUS removal during the study period. 94 (80.3%) patients had AUS removal due to urethral erosion. After median follow-up of 18.1 months (IQR 6.5 – 48.2) after AUS removal, there were a total 6 (4.0%) patients who developed a urethrocutaneous fistula with median time from AUS removal to fistula resolution of 6.5 months. Each patient with fistulae had presented with erosion of the urethra as indication for AUS removal. 67 (57.3%) patients underwent successful AUS reimplantation after removal with median time between explant and reimplant of 3.5 months (IQR3-4.8). Risk factors for urinary fistulae include urethral erosion, prior treatment with pelvic radiotherapy, and increasing age at time of AUS removal.

Conclusions

Urinary fistula can be prevented after urethral erosion with standardized surgical technique and peri-operative management in patients with an AUS.

Disclosure

No
202 Impact of COVID-19 Pandemic in Online Interest in Erectile Dysfunction
Authors: Bearrick E , Ziegelmann M , Kohler T , Helo S
Published: April 2022

Introduction

The COVID-19 pandemic has had a significant impact on global health. During uncertain times, priorities amongst patients shifted as many faced health concerns, economic uncertainty, and isolation. Access to general medical care during 2020 was challenging for many Americans who spent the year in quarantine. Without access to care, we hypothesize that patients were less likely to search for treatment options for a non-emergent condition like erectile dysfunction.

Objective

Herein, we aim to report on Google search trends observed in the pre COVID and post COVID era.

Methods

Google Trends was analyzed using search terms related to erectile dysfunction between June 2018 and June 2021. The search volume index (SVI), a relative measure of search volume on Google, was obtained for the following terms: erectile dysfunction, viagra, trimix, penile pump, and penile implant. Student t test was used to compare changes in mean SVI for each month compared to the same month one year prior.

Results

Compared to one year prior, the search for erectile dysfunction remained relatively stable over time with the exception of three months (9% decline Mar 2020, 38% increase Jan 2021, 8% increase Jun 2021). When compared to the preceding year, searches for Viagra declined during 9/37 (24%) months analyzed including Mar-Jun 2020, which coincided with the early part of the COVID-19 pandemic (p<0.05 for all). The only statistically significant increase occurred Oct 2020, a 16% change compared to Oct 2019 (p<0.05). In contrast, search for trimix did not change significantly over time except for an increase of 62% Mar 2021 and 60% Apr 2021 (p<0.05 for all). Search for the term penile pump did not change over time except for a 16 and 10% decline early during the pandemic, Feb and Mar 2020, respectively (p<0.05 for all). Lastly, search for penile implant declined 37% Mar 2020 and 32% Apr 2020 compared to 2019, and increased by 67% May 2021 compared to May 2020 (p<0.05 for all).

Conclusions

COVID-19 represented a major global health crisis, raising concerns and uncertainties for many. Erectile dysfunction remained a constant source of online interest. Despite limited access to medical care for elective conditions, only a few isolated increases in Google SVI were noted, most of which occurred during 2021 compared to 2020. This may be a reflection of the general public's lack of familiarity with treatments other than phosphodiesterase-5 inhibitors.

Disclosure

No
218 Evaluating the Relationship Among Erectile Dysfunction, Prostate Cancer Treatment Type and Inflatable Penile Prosthesis (IPP) Implantation
Authors: Shah T , Shen C , Jain K , Schasefer E , Zhou S , Fried D , Helmer D , Sadeghi-Nejad H
Published: April 2022

Introduction

Sexual health problems affect approximately 60% of male cancer survivors in the U.S. Erectile dysfunction (ED) is the most common sexual health condition men seek professional help for after cancer treatment with some studies reporting ED rates as high as 85% in these men. Inflatable penile prosthesis (IPP) implantation is a safe and highly effective form of ED treatment for patients who fail or cannot tolerate medical therapies. A 2011 study suggested that IPPs are under-utilized by urologists, as less than 1% of men with prostate cancer and ED received IPP following radical prostatectomy or external beam radiation.

Objective

To better characterize the utilization of IPP treatment, we examined the relationships between ED, prostate cancer treatment type and IPP implantation in a national cohort.

Methods

We performed a retrospective review of older SEER-Medicare patients who were diagnosed with local/regional prostate cancer between 2006 and 2011 and treated with surgery or radiation for it, with and without ED. Using ICD9/CPT/HCPCS codes we created a cohort of patients who has receipt of surgery or radiation within 3 months of cancer diagnosis as well as diagnosed ED within 5-years after undergoing treatment. Chi-square/Wilcoxon tests were used to detect significant differences between the surgical and radiation treatment groups for ED rates and use of IPP among those with ED.

Results

Of the 31,854 patients in our cohort, 10,475 (32.9%) received surgery and 21,152 (66.4%) received radiation only. Overall, ED was significantly more common for surgical (65.2%) than for radiation patients (33.8%, p<.001). For the subset of 14,121 patients with ED (overall IPP use=2.5%), IPP implantation was significantly more frequent for surgical patients (n=6,976, IPP use= 3.6%) than for radiation patients (n=7,145, IPP use=1.4%, p<.001).

Conclusions

Shockingly few (2.5%) prostate cancer patients with ED received IPP, with only 1.4% of radiation patients undergoing IPP vs. 3.6% of RALP patients. IPP under-utilization may be due to greater clinical focus on cancer treatment rather than quality-of-life issues. Discrepancies in ED rates between radiation and surgery may also be partially explained by lack of follow-up standardization and highly variable sexual dysfunction reporting, especially in the radiation literature. These findings highlight the importance of thorough counseling about all treatment options including penile prosthesis surgery for prostate cancer patients with ED.

Disclosure

No
221 Impact of Environmental and Socioeconomic Factors on Semen Quality in the United States
Authors: Rabinowitz M , Bowring MG , Kohn T , Levy J , Herati A
Published: April 2022

Introduction

It has been stated that sperm counts worldwide have declined by as much as 50% since 1973, with increasing environmental pollutants cited as one of many possible root causes. Recent theories challenge the validity of these contentious claims, such as the sperm count bioavailability (SCB) hypothesis, which asserts that global sperm health remains highly heterogenous across bodies, ecologies, and even time periods. Specifically, the impact of ecological factors on sperm health in the United States remains grossly understudied.

Objective

To examine the effect of environmental and socioeconomic factors, such as air quality, rurality, median income, and poverty rates, on sperm quality in the United States.

Methods

An ecological study was conducted using a nation-wide sample obtained from Dadi Kit, a company which produces at-home sperm testing kits, containing the zip code, age, and semen analyses for all subjects consenting to research. Subjects were linked via zip code to national, geographical databases on Air Quality Index (Environmental Protection Agency), rurality (Federal Office of Rural Health Policy), median household income (Census Bureau), and poverty rates (Census Bureau). Comparative analyses were conducted on Stata (College Station, TX). Linear regression models adjusted for age were used to analyze associations of sperm concentration (millions/mL of semen), motility (%), and semen volume (mL) with each exposure variable.

Results

A total of 1,343 male subjects with a median age of 32 (interquartile range [IQR]: 28-38) were included, representing 1,035 unique zip codes and 306 United States counties. Median values of sperm concentration, motility, and semen volume were 126.8 million/mL (IQR: 64.2-226.5 million/mL), 25.9% (IQR: 15.7-38%), and 2.2 mL (IQR: 1.4-3.6 mL), respectively. As illustrated in Table 1, air quality index, median household income, and poverty rates were not significantly correlated with any of the three semen parameters measured. A significant negative correlation between rurality and sperm motility was observed (P=.04), yet no association was observed with sperm concentration or semen volume.

Conclusions

Our study found no apparent link between air quality, median income, or poverty rates and any of the semen parameters measured in our nation-wide sample, while rurality was negatively associated with sperm motility only. Further longitudinal studies at the individual level are needed to dismiss a link between socioeconomic factors and sperm quality in the United States.

Disclosure

Yes, this is sponsored by industry/sponsor: Dadi Kit

Clarification

No industry support in study design or execution

Any of the authors act as a consultant, employee or shareholder of an industry for: Dadi Kit
227 The Clinical Significance of Imperfection: Do Asymmetry or Occult Curvature Matter in Penile Prosthesis Placement?
Authors: Bole R , Ahmed M , Gopalakrishna A , Ziegelmann M , Kohler T , Helo S
Published: April 2022

Introduction

Patient satisfaction after inflatable penile prosthesis (IPP) placement has been linked to preexisting curvature. Intraoperative findings such as curvature on artificial erection (AE) or asymmetric corporal measurements (ACM) are incompletely characterized in terms of impact on IPP outcome.

Objective

We sought to evaluate the clinical utility of AE and the significance of ACM during IPP surgery.

Methods

A single institution retrospective review of patients undergoing primary IPP placement between 7/2019-9/2020 was performed. Patient characteristics and intraoperative measurements were compared. Threshold for statistical significance was p≤0.05.

Results

A total of 130 patients underwent primary placement of penile prosthesis. Median age was 67 years (IQR 13). Comorbidities included prostatectomy in 33.8%, and known Peyronie's disease in 21.5%. Of the 27.7% (n=36) of patients who underwent intraoperative AE, 63.9% (n=23) had visible curvature. Of the patients with visible curvature, 70% (n=16) had a preoperative diagnosis of Peyronie's disease and 56.3% (n=9) underwent straightening procedures compared to 28.6% (n=2) of the 30% (n=7) with no known curvature. Incision and grafting was most frequently performed (6/11)- with a minority undergoing plication (2/11). Of the 72.3% (n=94) who did not undergo AE, only 2.1% (n=2) required additional measures for curvature correction. Median corporal measurement was 21 (IQR 2) bilaterally and median cylinder size 20 cm (IQR 4) bilaterally with 1cm rear tip extenders. Of the 18.5% (24/130) of patients with ACM, asymmetry was as follows: 20.8% (5/24) had less than 1 cm, 70.8% (17/24) had 1 to <2 cm, and 8.3% (2/24) had 2 cm or greater. Of these patients 87.5% (21/24) underwent placement of an asymmetric device, only 5% (1/21) of which had residual curvature less than 30 degrees. Despite ACMs, 12.5% (3/24) of patients had a symmetric device placed, one of which had residual curvature. Only 2 patients underwent straightening procedures including plication and incision/grafting.

Conclusions

Intraoperative AE is effective at revealing occult penile curvature at time of IPP placement, however most men with newly detected curvature do not require additional straightening measures. We also found that 1 in 5 patients undergoing IPP had ACM but this did not correspond to residual curvature following IPP or requirement for adjunct straightening. These findings may provide reassurance to urologists who do not routinely perform AE or those who encounter ACM during corporal dilation

Disclosure

Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific, Coloplast
228 Reservoir Distance from Critical Pelvic Structures: Radiographic Comparison of High Submuscular and Space of Retzius Inflatable Penile Prosthesis Placement Techniques
Authors: Kavoussi M , Cook G , Nordeck S , Dropkin B , Joice G , Sanders S , Pruitt J , Hudak S , Morey A
Published: April 2022

Introduction

Inflatable penile prosthesis (IPP) reservoir placement into the High Submuscular space (HSM) has been proposed as a strategy to prevent injury to organs adjacent to the Space of Retzius (SOR). SOR reservoir proximity to critical pelvic structures (CPS) has been previously established in a cadaver study.

Objective

We sought to evaluate reservoir distance from CPS for SOR and HSM placements using cross-sectional imaging obtained following IPP insertion.

Methods

We retrospectively reviewed our institutional database and identified men who underwent IPP insertion between 2007 and 2020. Men who underwent subsequent cross-sectional abdominopelvic imaging following IPP insertion until October 2020 were included in this study. Two radiologists blinded to IPP surgical technique evaluated reservoir position to determine (a) mass effect on the bladder and iliac vessels and (b) the shortest distance between each of these structures and the reservoir. Men were grouped based on reservoir placement technique (SOR vs. HSM) as documented in the operative notes. Variables were analyzed using chi-squared, fisher's exact, and student's T-tests as indicated.

Results

Among 1010 IPP cases performed during the study interval, 139 (13.7%) met our inclusion criteria with imaging obtained an average of 827 (± 785) days after IPP insertion. Oncologic follow-up (46%) was the most common indication for imaging. Compared with SOR reservoirs (n = 32), HSM reservoirs (n =107) were significantly less likely to induce a mass effect on the bladder (72 vs. 9%) or iliac vessels (34 vs. 4%) and were located roughly 5x further from the bladder (10 ± 22 vs. 49 ± 36 mm) and iliac vessels (5 ± 9 vs. 23 ± 26 mm, Table 1).

Conclusions

This study radiographically confirms that IPP reservoirs are located significantly further away from CPS following HSM placement compared to SOR placement. These findings suggest a potential patient safety benefit via avoidance of bladder and iliac vessel-related IPP reservoir complications.

Disclosure

Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast
229 Global Trends in Prevalence, Treatments, and Costs of Penile Prosthesis for Erectile Dysfunction in Men
Authors: Kohn TP , Nguyen HMT , Rajanahally S , Hellstrom W , Hsieh T , Raheem OA
Published: April 2022

Introduction

Penile prosthesis is a durable and effective treatment for erectile dysfunction (ED). Even as other treatment options for ED have been brought to market, penile prosthetic surgery remains a mainstay for urologists treating ED. No systematic study has yet summarized the global trends in penile prosthetic surgery.

Objective

To systematically review studies of trends in penile prosthetic surgery to determine global movements in implantation rates, malleable vs inflatable prosthetic surgery, inpatient vs outpatient implantation surgery, the proportion of men with ED undergoing penile prosthetic surgery, and prosthetic cost.

Methods

A systematic review of MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov was performed for studies assessing trends in penile prosthetic surgeries and costs associated with penile prosthetic device and inclusive surgical costs.

Results

Twenty-seven studies were identified during the systematic review, comprising 447,204 penile prosthetic surgeries reported from 1988 to 2019. Trend analysis demonstrates that rates of penile prosthetic surgery dramatically declined in the late 1980s and early1990s but has demonstrated modest growth since the mid-2000s. Outpatient inflatable penile prosthetic surgery has strongly trended upward. Penile prostheses device costs have matched the rate of inflation, but inclusive surgical cost has radically outpaced inflation. Growth has mainly been seen in the United States, with a more modest global growth.

Conclusions

Penile prosthesis remains a viable option for the treatment of ED. Trends such as outpatient surgery and inflatable penile prosthesis placement may be driving the recent steady growth of penile prosthetic surgeries but surging inclusive surgical cost may present a barrier for some patients without insurance coverage.

Disclosure

No
231 Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice
Authors: Kavoussi M , Cook G , Nordeck S , Dropkin B , Joice G , Sanders S , Pruitt J , Hudak S , Morey A
Published: April 2022

Introduction

Inflatable penile prosthesis (IPP) reservoirs are typically placed into the Space of Retzius (SOR), High Submuscular Space (HSM), or alternative locations via a transinguinal (TI) approach or a lower abdominal counter incision (CI). A cadaver study showed variability in reservoir location after TI-HSM placement (JSM: 2016 Sep;13(9):1425-1431).

Objective

We sought to evaluate reservoir location using cross-sectional imaging following contemporary IPP insertion.

Methods

We retrospectively reviewed our institutional database and identified men who underwent virgin penoscrotal IPP insertion from 2007 to 2019. We then identified those men who subsequently underwent cross-sectional imaging prior to October 2019. Radiologists blinded to reservoir placement technique evaluated cross-sectional imaging and categorized each reservoir location in relation to the abdominal wall musculature, transversalis fascia, and peritoneum. Statistical analysis was performed using Chi-squared and Fisher's exact tests.

Results

Among 561 men who underwent virgin IPP insertion during the 12 year study period, 114 had cross-sectional imaging subsequently obtained: 29 TI-SOR, 80 TI-HSM, and 5 CI-HSM (Table). TI-HSM reservoirs were more likely than TI-SOR to be located anterior to the transversalis fascia (14 vs. 48%, p=0.001). TI-HSM reservoirs were less likely than TI-SOR to be located in the preperitoneal space (62 vs. 18%, p<0.001). Rates of retroperitoneal reservoir location were similar between the TI-HSM and TI-SOR groups. Among all 561 patients (131 TI-SOR, 405 TI-HSM, and 25 CI-HSM), rates of reservoir-related complications requiring operative intervention were similar between groups (5 vs. 2 vs. 0%, p = 0.24).

Conclusions

Roughly half of the TI-HSM reservoirs in this series appeared to be located posterior to the transversalis fascia on cross-sectional imaging. Although preperitoneal and retroperitoneal locations were common in both groups, reservoir related complications were rare.

Disclosure

Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast
238 A Novel Algorithm for Peyronie's Management At the Time of Penile Prosthesis to Maximize Length Without Elevation of the Neurovascular Bundle
Authors: Balzano F , Miran A , Warner J
Published: April 2022

Introduction

Peyronie's disease (PD) is a fibrous transformation of the tunica albuginea within the corpora cavernosa causing curvature of the penis while erect. This can not only be painful but can also cause narrowing, shortening, an hourglass deformity and problems with penetrative intercourse.

Objective

There are many means of management of Peyronie's disease at the time of penile implant. Modelling is a commonly used approach but leaves the penis without increased length. Multi-incisional techniques enhance length restoration, but risk significant vascular and neurologic compromise. Herein, we present our experience with a novel algorithm to approach Peyronie's disease with an effort to enhance and restore length without elevation of the neurovascular bundle.

Methods

A retrospective review was performed of an institutional review board approved database. Patients treated for Peyronie's disease and erectile dysfunction with penile implant from 8/16/18 to 8/20/2020 were evaluated.

Results

In our cohort of 33 patients there is an average of 1.9 cm average stretch difference in stretch penile length. There was a 2.15 cm difference in the cohort subset that utilized the Brock technique. We had no loss of sensation or glans ischemia. There was one patient with autoinflation. All patient had less than 10 degrees of residual curvature.

Conclusions

In conclusion with the proposed algorithm we are able to safely maximize length restoration without elevation of the neurovascular bundle. We do require more patients with longer follow-up however to ensure the safety of this algorithm.

Disclosure

Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific, Olympus
107 Outcomes for Chronic Pelvic and Genital Pain Using Through an Interdisciplinary Pain Rehabilitation Program
Authors: Roshandel R , Ziegelmann M , Betcher H , Helo S , Collins CS , Kacel E , Gilliam W
Published: April 2022

Introduction

Chronic pelvic and/or genital pain is a disabling condition and commonly associated with poor quality of life, impaired sexual function and decreased productivity.

Objective

To examine treatment outcomes among a cohort of patients diagnosed with refractory pelvic and/or genital pain enrolled in a 3-week interdisciplinary pain rehabilitation program (IPRP).

Methods

A series of with-in subjects ANOVAs (corrected for multiple comparisons) were used to evaluate the effectiveness of IPRP on self-report (pain severity, interference, depressive symptoms, quality of life) and observer-rated outcome (5 minute walk) among 15 treated patients receiving care at the Mayo Clinic IPRP between 2016-2018.

Results

Fifteen patients (5 male, 10 female) were identified. Mean age was 47.0 (range: 24-78) and primary diagnoses were pelvic pain (n=13) and penile pain (n=2). Significant within-subject effects were detected for all self-report outcomes and the 5-minute walk test (see table 1). Six patients were on opioid therapy (MME = 49mg), and all but one successfully tapered off opioids. In the remaining patient, daily MME decreased from 150 mg to 30 mg.

Conclusions

Intensive outpatient IPRP significantly improves quality of life for patients with treatment-refractory chronic pelvic and/or genital pain. These results support multi-disciplinary treatment paradigms for refractory urogenital pain.

Disclosure

No
108 Impact of Health Literacy on Satisfaction Following Inflatable Penile Prosthesis Surgery
Authors: Bhalla R , Furuyama W , Calvert J , Ball M , Dropkin B , Milam D , Kaufman M , Johnsen N
Published: April 2022

Introduction

Health literacy - the ability to obtain, comprehend, and act on basic medical information - can impact surgical outcomes and patient quality of life (QOL). Urologic prosthetic surgery aims to improve a patient's QOL, therefore patient satisfaction is a fundamental measure of success.

Objective

We sought to determine whether health literacy impacts patient satisfaction following inflatable penile prosthesis (IPP) surgery for erectile dysfunction.

Methods

We performed a single-institution retrospective study of patients who underwent IPP insertion between January 1st 2016 and July 31st 2020. A patient satisfaction phone questionnaire was administered between October 2020 and January 2021 to measure: (1) overall satisfaction with IPP surgery on a Likert scale and (2) if patients would undergo IPP surgery again. Baseline health literacy was measured using the Brief Health Literacy Screen (BHLS) – a validated 3-item questionnaire. Ordinal logistic regression was used to assess the association between health literacy and patient satisfaction, adjusting for the predetermined covariates of patient age, marital status, preoperative Sexual Health Inventory for Men (SHIM) scores, time from surgery to phone questionnaire, and device functionality.

Results

A total of 162 IPP patients met study inclusion criteria. The cohort consisted of primarily Caucasian (81.5%) and married (74.7%) men with a median age of 64.5 years and an interquartile range (IQR) of 57.5-69.5 years. The median (IQR) BHLS score was 15 (13-15) and the median (IQR) time from the index surgery to phone questionnaire administration was 2.41 (1.39-3.98) years. 69.8% of men were either very satisfied or satisfied with their procedure, and 74.1% of men would again undergo IPP surgery. After adjustment for potential confounders, BHLS score was significantly associated with patient satisfaction after IPP surgery (OR 1.31, 95% CI 1.11-1.54; p=0.001) and was positively associated with likelihood of again undergoing IPP surgery (OR 1.53, 95% CI 1.25-1.87; p<0.001) (Table 1).

Conclusions

Patients with lower health literacy are less likely to be satisfied following IPP placement. The BHLS score is an important tool that can be used to identify patients who may benefit from increased preoperative counseling and education to further improve patient expectations and QOL following IPP surgery.

Disclosure

Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific
109 Caprini Risk Score is Shockingly High in Penile Prosthesis Surgery Patients
Authors: Habashy E , Hebert K , Helo S , Ziegelmann M , Collins S , Trost L , Kohler T
Published: April 2022

Introduction

The significant overlap of risk factors for erectile dysfunction and venous thromboembolism (VTE) may disproportionally increase the risk of VTE in men undergoing inflatable penile prosthesis (IPP) surgery. Owing to the absence of available literature, AUA and EAU perioperative VTE guidelines do not address VTE risk with IPP surgery and generally recommend against pharmacologic prophylaxis with outpatient surgery. The Caprini Score is a validated scoring system to estimate VTE risk in the perioperative period.

Objective

We sought to assess the risk of VTE by calculating Caprini Scores in men undergoing IPP surgery.

Methods

We retrospectively reviewed and calculated Caprini Scores for patients undergoing IPP surgery at our institution between July 2017 and June 2019.

Results

215 patients undergoing IPP surgery were identified with a mean and median Caprini score of 5.96 (SD, 1.63) and 6 (IQR 5,7), respectively. 84% of the cohort was classified as high or highest risk for VTE (Figure 1). This is in part due to our cohort's mean age of 64, mean BMI of 31 and history of prostate cancer treatment as the cause of ED. Prior history of VTE (deep vein thrombosis(DVT) or pulmonary embolism (PE)was identified in 17 (8%) patients with 5 (2%) have a history of both DVT and PE.

Conclusions

Men undergoing IPP surgery are high risk for VTE based on Caprini score assessment. VTE prophylaxis should be considered in men undergoing penile implant surgery. Before widespread application, long-term data is necessary to assess safety and efficacy of VTE prophylaxis in the IPP surgery population.

Disclosure

Any of the authors act as a consultant, employee or shareholder of an industry for: Senior author consultant for Coloplast
111 Decreasing Intraoperative Narcotic Use: Pudendal Nerve Block Prior to Inflatable Penile Prosthesis Implantation
Authors: Sayyid R , Owens-Walton J , Taylor N , Oberle M , Fratino K , King S
Published: April 2022

Introduction

The opioid epidemic has proven to be a public health crisis in the United States over the past two decades and efforts to decrease opioid exposure, and thus risk of dependence, are sorely needed.

Objective

To determine whether pudendal nerve block (PNB) utilization in the immediate pre-operative setting decreases intra-operative opioid analgesic requirements in veteran patients undergoing a primary inflatable penile prosthesis (IPP) implantation.

Methods

A retrospective cohort analysis of all patients undergoing a primary IPP implantation between January 2017 and July 2020 at the Charlie Norwood VA Medical Center in Augusta, GA were included. Patients undergoing implant revisions or concurrent procedures were excluded. PNBs were performed in the standard fashion bilaterally with 10 cc of combination 0.25% Marcaine without epinephrine and Solu-Medrol (Methylprednisolone sodium succinate). Univariable and multivariable gamma regression analyses were performed to evaluate the association between PNB utilization and intra-operative opioid analgesic requirements, abstracted from individual patient's anesthesia provider medication administration record. The primary study outcome was intra-operative opioid analgesic requirements, quantified in morphine milligram equivalents (MME), and the secondary outcome was post-operative opioid analgesic requirements.

Results

The study cohort consisted of 122 patients, 35 (28.7%) of whom underwent a PNB. Twelve (34.3%) and 17 (19.5%) patients in the PNB and non-PNB groups had an active opioid analgesic prescription at the time of their pre-operative visit. Median intra-operative opioid analgesic requirements were significantly lower in the PNB group (16.3 versus 26.0 MME, p=0.036). Receipt of an immediate pre-operative PNB was significantly associated with lower intra-operative opioid analgesic requirements on multivariable (coefficient 0.84, p=0.038) regression analysis. There was no significant difference in post-operative opioid analgesic requirements (37.5 MME in both groups, p=0.15).

Conclusions

Immediate pre-operative pudendal nerve blocks decrease intra-operative opioid analgesic requirements in veteran patients undergoing a primary inflatable penile prosthesis implantation, and should be considered to decrease intra-operative opioid analgesic requirements.

Disclosure

Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific
114 Patient Risk Factors for Prolonged Opioid Dependence Following Primary Inflatable Penile Prosthesis Placement Managed with Multimodal Analgesia
Authors: Braun A , Sudhakar A , Lucas J , Patel R , Gross M , Simhan J
Published: April 2022

Introduction

Multimodal analgesia (MMA) following inflatable penile prosthesis (IPP) placement has previously demonstrated substantially improved pain control with reduced opioid burden both in the acute and prolonged postoperative period. However, some patients receiving MMA still require opioid pain management beyond the immediate postoperative recovery, placing them at risk for developing prolonged opioid dependence.

Objective

In this analysis, we examine patient-specific and perioperative factors predicting increased pain and prolonged use of opioids in the recovery period following primary IPP surgery in those managed with MMA only.

Methods

This is a multicenter retrospective review of 165 primary three-piece IPP recipients from 12/2018 to 12/2020 managed with a standardized MMA protocol. Patients on narcotics preoperatively were excluded. Prolonged opioid dependence was defined as active opioid prescriptions in the Prescription Drug Monitoring Program (PDMP) 90 days after surgery in previously opioid-naïve patients. Preoperative, intraoperative and immediate postoperative factors were analyzed to assess correlative risk for increased pain and development of opioid dependence in the MMA cohort.

Results

The prolonged opioid use group (2/165) demonstrated substantially higher Visual Analog Scale (VAS) pain scores in PACU (p=0.014) with trends towards higher total morphine equivalents (TME) in PACU (p=0.076). Also seen were higher total morphine equivalents (TME) in postoperative day 0 (p=0.0425), while VAS scores on POD1 (p=0.123) and total TME prescribed at discharge (p=0.646) did not reach statistical significance. In assessing preoperative factors associated with developing opioid-dependence, age (p=0.194), race (p=0.414), BMI (p=0.202) and prevalence of diabetes (p=0.656) and chronic pain (p=0.291) did not demonstrate statistical significance. Intraoperative factors analyzed including operative time (p=0.719), surgical approach (p=1.00), cylinder size (p=0.938), use of rear-tip extenders (p=1.00), reservoir size (p=0.346) and use of drain (p=1.00) also did not yield significance.

Conclusions

Patients who developed prolonged postoperative opioid dependence tended to experience higher PACU VAS scores and increased TME requirements throughout their hospitalization. MMA appears to reduce risk of prolonged postoperative opioid dependence in this series. We found no clear preoperative or operative trends for prolonged opioid dependence in MMA patients.

Disclosure

Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast
115 Two Cases of “Drained and Retained” Inflatable Penile Prosthesis and Artificial Urinary Sphincter Reservoirs causing Small Bowel Obstruction
Authors: Loloi J , Davila J , Matloubieh J , Gottlieb J , Maria P , Donnelly J , Small A
Published: April 2022

Introduction

Inflatable penile prosthesis (IPP) and artificial urinary sphincter (AUS) are the most common surgical implants in the field of men's health. Infected or defective implants can be removed or replaced. The “drain and retain” strategy has been described as generally safe when prosthetic reservoirs are not easily retrieved. However, case reports of complications related to retained balloons have been described including erosion into the bowel and bladder, intraperitoneal migration and vascular compression. Here we describe two rare cases of reservoir-induced small bowel obstruction (SBO) from IPP and AUS reservoirs.

Objective

Describe two rare cases of retained IPP and AUS reservoirs causing SBO.

Methods

Single institutional retrospective case series.

Results

Case 1: 75 year old male who underwent IPP placement in 2001. Due to device malfunction, IPP cylinders were removed and replaced with 2-piece device in 2017, and the reservoir was “drained and retained.” The patient presented 4 years later with abdominal pain, nausea/vomiting, and right lower quadrant (RLQ) feculent cutaneous drainage. CT scan showed SBO with a transition within the terminal ileum due and an endoluminal foreign body in the cecum (consistent with the retained reservoir) (Figure 1A). Additionally, a contained bowel perforation with entero-cutaneous fistula tract to the skin was identified. Diagnostic laparoscopy revealed a thickened terminal ileum, walled-off perforation in the RLQ (Figure 1B) thought to be due to reservoir entry into the bowel, and a fistula to the right abdominal wall. The bowel was resected, thorough investigation including right-sided colonoscopy was unable to identify the reservoir, and primary anastomosis was performed. Follow up CT scan 3 days later showed passage of reservoir, presumably in the patient's bowel movements. Case 2: 81 year old male with a history of AUS placement in 2016. The device was removed for infection 5 years later. The reservoir was “drained and retained” given difficult access and no sign of reservoir infection. One month later, he presented with abdominal distention, nausea and vomiting. A CT scan revealed dilated loops of small bowel with an abrupt transition point in the RLQ adjacent to the retained reservoir (Figure 1C). Exploratory laparotomy showed SBO with the reservoir and tubing embedded into the small bowel wall (Figure 1D). The foreign bodies were successfully retrieved and the affected bowel was resected and repaired with a primary anastomosis.

Conclusions

These two cases of SBO due to IPP and AUS reservoirs show a potential danger of the “drain and retain” strategy, especially when reservoirs are placed intraperitoneal. These cases may be helpful to inform patient counseling on the rare risks of implant revision surgery. Innovative means of reservoir retrieval at explantation are needed to mitigate these risks.

Disclosure

No
116 Dorsal Artery Branches to the Corpora Cavernosa
Authors: Trussler J , Aponte-Colon D , Alnammi M , Flacke S , McCullough A
Published: April 2022

Introduction

Understanding the penile arterial anatomy and its preservation is of interest to reconstructive and oncologic surgeons. The predominant cavernosal arterial supply is provided by the cavernous artery (CA) as it branches from the internal pudendal artery (IPA). Penile ultrasound and cavernosography have demonstrated the existence of accessory arteries originating from the dorsal artery of the penis (DA). Assessment of the arterial anatomy has largely been limited to imprecise ultrasound or invasive angiography.

Objective

To describe the anatomic findings relating to DA branching patterns in the penis among men undergoing CT cavernosography for evaluation of sexual dysfunction.

Methods

Images from CT cavernosography were reviewed in a sequential cohort of men. Imaging was reviewed to delineate the arterial anatomy with respect to the CA and DA branches distal to the pubic symphysis as noted by an absence of contrast in a linear hiatus within the corpora cavernosa. Data included the presence of an identifiable CA or DA branch, their diameters, the number of DA branches, distance from the pubic symphysis, and the approximate branching angle.

Results

68 men had imaging available for analysis, 57 of whom underwent evaluation for ED and 37 for penile curvature. At least one CA was identifiable in 88% of men with a mean diameter of 1.66mm (Median 1.40, [IQR 1.30, 1.90]). DA perforating branches were identified in 90.8% of men, with a mean of 2.1 discrete branches per patient (Median 2, [IQR 1,3]). 26 men had penile doppler data available for comparison. Among those men, the mean CA diameter after injection was 1.51mm and the ratio between diameter measured on doppler and CT was 1.0. 4 patients had a DA branch identified on penile doppler and all had at least one DA branch identified on CT. 19 patients had at least one DA branch identified on CT which was not seen on penile doppler. In a subset of 33 patients with further CT data available for review, the mean number of DA branches identified was 2.24 (Median 2, [IQR 1,3]), with a mean DA branch diameter of 1.39mm (Median 1.40, [IQR 1, 1.70]). The first branch was identified at a mean of 2.06cm distal to the pubic symphysis with a branching angle of approximately 49.75 degrees, and the second branch was identified at a mean of 3.4cm distal to the pubic symphysis with a branching angle of approximately 50.62 degrees.

Conclusions

Dorsal artery contribution to the cavernosal blood supply may be more variable than previously thought. This is of interest to those performing penile doppler for assessment of blood flow given that it may be difficult to delineate the CA and DA in some patients. The impact of these DA branches on sexual function is not clear and warrants further investigation.

Disclosure

No
Early Sport Specialization and Past Injury in Competitive Youth Rock Climbers
Authors: Chen Daniel L. , Meyers Rachel N. , Provance Aaron J. , Zynda Aaron J. , Wagner K. John , Siegel Shannon R. , Howell David R. , Miller Shane M.
Published: April 2022

Introduction

Sport specialization has been shown to have negative effects on athletes but has not been studied within rock climbing. This study seeks to evaluate the proportion and impact of specialization in pediatric climbers.

Methods

Climbers (ages 8–18 y) were recruited from throughout the United States to complete a 1-time survey regarding climbing experience, training patterns, and injury history. The main outcome of proportion of climbers suffering an injury was assessed within the last 12 mo and within their entire climbing experience (defined as “lifetime” injury). Early specialization was defined as exclusive participation in climbing, with training for >8 mo‧y-1, prior to age 12 y (late specialization if after age 12 y).

Results

Participants (n=111, 14±3 y [mean±SD], 69 females) were high-level climbers. Fifty-five percent of participants specialized in climbing, and 69% of those specialized early. Hand and ankle injuries occurred most commonly. Seventy-eight percent of late specialized climbers had a lifetime injury. Late specialized climbers were 1.6 times (95% CI: 1.1–2.3) more likely than early specialized climbers to have had a lifetime injury and 1.8 times (95% CI: 1.1–2.8) more likely to have had an injury in the last 12 mo. No difference in overuse injuries was found between specialization groups.

Conclusions

Early specialization is common among youth climbers but was not associated with an increase in injuries. Late specialization was associated with a higher likelihood of having had a climbing injury in the last 12 mo and during an entire climbing career.
What Went Right
Authors: Liechty Mark
Published: April 2022

This book explores why Nepal's hydropower sector is one of its few development success stories. Unlike most other 'developing' countries, in Nepal local firms design and build hydropower facilities using Nepali engineers, builders and labor. Nepal has largely avoided the trap whereby most poor countries are forced to accept energy infrastructure projects that are foreign designed, funded and built – typically resulting in debt, dependency and unsustainability. It traces the struggle between two competing development paradigms: one that emphasizes gradual national human capacity building – at the expense of speed and efficiency – and another that emphasizes rapid, large-scale infrastructure building – at the risk of unsustainability and dependency. At stake is whether what passes for 'development' benefits the countries in which it occurs, or the banks and investors that finance capital-intensive projects. What Went Right brings a vision for sustainable development into vigorous conversation with development strategies that have proven to be less productive.
Representing Magic in Modern Ireland
Authors: Sneddon Andrew
Published: April 2022

This Element argues that Ireland did not experience a disenchanted modernity, nor a decline in magic. It suggests that beliefs, practices and traditions concerning witchcraft and magic developed and adapted to modernity to retain cultural currency until the end of the twentieth century. This analysis provides the backdrop for the first systematic exploration of how historic Irish trials of witches and cunning-folk were represented by historians, antiquarians, journalists, dramatists, poets, and novelists in Ireland between the late eighteenth and late twentieth century. It is demonstrated that this work created an accepted narrative of Irish witchcraft and magic which glossed over, ignored, or obscured the depth of belief in witchcraft, both in the past and in contemporary society. Collectively, their work gendered Irish witchcraft, created a myth of a disenchanted, modern Ireland, and reinforced competing views of Irishness and Irish identity. These long-held stereotypes were only challenged in the late twentieth-century.
Self-Explanation and Empty-Base Explanation
Authors: KAPPES YANNIC
Published: April 2022

This paper explores a novel notion of self-explanation that combines ideas from two sources: (1) the tripartite account of explanation, according to which a proposition can help explain another either in the capacity of a reason why the latter obtains or in the capacity of an explanatory link, and (2) the notion of an empty-base explanation, which generalizes the ideas of explanation by zero-grounding and explanation by status. After having introduced these ideas and the novel notion of self-explanation, I argue that the latter has the potential to resist extant arguments against the possibility of self-explanation. In the remainder of the paper, I discuss candidates for such self-explanatory propositions and suggest possible applications for Humeanism about laws of nature, the debate on the grounds of ground, the rationalist tradition, and philosophical theology.
A national study of antibiotic use in Greek pediatric hematology oncology and bone marrow transplant units
Authors: Mantadakis Elpis , Kopsidas Ioannis , Coffin Susan , Dimitriou Gabriel , Gkentzi Despoina , Hatzipantelis Emmanouel , Kaisari Aikaterini , Kattamis Antonis , Kourkouni Eleni , Papachristidou Smaragda , Papakonstantinou Evgenia , Polychronopoulou Sophia , Roilides Emmanuel , Spyridis Nikos , Tsiodras Sotirios , Tsolia Maria N. , Tsopela Grammatiki-Christina , Zaoutis Theoklis , Tragiannidis Athanasios
Published: April 2022

Objective:

We surveyed antimicrobials used in Greek pediatric hematology–oncology (PHO) and bone marrow transplant (BMT) units before and after an intervention involving education regarding the 2017 clinical practice guidelines (CPG) for the management of febrile neutropenia in children with cancer and hematopoietic stem-cell transplant recipients.

Design:

Antibiotic prescribing practices were prospectively recorded between June 2016 and November 2017.

Intervention:

In December 2017, baseline data feedback was provided, and CPG education was provided. Prescribing practices were followed for one more year. For antibiotic stewardship, days of therapy, and length of therapy were calculated.

Setting:

Five of the 6 PHO units in Greece and the single pediatric BMT unit participated.

Participants:

Admitted children in each unit who received the first 15 new antibiotic courses each month.

Results:

Administration of ≥4 antibiotics simultaneously and administration of antibiotics with overlapping activity for ≥2 days were significantly more common in PHO units in general hospitals compared to children’s hospitals. Use of at least 1 antifungal was recorded in ∼47% of the patients before and after the intervention. De-escalation and/or discontinuation of antibiotics on day 6 of initial treatment increased significantly from 43% to 53.5% (P = .032). Although the number of patients requiring intensive care support for sepsis did not change, a significant drop was noted in all-cause mortality (P = .008).

Conclusions:

We recorded the antibiotic prescribing practices in Greek PHO and BMT units, we achieved improved prescribing with a simple intervention, and we identified areas in need of improvement.