bluuebunny/crossref_metadata_2025_split huggingface dataset:
Liver paranchyma orignated accessory cystic artery: Case report and review article
Authors: alharbi mohammad bukhetan 
Published: April 2022

ABSTRACT

Introduction:
The cystic artery continues to be a significant structure visualized during laparoscopic cholecystectomy. Despite numerous reports on the variable anatomy of the cystic artery, only a few discuss the liver parenchyma that developed as an accessory to the cystic artery.

Case presentation:
I present a middle-aged patient who had an elective laparoscopic cholecystectomy by blunt dissection to separate tissues in the surgical field surrounding her gallbladder. The inferolateral liver parenchyma segment 5 accessory cystic artery was visualized and clipped safely.

Conclusion:
Blunt, careful dissection of the inferolateral aspect of the gallbladder may reduce the chance of bleeding due to aberrant dissection with abnormal blood supply to the gallbladder.

Highlights
4 The Effect of Route of Testosterone on Changes in Hematocrit: A Systematic Review and Bayesian Network Meta-Analysis of Randomized Trials
Authors: Nackeeran S , Ory J , Gonzalez D , Kohn T , White J , Ramasamy R 
Published: April 2022

ABSTRACT

Introduction
Testosterone therapy (TT) is known to be associated with secondary erythrocytosis. Previous studies have shown that method of administration and formulation may result in variances in hematocrit (Hct) increases. Given the increasing demand for TT and newer formulations becoming available, an updated review and meta-analysis of relative increases in hematocrit is warranted. As head-to-head trials are rare, network meta-analysis of the contemporary studies is the only way to compare hematocrit changes by testosterone type, including topical gels and patches, injectables (both short-acting and long-acting) and oral tablets.

Objective
We aimed to characterize hematocrit changes by testosterone type, including gel, patch, oral testosterone undecanoate (TU), intramuscular (IM) TU, and IM testosterone enanthate/cypionate (TE/C) through a review and meta-analysis of randomized control trials (RCTs) on this topic.

Methods
We conducted a thorough search of listed publications in Scopus, PubMed, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov. Twenty-nine placebo-controlled randomized trials (3,393 men) met inclusion criteria for analysis of mean hematocrit change after testosterone therapy. Randomized controlled trial data for the following formulations of testosterone were pooled via network meta-analysis: gel, patch, oral testosterone undecanoate, intramuscular testosterone undecanoate, and intramuscular testosterone enanthate/cypionate.

Results
All types of testosterone therapies result in statistically significant increases in mean hematocrit when compared with placebo. Meta-analysis revealed all formulations, including gel (3.0%, 95% CI 1.8-4.3%), oral testosterone undecanoate (4.3%, 0.7-8.0%), patch (1.4%, 0.2-2.6%), intramuscular testosterone enanthate/cypionate (4.0%, 2.9-5.1%), and intramuscular testosterone undecanoate (1.6%, 0.3-3.0%) result in statistically significant increases in mean hematocrit when compared with placebo. When comparing all formulations against one another, intramuscular testosterone cypionate/enanthate were associated with a significantly higher increase in mean hematocrit compared to patch, but no differences in hematocrit between other formulations were detected.

Conclusions
All types of testosterone are associated with increased hematocrit; however, the clinical concern of this increase remains questionable, warranting future studies. This is the first network meta-analysis to quantify mean hematocrit change and compare formulations, given the absence of head-to-head trials.

Disclosure
No
5 Continuous Testosterone Therapy with Recombinant FSH & HCG Improves Semen Parameters: A Pilot Study
Authors: Hakky T , Shirazi H , Christensen M , Pastuszak A 
Published: April 2022

ABSTRACT

Introduction
Male hypogonadism is characterized by inadequate production of Testosterone (T) and a deficiency in spermatogenesis. The main treatment of male hypogonadism is T therapy (TTh), which can disrupt normal hypothalamic-pituitary-gonadal axis function and cause oligospermia and/or azoospermia with testicular atrophy.

Objective
We evaluated the safety and efficacy of continuous intramuscular testosterone administration in combination with low doses of human chorionic gonadotropin (HCG) and recombinant follicle stimulating hormone (FSH) on semen parameters.

Methods
A total of 10 hypogonadal men on TTh, HCG, and FSH who had achieved pregnancy with their partners or had successful sperm retrievals were retrospectively identified. All of the men were maintained on continuous intramuscular testosterone therapy, HCG at 750 IU subcutaneously twice weekly and recombinant FSH 75 IU every other day. A semen analysis was performed in men who had not had vasectomy prior to or after starting therapy, and serum testosterone, estrogen, FSH, LH, hemoglobin and hematocrit levels, as well as a scrotal ultrasound for testicle size determination, were obtained.

Results
Of the 10 men with a mean(SD) age of 39.5(6.4) years) who underwent treatment, 7 achieved pregnancy naturally and 3 underwent sperm retrieval due to prior vasectomy, with successful sperm retrieval in all 3. Mean(SD) pretreatment T levels were 745(614) ng/dl, Estradiol 38.7(42.8) pg/ml, LH 0.18(0.24) IU/L, FSH 0.47(0.46) IU/L. Mean(SD) total motile sperm count (TMSC) was 1.43(2.99) million total motile sperm. Mean(SD) pretreatment testicular volume was 11.1(3.3)cc and post-treatment was 11(5.5) cc. Mean(SD) post-treatment T levels were 1185(482) ng/dl, Estradiol 26.0(16.9) pg/ml, LH 0.43(0.23) IU/L, FSH 1.78(0.91) IU/L, with TMSC 102.8(89.4) million.

Conclusions
Across a cohort of 10 men, TTh in combination with HCG and FSH resulted in resumption or increase in TMSC during treatment, resulting in either natural pregnancy or successful sperm retrieval and supporting the conclusion that TTh does not require cessation in men desiring fertility during TTh. Further prospective studies are required to validate these findings.

Disclosure
Any of the authors act as a consultant, employee or shareholder of an industry for: Vault Health
12 Early Experience with Subcutaneous Injection of Non-Proprietary Testosterone as an Alternative Approach for Testosterone Replacement
Authors: Alter K , Roadman D , Amarasekera C , Levine L 
Published: April 2022

ABSTRACT

Introduction
Testosterone replacement therapy (TRT) has been demonstrated to benefit men with a diagnosis of hypogonadism. We elected to offer a non-proprietary subcutaneous injection (subQ) using a ½ inch 27g needle for TRT as an alternative treatment for hypogonadism.

Objective
To investigate the effect of subQ TRT in hypogonadal men, in order to compare satisfaction, HCT, and PSA levels to other forms of TRT.

Methods
The study period was defined as the most recent follow-up appointment after beginning subQ TRT with a mean follow-up of 4.2 months (range 1-6 months). Variables were obtained prior to beginning subQ TRT and at last follow-up visit. Patients either began subQ TRT primarily or switched from another method. Additionally, patients completed a satisfaction survey. Statistical analysis was performed with SPSS 24. Associations between testosterone levels and clinical variables were analyzed by a univariate analysis.

Results
32 total patients received subQ TRT. Pre and post-subQ TRT testosterone levels (increased 299.7 +/- 61.5), HCT levels (increased 0.8 +/- 1.0%), PSA levels (increased 0.87 +/- 0.3 ng/mL), AUASS (decreased 3.7 +/- 1.7), and SHIM scores (increased 2.1 +/- 2.4) were recorded (Table 1). 21 patients received other forms of TRT prior to beginning subQ TRT and variables were collected and analyzed (Table 2). Overall, 21 patients completed the follow-up satisfaction survey. 19 (90.5%) were satisfied with subQ TRT and 2 (9.5%) patients attributed their dissatisfaction to greater symptom improvement on previous therapies (Testopel, Jatenzo). 11 (84.6%) patients reported better or same satisfaction on subQ TRT than with prior therapy. Furthermore, 8 (88.9%) patients said subQ TRT was easier to use than prior TRT injection (Intramuscular and Testopel), while 1 (11.1%) patient preferred fewer treatments with Testopel. Lastly, all patients reported subQ TRT as less painful during administration.

Conclusions
SubQ TRT led to higher testosterone levels, positive satisfaction scores, and improved AUASS and SHIM scores at most recent follow-up. There was also no significant change to HCT or PSA levels. Ongoing monitoring focusing on longer duration of follow-up, erythrocytosis, satisfaction, and side effects are being conducted and will be reported.

Disclosure
No
29 Temporal Effects of Clomiphene Citrate on Testosterone and Semen Parameters
Authors: Jiang T , Sigalos J , Santamaria A , Modiri N , Zheng M , Osadchiy V , Jayadevan R , Islam M , Mills J , Eleswarapu S 
Published: April 2022

ABSTRACT

Introduction
In men with secondary hypogonadism or impaired sperm concentrations, clomiphene citrate (CC) is often prescribed off-label to improve testosterone levels and fertility parameters. Prior studies have largely focused on outcomes in the short term (∼3 months). Longer-term efficacy of CC use is less clear, particularly if and when improvement may reach a plateau.

Objective
We sought to determine the magnitude of improvement in total testosterone and sperm concentration in men taking CC for fertility optimization 3, 6, 9, and 12-month interval follow-up.

Methods
With IRB approval, we retrospectively evaluated men presenting to an academic andrology clinic for fertility evaluation who were prescribed CC from January 2016 through May 2021. We identified men with 3, 6, 9, and 12-month follow-up data for total testosterone (TT) and 3, 6, and 9-month follow-up semen analyses. Mean absolute change in TT and sperm concentration are reported, along with 95% confidence intervals. Men with previous genitourinary procedures or hormone therapy were excluded. Paired t-tests were used to compare change in TT and sperm concentration at each time point to baseline, and statistical significance was set at p&lt;0.05.

Results
CC (25 mg qd or 50 mg qod) was prescribed to 235 men seeking fertility optimization during the 5-year period. Mean age was 37.7 (SD 6.7, range 24-52). Of these 235, data for TT at 3, 6, 9, and 12 months were available for 25 men, and semen analyses at 3, 6, and 9 months were available for 26 men. Baseline TT at time of prescription was 358±145 ng/dL, and baseline sperm concentration was 13±17.2 M/mL. In the subset of 25 men with long-term follow-up data, a statistically significant improvement in TT was identified at 3 months (+62.7 ng/dL, 95% CI: 0.49-125.0 ng/dL, p=0.048), and additional benefit was seen at 6 months (+181.8 ng/dL, 95% CI: 114.1-249.5 ng/dL, p&lt;0.01) followed by plateau at 9 and 12 months (Figure A). Improvement in sperm concentration was first noted at 9 months of treatment with CC (+20.7 M/mL, 95% CI: 10.2-31.2 M/mL, p&lt;0.01) (Figure B). At no point were there improvements of semen volume and % motility at any follow-up.

Conclusions
In men prescribed CC for fertility optimization, we observed a maximal improvement in TT at 6 months, followed by plateau. Sperm concentrations showed a statistically significant improvement at 9 months. Our results suggest that longer duration of CC therapy may be needed to fully appreciate a benefit from CC treatment. Our study is limited by retrospective analysis, absence of controls, and small sample size. Work is under way to examine long-term follow-up data of CC in men seeking treatment for hypogonadism rather than optimization of fertility.

Disclosure
Any of the authors act as a consultant, employee or shareholder of an industry for: JNM: Antares Pharma, Boston Scientific, and Endo Pharmaceuticals
32 Testosterone Replacement Therapy (TRT) is not Associated with a Higher Risk of DVT: Retrospective Analysis of US Claims Data
Authors: Hernandez-Vegas E , Hotaling J , Son L , Horns J , Paudel N , Gross K , Pastuszak A , Patel D 
Published: April 2022

ABSTRACT

Introduction
As the prevalence of male hypogonadism (HG) has increased, more patients are prescribed TRT. TRT may be associated with an increased risk of deep venous thrombosis (DVT). Although in recent years there have been more studies dedicated to adverse effects of TRT, the literature is mixed on whether TRT increases the risk of DVT.

Objective
This study evaluates the risk of developing DVT in men with hypogonadism based on which types of treatments trends they receive using the MarketScan insurance claims database.

Methods
We performed a retrospective analysis of the IBM MarketScan™ Commercial Claims and Encounters database between 2008-2017. We identified all men with an HG diagnosis using the International Classification of Disease 9th edition (ICD-9) or 10th edition (ICD-10). We recorded how often they received TRT (including formulations as oral, topical/transdermal gels/creams/patches, intranasal, injections, and pellet implants). We followed men to see how many were diagnosed with DVT or pulmonary embolism. We excluded men who had a record of thromboembolic events before their first HG diagnosis. We performed univariate tests of variation across different demographics in three separate stratifications: 1) In all patients stratified by whether they suffered DVT; 2) In patients with DVT stratified by whether they received any kind of treatment at any time; 3) In patients with DVT and any treatment stratified by the type of treatment. Hazard Ratios from Cox Models were calculated for the effects of TRT in the previous 6 months on DVT controlling for the following confounding variables: age and comorbidities such as smoking, drug abuse, obesity, heart disease, cardiovascular problems and surgery/immobilization. Age and TRT in the previous 6 months were included as time-varying covariates.

Results
We identified 1,853,889 total men with HG, of which 21,414 (1.16%) were diagnosed with DVT. Among men who suffered DVT, 7,487 (34.96%) received TRT at some point compared to 605,534 (33.04%) of the men who did not suffer DVT. Results from time-varying Cox models suggest that receipt of TRT in the previous 6 months does not significantly increase the risk of developing a DVT (hazard ratio (HR) 1.049; 95% CI: 0.85, 1.29) among men with HG.

Conclusions
Our study suggests that TRT is not associated with a higher risk of developing DVT. DVT has evidence that the association was more pronounced among patients of later middle age and with chronic disease, whether with or without TRT. Further investigation is warranted to assess the risk effect of TRT on DVT development, which may allow for a more proactive approach in management.

Disclosure
No
60 Improved Peyronie's Disease Curvature Outcomes Using a More Aggressive Collagenase Technique
Authors: Tyler A , Green B , Savage J , Brearton K , Burgon H , Trost L 
Published: April 2022

ABSTRACT

Introduction
Since the FDA approval of Collagenase Clostridium Histolyticum (CCH) for the treatment of Peyronie's Disease (PD), several investigators have reported outcomes of CCH, with improvements ranging from approximately 15-30%. More recently, we reported improved results (49% mean improvement) when CCH was combined with RestoreX penile traction therapy (RxPTT). Since then, we have made additional modifications to create a more aggressive injection / traction protocol to further optimize outcomes.

Objective
To report outcomes of a more aggressive CCH injection / traction protocol in men with PD.

Methods
A prospective database has been maintained of all individuals undergoing CCH injections since 2014. Our CCH injection protocol has evolved from the one described in the IMPRESS trials to a more aggressive use of injections and manual and mechanical traction. Currently, the protocol consists of injecting 0.9 mg of CCH in 0.7 ml of saline into approximately 15-20 sites around the point of maximal curvature (pharmacologically-induced erection performed with the first injection of each series). Injections are only performed on subsequent days (not 2-3 days apart), and very aggressive (i.e. 10-15 lbs of force) modeling is performed with the 2nd injection. Patients are counseled to begin RestoreX traction at 24-48 hours after the 2nd injection for 30-60 minutes daily, and to continue aggressive manual modeling for at least the first week post injection. Penile wraps are applied for 5 days post injection. A descriptive analysis was subsequently performed to review outcomes.

Results
A total of 320 men underwent at least 1 series of CCH and had baseline and follow-up curve assessment data available. Mean age was 55.8 (SD 10.4), with a mean PD duration of 27.8 months (SD 53) and a median baseline composite curvature of 64 degrees (IQR 45-80). Curvature improvements (most recent minus baseline) improved over time, correlating with increased injection experience and implementation of more aggressive traction protocols: 2014-2020 (20 degrees, 29% improvement) vs 2020-mid 2021 (27.8 degrees, 50%, p&lt;0.001). When men were stratified by those who either completed 8 injections or indicated that they were satisfied with outcomes (n=147), median results were more pronounced: 2014-2017 (29% improvement), 2018 (38%), 2019 (47%), 2020-mid 2021 (59%), p&lt;0.01.

Conclusions
Progressive implementation of a more aggressive CCH injection protocol has resulted in improved curvature outcomes. Given the specialized nature of technique modifications described, these results would argue for a center-of-excellence model for CCH administration to achieve optimal outcomes.

Disclosure
No
75 Peyronie's Disease: Identification of Patients Requiring Additional Therapy
Authors: Parikh N , Ahmed M , Jimbo M , Bole R , Britton C , Helo S , Kohler T , Ziegelmann M 
Published: April 2022

ABSTRACT

Introduction
Peyronie's disease (PD) is a connective tissue disorder of the penile tunica albuginea, that can often cause penile deformity, pain, sexual dysfunction, and shortening. Therapies available include penile traction, oral medications, intralesional therapy, and surgical management. Many patients undergo multiple therapies for this disease due to poor satisfaction or lack of subjective improvement.

Objective
We thus sought out to delineate which patients were more likely to undergo a second therapy.

Methods
A cohort of 385 men who underwent therapy for Peyronie's disease from 2014-2018 were analyzed. A univariate analysis of patient demographics, subjective complaints, IIEF score parameters, primary treatments, and secondary treatment approaches was conducted.

Results
Of the 385 men identified, 29 patients ultimately decided to undergo a secondary treatment approach with 14 patients undergoing penile traction therapy, 7 intralesional therapy (Xiaflex) and 9 surgical therapy (5 penile plication, 2 insertion of inflatable penile prosthesis, and 2 grafting). 17 patients initially underwent surgery for PD with 23.53% of these patients undergoing a second line therapy (p&lt;0.0469). 148 patients initially underwent Xiaflex injections with 12.16% of these patients undergoing a second line therapy (p&lt;0.0227). Patients with poor orgasmic function as determined by IIEF questionnaire (median scores 8 vs 2, p&lt;0.0420), men with greater objective curvature (median curvature 45 vs 35, p&lt;0.0220), and men with greater stretched penile length (13.5 cm vs 12 cm, p=0.0284) were also more likely to undergo secondary therapy. Table 1 shows all factors associated with increased likelihood for secondary therapy.

Conclusions
Peyronie's disease is often a complex condition to treat due to the mental, emotional, and physical toll this disease takes on patients. It is helpful to determine which patients could likely require secondary therapy as this may help guide patient counseling and further management.

Disclosure
No
82 Utility of Ceramide Testing in Men with Erectile Dysfunction
Authors: Alom M , Yang D , Collins S , Ziegelmann M , Helo S , Kopecky S , Kohler T 
Published: April 2022

ABSTRACT

Introduction
Erectile dysfunction (ED) is a known precursor and sequelae to diagnosed cardiovascular disease (CVD). ED AUA guidelines recommend evaluating standard CV risk factors including serum lipids and penile doppler to help stratify CV risk, but few patients are referred for further evaluation. Plasma ceramides are metabolic byproducts that are novel predictors of adverse cardiovascular events resulting from unstable atherosclerotic plaque. CVD risk conferred by ceramide levels has been shown to be independent of conventional risk factors such as LDL and hsCRP levels. Thus, Plasma MI-Heart Ceramide is a new test that useful for evaluating shorter term major adverse cardiovascular events (MACE) in the next 1 to 5 years.

Objective
We sought to evaluate the utility of ceramide levels in ED patients

Methods
We initiated ceramide testing in all patients with ED in late 2019 (in addition to lipids and Hgba1c). We queried our electronic medical record for ceramide levels and men with a diagnosis of ED. Ceramide levels stratified patients in normal, moderate, high, and very high risk. Twenty eight patients additionally had penile duplex ultrasound (DUS). Left and right peak systolic velocity values were averaged and a value of &lt;25 cm/s was defined as penile arterial insufficiency.

Results
245 men with ED and ceramide levels were analyzed. 44% (n=107) were normal, 42% (n=103) were moderate risk, 12% (n=29) were high risk and 2% (n=6) were very high risk. As result of their ceramide and office evaluation, 42% (15/35) of high/very high risk patients were referred for cardiac evaluation. Comparing ceramide scores in men with penile arterial insufficiency (16.7 cm/sec) vs patients without (43.2 cm/sec), we found no significant difference (p=1). Similarly, when comparing DUS results between ceramide risk categories, we found no significant differences (p=1).

Conclusions
One in 7 men presenting to an ED clinic had a high or very high ceramide risk. DUS results did not correlate with ceramide risk. Patients undergoing DUS (even without arterial insufficiency) may benefit from additional ceramide testing and possible cardiac referral. Further study is warranted to optimize utility of ceramide in men with ED and potentially decrease peri-procedural IPP cardiac morbidity.

Disclosure
No