Bradley Holland

Minimizing Penile Implant Infection: A Literature Review of Patient and Surgical Factors

Inflatable penile prosthesis (IPP) is an effective treatment for erectile dysfunction in patients’ refractory to oral or injectable treatment. While the rate of infection has decreased over the past decade, it is still the most feared complication of IPP placement. Here, we assemble possible patient and surgical factors attributing to the risk of infection. Studies have been gathered addressing each of these factors, and an Oxford Level of Evidence is assigned to each recommendation based on strength of the study. The goal of this review is to inform surgeons of possible risks in order to further reduce the risk of infection and thus increase success of IPP placement.

3-year treatment outcomes of water vapor thermal therapy (Rezūm System) compared to doxazosin, finasteride and combination drug therapy for men with benign prostatic hyperplasia: cohort data from the Medical Therapy of Prostatic Symptoms (MTOPS) Trial

Purpose: We evaluated the long‐term outcomes of treatment of lower urinary tract symptoms due to benign prostatic hyperplasia to compare a 1‐time water vapor thermal therapy procedure with daily medical therapy in cohorts from the MTOPS (Medical Therapy of Prostatic Symptoms) study. Materials and Methods: Results in the treatment arm of a randomized, controlled trial of thermal therapy using the Rezum® System were compared to MTOPS subjects treated with doxazosin and/or finasteride. Evaluations were restricted to medical therapy subjects, representing 1,140 of the original 3,047 (37.4%), with a prostate volume of 30 to 80 cc and an International Prostate Symptom Score of 13 or greater to include men who met key criteria of the Rezum and MTOPS trials. Outcomes were compared during 3 years for symptom changes and clinical progression rates. Results: Thermal therapy improved symptom scores by approximately 50% throughout 36 months (p <0.0001). Symptom improvement was greater than with either drug alone but similar to that of combination drugs (p ≤0.02 and 0.73, respectively). The peak flow rate improved 4 to 5 ml per second after thermal therapy and doxazosin while thermal therapy was superior to finasteride and combination drugs for 24 and 12 months (p <0.001 and <0.01, respectively). Observed rates of clinical progression during 3 years corroborate these outcomes with approximately 5 times greater progression for any medical therapy vs a single thermal therapy procedure. Conclusions: A single water vapor thermal therapy procedure provided effective and durable improvements in symptom scores with lower observed clinical progression rates compared to daily long‐term use of pharmaceutical agents.

Antibiotics prophylaxis before prostate biopsy in practice: Review of online clinical guidelines.

Sir, The inaugural American Urologic Association (AUA) Quality Improvement Summit on January 25, 2014 introduced the directive to compile a white paper on the incidence, prevention, and treatment of complications related to prostate needle biopsy. We believe this summit brings to the urologic community’s attention the critical fact that published guidelines in antibiotic prophylaxis do not reflect the escalating danger of post prostate needle biopsy infections. The known infectious complication rates range from 0.1% to 7%, depending on the antimicrobial agent used.[1] Even with prophylactic antibiotics, 5% of men will develop asymptomatic bacteriuria and 2–3% will develop symptomatic urinary tract infection.[2] The current AUA best practice policy statement on urologic surgery antimicrobial prophylaxis, last updated in February 2012, recommends fluoroquinolones or 1st through 3rd generation cephalosporins as the prophylactic antimicrobial agents of choice preceding prostate needle biopsy. This recommendation does not account for the fact that the overall risk of post-biopsy infections has risen over the past decade.[2-4] It also does not account for the increasing rate of quinolone resistance, as evidenced by the dramatic 22% of men found to have quinolone-resistant flora on prebiopsy rectal swab.[1] While the origin of this change in microbial sensitivity is likely complex and multifactorial, possibly related to increased, inappropriate, or repeated utilization of antibiotics, the fact remains that our guidelines for prophylaxis need to reflect these factors in order to effectively protect patients receiving prostate needle biopsies.

A Review of the FAERS Data on 5-Alpha Reductase Inhibitors: Implications for Postfinasteride Syndrome

OBJECTIVE To quantify reports made to the Food and Drug Administration Adverse Event Reporting System (FAERS), create a demographic of patient reports, and examine the cluster of symptoms to correlate consistency of postfinasteride syndrome (PFS) complaints. PFS is a provisional diagnosis encompassing a cluster of sexual, physical, and psychological and/or neurologic symptoms associated with 5-alpha reductase inhibitor use that emerge or continue after discontinuation of medication. MATERIALS AND METHODS FAERS dataset of 5-alpha reductase inhibitors from April 2011 to October 2014 was obtained. Each FAERS report had 16 categories for completion, but not every report was fully completed. Statistical analysis compared variables of interest between the 2 doses of finasteride (1 mg vs 5 mg). RESULTS From FAERS, 2048 monotherapy cases were identified: 1581 of finasteride 1 mg, 240 of finasteride 5 mg, and 226 of unreported doses. Possibly related to labeling changes, from 2011 to 2014, there was a significant increase in adverse events (AEs) reported involving 1 mg dosing. Finasteride use was reported with many sexual AEs including diminished libido, erectile dysfunction, and ejaculatory complaints. Other common AEs included dermatologic, metabolic, and psychological and/or neurologic complaints. There were more AE reports with the 1 mg dose than the 5 mg dose. One case of dutasteride reported back pain, not generally attributed to PFS. CONCLUSION FAERS data suggests that finasteride exposure is reported with a diverse collection of symptoms, particularly in younger men on 1 mg dosage compared to older men on 5 mg. Many of these complaints fall well out of the realm of previously established AEs from long-term controlled studies.

Optimizing Research in Surgical Residents and Medical Students

Scientific research is the foundation of technological advancement. How does one kindle the flame of research curiosity in arguably some of our brightest minds? The fact that research is an outright requirement in US medical schools, surgical residencies, and fellowship programs is not enough. Difficulties are rested in finding research opportunities, incorporating them into an already full schedule of classes and clinical rotations, and following the protocols so as not to break any regulations along the way. This chapter hopes to inform the reader how to both effectively encourage research in surgical trainees and construct an effective and productive research program. Establishing a program that allows for direct oversight, coordination, and mentorship in conducting research with fellows, residents, and medical students creates a robust academic environment that is mutually beneficial for trainees, departments, and the advancement for medicine alike.

MP27-20 CONVECTIVE RADIOFREQUENCY WATER VAPOR ENERGY PROSTATE ABLATION (REZUM®) EFFECTIVELY TREATS URINARY RETENTION

INTRODUCTION AND OBJECTIVES: New minimally invasive surgical therapies (MIST) for lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) such as prostatic urethral lift and convective radiofrequency water vapor energy prostate ablation (WaVE) have shown promising intermediate-term results in improving voiding symptoms. However, the initial trials excluded men in urinary retention; thus the ability of these new technologies to achieve catheter independence has not been evaluated. This study investigated outcomes of patients with urinary retention at baseline treated with WaVE. METHODS: Patients in urinary retention who underwent WaVE were retrospectively identified. Urinary retention was defined as dependence on an indwelling catheter or performance of clean intermittent catheterization (CIC) for bladder emptying. Age, duration of catheter dependence, prostate size, baseline IPSS and PVR, and number of treatments per procedure were recorded. For subjects with successful trials without catheter (TWOC), time to catheter independence and post-procedure PVR and IPSS were recorded. Baseline characteristics between subjects with successful TWOC and unsuccessful TWOC were compared using Mann Whitney U test and T-test for continuous variables and Chi-square test and Fisher0s exact test for non-continuous variables. RESULTS: 30 patients were identified with urinary retention who underwent WaVE. 22 subjects had an indwelling catheter, 8 subjects performed clean intermittent catheterization (CIC). Mean age was 76 years. Relevant baseline measures included (mean): duration of catheter dependence (6.9mo), prostate size (64.3 ml), PVR (538 mL), and number of treatments per procedure (6.4). 28/30 subjects had middle lobe treatment (1 treatment per procedure). 23 of 30 subjects (77%) achieved successful TWOC post-procedure. Mean time to catheter independence was 29 days post-procedure with mean post-procedure PVR 84 mL and post-procedure IPSS 9. There were no differences between subjects with or without successful TWOC in age, duration of catheter dependence, prostate size, baseline PVR, baseline IPSS, number of treatments per procedure, or treatment of median lobe. CONCLUSIONS: WaVE can effectively treat patients with urinary retention and successfully render patients catheter independent, including patients with a median lobe. Longer-term follow up is necessary to evaluate the durability of this technology.

The Utilization of Partial Orchiectomy in Treating Small Testicular Tumors in the United States

Introduction and objectives: There is increasing evidence supporting the feasibility of Partial Orchiectomy (PO) as a treatment for small testicular tumors. However, the prevalence of this practice is still unknown. We used the Surveillance, Epidemiology, and End Results (SEER) registry to characterize national practice patterns for surgical management of patients with testicular tumors ≤ 2 cm in size, and we examined factors that determined performing PO in such patients. Materials and methods: 32,211 patients with testicular tumors diagnosed between 1995 and 2011 were extracted for this analysis. The proportions of patients diagnosed with small tumors (≤ 2 cm) and patients treated with PO were determined. Trends were examined using joinpoint analysis and quantified using the Annual Percentage Change (APC). Multivariate survival models were developed to identify independent determinants of PO. Kaplan Meier analysis was used to examine the effect of PO on Cancer Specific Survival (CSS). Results: Of the 5,365 patients with small testicular tumors and identifiable surgical treatment, only 114 patients (2.21%) were treated with PO. The percentage of patients diagnosed with small testicular tumors (on average 18.5% of all testis tumor patients) was stable over the study period (APC -0.47%, 95% CI: -0.3-1.3%, P = 0.2), while the utilization of partial orchiectomy for these tumors remained low and did not increase (APC -11.9%, 95% CI: -16.6 (-6.9)%, P < 0.001). Older age, Black race, and living in areas with lower educational level were independent determinants of lower likelihood of receiving PO (all p values < 0.05). Cancer specific mortality was not worse for patients treated with PO vs. radical orchiectomy (Log-Rank P = 0.8605). Conclusions: While a significant proportion of patients are diagnosed with small testicular tumors, the utilization of PO in treating these patients remains very low. Patient characteristics influenced the chance of treatment with PO. A simple preliminary analysis shows no decrease in CSS with PO vs. RO in patients with testicular masses ≤ 2 cm.

The Effect of Targeted Therapy for Genitourinary Malignancies on Sexual Function and Fertility

Purpose of ReviewTargeted therapy for genitourinary cancer is being used at an increasing rate. These medications show great survival benefit but are relatively lacking in long-term adverse effect data. With increasing survivability, measures to improve quality of life must be considered for GU cancer and a large proponent of this is sexual function.Recent FindingsmTOR inhibitors have shown an effect on testosterone levels and may have a link to abnormal semen parameters. Tyrosine kinase inhibitors (TKIs) have shown no adverse sexual outcomes in the literature. There are laboratory links to tyrosine kinases having a beneficial effect on erectile and sexual function.SummaryPossible sexual side effects must be discussed with patients receiving a diagnosis of cancer. Further research is required to determine the exact mechanisms and outcomes of sexual function with new and emerging targeted therapy.

MP74-06 THE PRIVATES STUDY: PAIN RATES IN VASECTOMY AND TESTING TO ENSURE STERILITY

INTRODUCTION AND OBJECTIVES: Literature on post vasectomy pain rates and complications is disparate. Also, sterility implications of the updated AUA Guidelines on post vasectomy semen analysis is not yet known. METHODS: Four year, single surgeon (TSK) retrospective review of office vasectomies. Surgical and demographic data, semen analyses (SA), and patient post-procedure clinic contacts were assessed. RESULTS: We had 303 subjects with average age 38 years and a mean follow up of 1140 days. 9% of patients called with complaints and scheduled postoperative visits. Complaints included incisional concerns (3%, 9/303), scrotal pain (3%), epididymal fullness (1%) and infection (1%). Two percent of patients required a second visit for post-vasectomy pain (PVP) and one patient (with pre-procedure pain) returned 3 times. Two per cent (5/303) refilled narcotics while 4% were prescribed NSAIDs. No patients had PVP refractory to NSAIDs. Only 62% of men provided any required post-vasectomy SA. A phone call to the office for any reason increased the likelihood that a man would provide the SA (p<0.001). Using the new AUA vasectomy guidelines, 94% would have been cleared after the first sample, 99% after the 2nd sample and 100% after the 3rd sample. CONCLUSIONS: Men undergoing vasectomy can safely be told they are at a very low risk for refractory PVP, the need for narcotic refills, and secondary procedures of any kind. Using the new AUA guidelines, only 6% of men require a second SA to ensure sterility.