Peter J. Stahl

Impact of Surgeon Case Volume on Reoperation Rates after Inflatable Penile Prosthesis Surgery

Purpose: We investigated the impact of surgeon annual case volume on reoperation rates after inflatable penile prosthesis surgery. Materials and Methods: The New York Statewide Planning and Research Cooperative System database was queried for inflatable penile prosthesis cases from 1995 to 2014. Multivariate proportional hazards regression was performed to estimate the impact of surgeon annual case volume on inflatable penile prosthesis reoperation rates. We stratified our analysis by indication for reoperation to determine if surgeon volume had a similar effect on infectious and noninfectious complications. Results: A total of 14,969 men underwent inflatable penile prosthesis insertion. Median followup was 95.1 months (range 0.5 to 226.7) from the time of implant. The rates of overall reoperation, reoperation for infection and reoperation for noninfectious complications were 6.4%, 2.5% and 3.9%, respectively. Implants placed by lower volume implanters were more likely to require reoperation for infection but not for noninfectious complications. Multivariable analysis demonstrated that compared with patients treated by surgeons in the highest quartile of annual case volume (more than 31 cases per year), patients treated by surgeons in the lowest (0 to 2 cases per year), second (3 to 7 cases per year) and third (8 to 31 cases per year) annual case volume quartiles were 2.5 (p <0.001), 2.4 (p <0.001) and 2.1 (p=0.01) times more likely to require reoperation for inflatable penile prosthesis infection, respectively. Conclusions: Patients treated by higher volume implanters are less likely to require reoperation after inflatable penile prosthesis insertion than those treated by lower volume surgeons. This trend appears to be driven by associations between surgeon volume and the risk of prosthesis infection.

Clinical care pathways in andrology

Clinical care pathways in andrology / , Clinical care pathways in andrology / , کتابخانه دیجیتال جندی شاپور اهواز

Variation in Penile Hemodynamics by Anatomic Location of Cavernosal Artery Imaging in Penile Duplex Doppler Ultrasound

INTRODUCTIONnStandard operating procedures (SOP) for penile duplex Doppler ultrasound (PDDU) were published in 2013 to promote uniform vascular assessment for erectile dysfunction (ED). However, SOPs do not specify a standard anatomic location for cavernosal artery (CA) imaging.nnnAIMnThe aim of this study was to determine the effects of CA imaging location on measured penile hemodynamics assessed by PDDU.nnnMETHODSnPDDU was performed in men with ED and/or Peyronies disease. CA peak systolic velocity (PSV) and end diastolic velocity (EDV) were measured at three points: the origin of the CA within the penile crus, the proximal CA, and mid-CA. Differences in PSV and EDV were assessed by Friedman test and categorical vascular outcomes by Fishers exact test. Data were analyzed for the main cohort, the subgroup with maximal smooth muscle relaxation (SMR) as defined by negative EDV, and the subgroup with valid-for-intromission erections.nnnMAIN OUTCOME MEASURESnMean PSV and EDV at three specified CA locations and the vascular diagnoses resulting from these measurements.nnnRESULTSnOne hundred four CAs were imaged in 52 men. Mean PSVs at the crus, proximal, and mid-CA were 52.9u2009±u200920.2, 29.5u2009±u200915.1, and 21.6u2009±u200910.6u2009cm/s, respectively (Pu2009<u20090.0001); mean EDVs were 2.1u2009±u20098.9, 3.2u2009±u20095.4, and 3.3u2009±u20093.5u2009cm/s, respectively (Pu2009=u20090.1225). The distribution of arteriogenic (Pu2009<u20090.0001) and venogenic (Pu2009<u20090.0001) diagnoses both differed significantly by location. Significant differences in vasculogenic diagnoses were also observed in the subgroup of CAs with definite maximal SMR (nu2009=u200938, arteriogenic Pu2009<u20090.0001, venogenic Pu2009=u20090.007) and in those with valid-for-intromission erections (nu2009=u200968, arteriogenic Pu2009<u20090.0001, venogenic Pu2009=u20090.0002).nnnCONCLUSIONnThere is large variability in measured PSV and EDV on PDDU depending on the site of Doppler imaging, which can often sway clinical diagnosis. Future guidelines should attempt to incorporate standard locations of CA imaging, and new normative values may be necessary for each location.

Hypogonadism and Infertility

Male factor infertility is found in approximately 50 % of couples presenting for infertility evaluation in the United States. Hypogonadism (HG), or symptomatic low serum testosterone (T), is frequently associated with oligospermia and azoospermia. Patients presenting for infertility evaluation require a thorough evaluation as multiple etiologies with varying treatment paradigms exist.

A contemporary analysis of dual inflatable penile prosthesis and artificial urinary sphincters outcomes

Purpose: Inflatable penile prostheses and artificial urinary sphincters are used to treat men with erectile dysfunction and stress urinary incontinence, respectively. After prostate cancer treatment men often experience erectile dysfunction and stress urinary incontinence. Dual prosthetic implantation can improve the quality of life of these men. We evaluated reoperation outcomes in men who underwent dual implantation compared to each device implanted individually. Materials and Methods: We queried the SPARCS (New York State Department of Health Statewide Planning and Research Cooperative) database for men who underwent inflatable penile prosthesis and/or artificial urinary sphincter insertion between 2000 and 2014. The primary outcomes were the inflatable penile prosthesis and artificial urinary sphincter reoperation rates (revision, replacement or removal). Multivariable regression analysis was performed to assess the association of dual implantation with reoperation. Adjusted time to event analysis was also performed. Results: Median followup in the inflatable penile prosthesis cohort was 66 months (IQR 25–118) and in the artificial urinary sphincter cohort it was 69 months (IQR 27–121). Compared with men who received a penile prosthesis alone those with a penile prosthesis and an artificial urinary sphincter had a higher likelihood of undergoing inflatable penile prosthesis reoperation at 1 year (OR 2.08, 95% CI 1.32–3.27, p <0.01) and 3 years (OR 2.60, 95% CI 1.69–3.99, p <0.01). Compared with an artificial urinary sphincter alone patients with an inflatable penile prosthesis and an artificial urinary sphincter did not have a higher likelihood of undergoing artificial urinary sphincter reoperation at 1 year (p = 0.76) or 3 years (p = 0.73). Conclusions: Combined inflatable penile prosthesis and artificial urinary sphincter insertion portends a higher likelihood of inflatable penile prosthesis reoperation at 1 and 3 years. However, artificial urinary sphincter outcomes remain comparable. These findings should be used to better counsel patients about the risk of reoperation when undergoing dual implantation.

Trends in Penile Prosthetics: Influence of Patient Demographics, Surgeon Volume, and Hospital Volume on Type of Penile Prosthesis Inserted in New York State

INTRODUCTIONnPenile prostheses (PPs) are a discrete, well-tolerated treatment option for men with medical refractory erectile dysfunction. Despite the increasing prevalence of erectile dysfunction, multiple series evaluating inpatient data have found a decrease in the frequency of PP surgery during the past decade.nnnAIMSnTo investigate trends in PP surgery and factors affecting the choice of different PPs in New York State.nnnMETHODSnThis study used the New York State Department of Health Statewide Planning and Research Cooperative (SPARCS) data cohort that includes longitudinal information on hospital discharges, ambulatory surgery, emergency department visits, and outpatient services. Patients older than 18 years who underwent inflatable or non-inflatable PP insertion from 2000 to 2014 were included in the study.nnnOUTCOMESnInfluence of patient demographics, surgeon volume, and hospital volume on type of PP inserted.nnnRESULTSnSince 2000, 14,114 patients received PP surgery in New York State; 12,352 PPs (88%) were inflatable and 1,762 (12%) were non-inflatable, with facility-level variation from 0% to 100%. There was an increasing trend in the number of annual procedures performed, with rates of non-inflatable PP insertion decreasing annually (P < .01). More procedures were performed in the ambulatory setting over time (P < .01). Important predictors of device choice were insurance type, year of insertion, hospital and surgeon volume, and the presence of comorbidities.nnnCLINICAL IMPLICATIONSnMajor influences in choice of PP inserted include racial and socioeconomic factors and surgeon and hospital surgical volume.nnnSTRENGTHS AND LIMITATIONSnUse of the SPARCS database, which captures inpatient and outpatient services, allows for more accurate insight into trends in contrast to inpatient sampling alone. However, SPARCS is limited to patients within New York State and the results might not be generalizable to men in other states. Also, patient preference was not accounted for in these analyses, which can play a role in PP selection.nnnCONCLUSIONSnDuring the past 14 years, there has been an increasing trend in inflatable PP surgery for the management of erectile dysfunction. Most procedures are performed in the ambulatory setting and not previously captured by prior studies using inpatient data. Kashanian JA, Golan R, Sun T, etxa0al. Trends in Penile Prosthetics: Influence of Patient Demographics, Surgeon Volume, and Hospital Volume on Type of Penile Prosthesis Inserted in New York State. J Sex Med 2018;15:245-250.

Penile Length: Measurement Technique and Applications

INTRODUCTIONnPenile size has long been an important fixation in mens lives. On the one hand, a smaller penis has been associated with anxiety and apprehension; on the other hand, a larger penis has generally been related to virility and strength. These perceptions predominate during an erection, when penile size is representative of a mans masculinity.nnnAIMnTo assess adult penile length and summarize average penile length assessments from the literature; analyze how various urologic diseases and therapies affect penile length and volume; and review how surgical treatments for Peyronies disease, penile prosthesis implantation, and radical prostatectomy can affect penile size to appropriately counsel patients seeking such therapies and set realistic goals for patients.nnnMETHODSnTo achieve the aim of this review, we analyzed the literature on penile size and volume and how these can be affected by various urologic diagnoses and therapies. We summarize common diagnoses and therapies that can affect penile size.nnnMAIN OUTCOME MEASUREnWe thoroughly discuss how the aforementioned diagnoses and therapies can negatively affect penile size. In doing so, we allow readers to understand the intricacies of penile size when faced with such diagnoses and therapies in their patients.nnnRESULTSnSurgical treatments for Peyronies disease, penile prosthesis implantation for refractory erectile dysfunction, and radical prostatectomy for prostate cancer can lead to a decrease in penile size.nnnCONCLUSIONnUrologists must recognize that the different therapies they offer can affect a mans penile size, often negatively. This in turn can lead to poorer satisfaction outcomes in patients. Davoudzadeh EP, Davoudzadeh NP, Margolin E, etxa0al. Penile Length: Measurement Technique and Applications. Sex Med Rev 2018;6:261-271.

Risk Factors for Priapism Readmission

INTRODUCTIONnPriapism is a urologic emergency with a tendency to recur in some patients. The frequency of, time to, and risk factors for priapism recurrence have not been well characterized.nnnAIMnTo identify predictors of priapism readmission.nnnMETHODSnWe used the New York Statewide Planning and Research Cooperative System database to identify patients presenting to emergency departments with priapism from 2005 through 2014. Patients were tracked up to 12 months after initial presentation. Proportional hazards regression was used to identify risk factors for priapism readmission.nnnMAIN OUTCOME MEASURESnReadmissions for priapism.nnnRESULTSnThe analytic cohort included 3,372 men with a diagnosis of priapism. The average age at first presentation was 39 ± 18 years and 40% were black. Within 1 year, 24% of patients were readmitted for recurrent priapism, 68% of whom were readmitted within 60 days. On multivariate analysis, sickle cell disease (hazard ratio [HR]xa0= 2.5, 95% CIxa0= 2.0-3.0), drug abuse or psychiatric disease (HRxa0= 1.9, 95% CIxa0=xa01.6-2.2), erectile dysfunction history (HRxa0= 1.9, 95% CIxa0= 1.5-2.3), other than commercial medical insurance (HRxa0= 1.2, 95% CIxa0= 1.0-1.4), and inpatient admission for initial priapism event (HRxa0= 0.5, 95% CIxa0= 0.4-0.6) were significant risk factors for readmission.nnnCONCLUSIONnNearly one fourth of patients with priapism were readmitted for recurrent priapism within 1 year of initial presentation. Most readmissions were within 60 days. Future research should focus on strategies to decrease recurrences in high-risk patients.

Penile Length: Natural History, Preservation, and Recovery

Penile size has historically been an important preoccupation for adult men. Penile size has been associated with virility and strength for millennia; conversely, the perception of small size has long been a source of apprehension and anxiety. Penile size, especially during erection, is a symbol of masculinity and of great importance for some men. In this chapter, we discuss how to accurately measure adult penile length and illustrate average penile length from various previous studies in the literature. This chapter also explores the effects that various urological diseases and therapies have on penile length, namely erectile dysfunction, Peyronie’s disease, and radical prostatectomy. We finally discuss strategies for penile size preservation in addition to penile lengthening procedures.

Anejaculation, Retrograde Ejaculation, and Anorgasmia

Antegrade transit of sperm through the male genital ductal system and ultimately out the urethral meatus is among the most basic and essential biological processes for male reproduction. Neither natural conception nor assisted reproduction is possible unless sperm-containing semen can be delivered into the female reproductive tract or to the embryology laboratory. Anorgasmia, retrograde ejaculation, and anejaculation constitute the disorders in which there is failure of antegrade semen transit. In this chapter the physiology of the male sexual response cycle leading to orgasm and ejaculation is reviewed and used as a framework for understanding disorders of orgasm and ejaculation. Practical clinical approaches to the diagnosis and treatment of anorgasmia, retrograde ejaculation, and anejaculation are provided.