Testosterone deficiency in men with end stage renal disease and kidney transplantation: a narrative review.

Testosterone deficiency is a prevalent condition that frequently affects individuals with end-stage renal disease (ESRD) and those who have undergone renal transplantation. While the etiology of this condition is complex, its implications in this population are far-reaching, impacting various domains such as endocrine profile, sexual and erectile function, bone mineral density (BMD), anemia, and graft survival following renal transplantation. Herein, we review the most recent literature exploring the pathophysiology of testosterone deficiency in ESRD and renal transplant patients, examining its diverse effects on this demographic, and assessing the advantages of testosterone replacement therapy (TRT). Existing evidence suggests that TRT is a safe intervention in ESRD and renal transplant patients, demonstrating improvements across multiple domains. Despite valuable insights from numerous studies, a critical need persists for larger, high-quality prospective studies to comprehensively grasp the nuances of TRT, especially in this vulnerable population. Proactive screening and treatment of testosterone deficiency may prove beneficial, emphasizing the urgency for further research in this area.

Providing a post-vasectomy semen analysis cup at the time of vasectomy rather than post-operatively improves compliance.

Background: Post-vasectomy semen analysis (PVSA) completion rates after vasectomy are poor, and minimizing the need for an additional in-person visit may improve compliance. We hypothesized that providing PVSA specimen cup at time of vasectomy instead of at a postoperative appointment might be associated with higher PVSA completion rates. Methods: We performed a retrospective cohort study with historical control using medical records of all patients seen by a single provider for vasectomy consultation between October 2016 and June 2022. All patients who underwent vasectomy were included. Patients who underwent vasectomy prior to 05/01/2020 had PVSA specimen cup given at postoperative appointment two weeks following vasectomy, and those who underwent vasectomy after 05/01/2020 were given PVSA specimen cup at time of vasectomy. PVSA completion, demographic, and clinical outcomes data were collected. Logistic regressions were used to investigate associations between PVSA completion rates and timing of PVSA specimen cup provision. Results: There were no significant differences among study cohorts across all patient demographics analyzed, including age, body mass index (BMI), age of primary partner, presence of children, and history of prior genitourinary infection. A total of 491 patients were seen for vasectomy consultation between October 2016 and June 2022; among these patients, 370 underwent vasectomy. Of these, 173 (46.8%) patients underwent vasectomy prior to 05/01/2020 and were given PVSA specimen cup at postoperative visit; 197 (53.2%) patients underwent vasectomy after 05/01/2020 and were given PVSA specimen cup at vasectomy. Providing PVSA specimen cup at time of vasectomy was associated with higher odds of PVSA completion than providing PVSA specimen cup at postoperative visit [62.4% vs. 49.7%; odds ratio (OR) =1.68; 95% confidence interval (CI): 1.11, 2.55]. Adjusting for all identified confounders excludes 35 (9.5%) patients without a primary partner and shows no statistically significant association in cup timing [adjusted OR (aOR) =1.53; 95% CI: 0.98, 2.39]. Adjusting for all identified confounders except age of primary partner revealed timing of specimen cup provision at time of vasectomy was associated with higher odds of PVSA completion (aOR =1.64; 95% CI: 1.08, 2.52). Conclusions: PVSA specimen cup provision at time of vasectomy versus at postoperative appointment is associated with higher rates of PVSA completion in this retrospective cohort study.

Optimal timing of surgical intervention for penile fracture: a narrative review of the modern literature.

INTRODUCTION: Penile fracture is traditionally considered a surgical emergency warranting immediate repair with the goal to maximize long-term erectile function and minimize penile curvature. Nonetheless, consensus on the optimal timing for penile fracture repair remains to be elucidated and is the subject of continued research efforts. OBJECTIVES: This review aims to summarize the contemporary literature pertaining to optimal timing of penile fracture repair and associated outcomes. METHODS: We queried PubMed/MEDLINE and Google Scholar for relevant articles published between 2012 and 2022 to evaluate the most recent literature on the queried topic of early vs delayed intervention for penile fracture. All examined review articles were published within the last decade but may have included analyses of studies published prior to 2012. Reference lists of articles and reviews were manually reviewed to identify additional relevant articles. RESULTS: We identified 16 articles that met inclusion criteria: 12 primary articles and 4 systematic reviews or meta-analyses. Importantly, definitions of early and delayed intervention varied greatly among studies, making quantitative comparison challenging. In summary, 6 primary studies and 2 systematic review articles favored early intervention. There were also 6 primary studies and 2 systematic review articles suggesting equivocal outcomes between early and delayed repair. No articles demonstrated improved outcomes with delayed repair relative to early intervention. CONCLUSION: Surgical intervention for penile fracture remains the gold standard, with superior long-term sexual and functional outcomes when compared with conservative management. Optimal timing of penile fracture repair remains to be elucidated with data limited by low incidence, resulting in small case series and a lack of randomized controlled trials. Nonetheless, recent data suggest that a brief delay in surgical intervention for patients presenting with penile fractures does not affect long-term sexual and functional outcomes.

No Detectable Association Between Virtual Setting for Vasectomy Consultation and Vasectomy Completion Rate.

INTRODUCTION: The COVID-19 pandemic has fueled widespread incorporation of telehealth into urology practices. Vasectomy consultation via telehealth is convenient and improves access to care for male contraception. However, it does not allow for physical examination, inherently leading to possible day-of-procedure cancellations due to unforeseen anatomic concerns. This study aimed to compare vasectomy completion rates between patients undergoing virtual vs in-person consultation. METHODS: All patients seen by a single provider at NYU Langone Health for vasectomy consultation between October 2016 and June 2022 were included in the study. Most patients seen before March 2020 had in-person consultations, whereas the majority of patients seen afterwards had virtual consultations without option for in-person visit due to the emergence of COVID-19. All patients seen virtually were examined in a consult room prior to being prepped for the vasectomy in the procedure room. Visit type, demographic information, and clinical outcomes data were collected for all patients. A chi-square test was used to compare the rate of vasectomy completion between those with in-person and virtual consultation. Analysis was performed using R, version 4.0.5. RESULTS: Four hundred ninety-one patients were seen by a single provider for vasectomy consultation between October 2016 and June 2022. One hundred ninety-seven (40.1%) consultations were performed virtually and 294 (59.9%) consultations were performed in person. Three hundred seventy (75.4%) of all patients seen for consultation (both virtual and in person) ultimately underwent vasectomy. There was no evidence of difference in rate of completing vasectomy after virtual (75.6%) and in-person (75.2%) consultation (P = .91). Two of the 197 (1%) patients who consulted virtually had their vasectomy procedures cancelled on the day of the procedure based on their preoperative exam; one because of abnormal epididymal sensitivity after prior scrotal infection, the other because of a history of orchiopexy that the patient was not aware of until the surgeon started inquiring about scrotal scars present. CONCLUSIONS: Despite the lack of physical examination, virtual vasectomy consultation is both feasible and effective, with rates of vasectomy completion comparable to traditional in-person consultation.

ChatGPT's Ability to Assess Quality and Readability of Online Medical Information: Evidence From a Cross-Sectional Study.

Introduction Artificial Intelligence (AI) platforms have gained widespread attention for their distinct ability to generate automated responses to various prompts. However, its role in assessing the quality and readability of a provided text remains unclear. Thus, the purpose of this study is to evaluate the proficiency of the conversational generative pre-trained transformer (ChatGPT) in utilizing the DISCERN tool to evaluate the quality of online content regarding shock wave therapy for erectile dysfunction. Methods Websites were generated using a Google search of "shock wave therapy for erectile dysfunction" with location filters disabled. Readability was analyzed using Readable software (Readable.com, Horsham, United Kingdom). Quality was assessed independently by three reviewers using the DISCERN tool. The same plain text files collected were inputted into ChatGPT to determine whether they produced comparable metrics for readability and quality. Results The study results revealed a notable disparity between ChatGPT's readability assessment and that obtained from a reliable tool, Readable.com (p<0.05). This indicates a lack of alignment between ChatGPT's algorithm and that of established tools, such as Readable.com. Similarly, the DISCERN score generated by ChatGPT differed significantly from the scores generated manually by human evaluators (p<0.05), suggesting that ChatGPT may not be capable of accurately identifying poor-quality information sources regarding shock wave therapy as a treatment for erectile dysfunction. Conclusion ChatGPT's evaluation of the quality and readability of online text regarding shockwave therapy for erectile dysfunction differs from that of human raters and trusted tools. Therefore, ChatGPT's current capabilities were not sufficient for reliably assessing the quality and readability of textual content. Further research is needed to elucidate the role of AI in the objective evaluation of online medical content in other fields. Continued development in AI and incorporation of tools such as DISCERN into AI software may enhance the way patients navigate the web in search of high-quality medical content in the future.

The Revolving Door of Residency: Predictors of Residency Attrition for Urology Matriculants Between 2001 and 2016.

OBJECTIVE: To add to the literature which has reported higher attrition rates amongst General Surgery residents who identify as female or underrepresented in medicine (URM), we aimed to determine how these factors contribute to attrition within Urology. We hypothesized that women and URM Urology residents will similarly have higher attrition rates. METHODS: The Association of American Medical Colleges surveyed residents to obtain matriculation and attrition status from 2001 to 2016. Data included demographics, medical school type, and specialty. A multivariable logistic regression model was performed to identify predictors of attrition amongst Urology residents. RESULTS: In our sample of 4321 Urology residents, 22.5% were female, 9.9% were URM, 25.8% were older than 30 years, 2.5% were Doctor of Osteopathic Medicine graduates and 4.7% were International Medical Graduates. On multivariable analysis, being female (Odds ratio [OR] = 2.3, P < .001) was associated with increased residency attrition when compared to male residents. Additionally, residents who matriculated between 30 and 39 years old (OR = 1.9, P < .001) or ≥40 years old (OR = 10.7, P < .001) had an increased risk of residency attrition when compared to residents who matriculated between 26 and 29 years old. Attrition rates for URM trainees have recently increased. CONCLUSION: Women, older, and URM Urology residents experience higher rates of attrition compared to their peers. It is essential to identify trainees with a higher likelihood of attrition to determine system-level changes to combat departures from training programs. Our study highlights the need to foster more inclusive training environments and change institutional cultures to diversify the surgical workforce.

Native kidney small renal masses in patients with kidney transplants: Does chronic immunosuppression affect tumor biology?

INTRODUCTION: We compared clinicopathological characteristics and outcomes of radical nephrectomy (RN) for small renal masses (SRM) in patients with end-stage renal disease (ESRD) before or after transplant at a high-volume urologic and transplant center. METHODS: We performed a retrospective review of patients with ESRD (glomerular filtration rate [GFR] <15 mL/min) who underwent RN for suspected malignant SRM from 2000-2018. Group 1 consisted of patients who underwent RN after transplant; group 2 underwent RN prior to transplant, and group 3 underwent RN without subsequent transplant. Dominant tumor size and histopathological characteristics, recurrence, and survival outcomes were compared between groups. Chi-squared and Mann-Whitney U tests were used to compare categorical and continuous baseline and histopathologic characteristics, respectively. Univariate analysis and log rank test were used to compare RCC recurrence rates. RESULTS: We identified 34 nephrectomies in group 1, 27 nephrectomies in group 2, and 70 nephrectomies in group 3. Median time from transplant to SRM radiological diagnosis in group 1 was 87 months, and three months from diagnosis to nephrectomy for all groups. There were no statistically significant differences between pathological dominant mass size, histological subtype breakdown, grade, or stage between the groups. Rates of benign histology were similar between the groups. Univariate analysis did not reveal a statistically significant difference in recurrence-free survival between the groups (p=0.9). CONCLUSIONS: Patients undergoing nephrectomy before or after transplant for SRM have similar indolent clinicopathological characteristics and low recurrence rates. Our results suggest that chronic immunosuppression does not adversely affect SRM biology.

Tobacco Screening and Treatment during Outpatient Urology Office Visits in the United States.

PURPOSE: Tobacco use is a causative or exacerbating risk factor for benign and malignant urological disease. However, it is not well known how often urologists screen for tobacco use and provide tobacco cessation treatment at the population level. We sought to evaluate how often urologists see patients for tobacco-related diagnoses in the outpatient setting and how often these visits include tobacco use screening and treatment. MATERIALS AND METHODS: We used the National Ambulatory Medical Care Survey public use files for the years 2014-2016 to identify all outpatient urology visits with adults 18 years old or older. Clinic visit reasons were categorized according to diagnoses associated with the encounter: all urological diagnoses, a tobacco-related urological condition or a urological cancer. Our primary outcome was the percentage of visits during which tobacco screening was reported. Secondary outcomes included reported delivery of cessation counseling and provision of cessation pharmacotherapy. RESULTS: We identified 4,625 unique urological outpatient encounters, representing a population-weighted estimate of 63.9 million visits over 3 years. Approximately a third of all urology visits were for a tobacco-related urological diagnosis and 15% were for urological cancers. An estimated 1.1 million visits over 3 years were with patients who identified as current tobacco users. Of all visits, 70% included tobacco screening. However, only 7% of visits with current smokers included counseling and only 3% of patients were prescribed medications. No differences in screening and treatment were observed between visit types. CONCLUSIONS: Urologists regularly see patients for tobacco-related conditions and frequently, although not universally, screen patients for tobacco. However, urologists rarely offer counseling or cessation treatment. These findings may represent missed opportunities to decrease the morbidity associated with tobacco use.

100% N4-acetyl-sulfamethoxazole stone induced by Trimethoprim-Sulfamethoxazole in an HIV patient being treated for toxoplasmosis.

Trimethoprim-Sulfamethoxazole is a common antibiotic used to treat urinary tract infections, as well as a prophylactic agent in HIV patients with low CD4 counts. Exceedingly rare are stones consisting purely of its metabolite, N4-acetyl-sulfamethoxazole, and management strategies are not well documented in the literature. We present a case of a patient with HIV who was found to have obstructing ureteral calculi composed of 100% N4-acetyl-sulfamethoxazole. Our report contributes a unique case of a Bactrim-induced stone in an immunocompromised patient. Similar patients can be prophylactically treated with diuresis and urinary alkalinization, as well as consideration for alternative medication use.

Bilateral Open Ureteroceles with Concomitant Bladder Calculi in an Adult Male.

Background: Bilateral ureteroceles in adult males are a rare occurrence, made even more so with simultaneous presence of bladder calculi. Management strategies for such patients are not well documented in the literature. We present a rare case of bilateral open ureteroceles with large concomitant bladder calculi to contribute to the paucity of literature on management of such patients. Case Presentation: We present the case of a 35-year-old man whose gross hematuria work-up demonstrated right-sided hydroureteronephrosis in the setting of bilateral ureteroceles and multiple large bladder calculi up to 3.8 cm. Conclusion: Bilateral orthotopic single-system ureteroceles in an adult male are a rare finding especially when intraoperatively found to be open secondary to traumatic effects of large calculi. Ultrasonic and pneumatic lithotripsy is a safe, appropriate, and effective option for bilateral ureteroceles contributing to a large bladder stone burden. Our report contributes to the growing body of literature on orthotopic bilateral single-system ureteroceles in the adult population with concomitant significant stone burden.

Variations in Perioperative Antibiotic Prescriptions Among Academic Urologists After Ambulatory Endoscopic Urologic Surgery: Impact on Infection Rates and Validation of 2019 Best Practice Statement.

OBJECTIVE: To evaluate adherence to the American Urologic Association (AUA) best practice statement guidelines regarding antibiotic duration in the perioperative setting for endoscopic urologic surgery. We assessed concordance to these guidelines among adult urologists at a single academic institution and its correlation with postoperative positive urine cultures as it relates to the revised 2019 best practice statement. METHODS: We performed a retrospective review of all adult endoscopic ambulatory urologic surgeries performed over an 18-month period by urologists at our institution. Patient demographics, pre- and postoperative urine cultures, operative details, stent or foley use, and antibiotic prescriptions were reviewed. Chi-squared and linear regression analyses were done. RESULTS: Three hundred thirty patients were included for analysis. Sixty-two percent of patients were prescribed postoperative antibiotics, for an average of 4 days. Trimethoprim/Sulfamethoxazole and fluroquinolones were most often prescribed (43% and 38%, respectively). Intraoperative stent placement, positive urine culture within 30 days prior to surgery, and a positive urine culture within 1 year prior to surgery predicted antibiotic prescription. No significant differences were seen in rates of positive postoperative urine culture rates between cohorts that received antibiotics postoperatively vs those who did not. CONCLUSIONS: At our academic institution, we observed poor concordance with the AUA best practice statement for perioperative antibiotic prescription after ambulatory endoscopic urologic surgery. Rates of positive postoperative cultures were low and not associated with receipt or duration of antibiotic prescription at the time of surgery, supporting minimal use of antibiotics for most endoscopic cases.

Does total testicular volume predict testicular volume difference in adolescent males with varicocele?

ABSTRACT Introduction: We evaluated the relationship between total testicular volume (TTV) and testicular volume differential (TVD) in adolescent males with varicocele. Both low TTV and high TVD have been independently associated with higher incidences of infertility later in life, but a predictive relationship between TTV and TVD directly has yet to be described. Materials and Methods: We retrospectively analyzed a database of Tanner 5 boys ages 16-21 who presented with varicocele at a single institution between 2009 and 2017. All patients had a scrotal sonogram prior to surgical intervention. TTV and TVD were calculated for each individual and four non-exclusive groupings of patients were created for statistical analysis. We chose 30 cc as a cut off value for low TTV based on prior studies. Results: 209 patients met our inclusion criteria. Mean age was 18.3 years (16-21, SD 1.7) with a mean total testicular volume of 36 cc (13.5-78.2, SD 11.1). Cut off points of TVD of 20% and TTV of 30 cc were used to separate patients. There were 65 boys (31%) with TTV < 30 cc and 58 boys (28%) with TVD ≥ 20%. Among males with TTV < 30 cc, 23 (35%) had a TVD ≥ 20%. Among males with TTV ≥ 30 cc, 35 (24%) had a TVD ≥ 20%. The relationship between TVD and TTV was found to be non-significant (p > 0.05). Discussion: Adolescent varicoceles continue to pose a challenge to pediatric urologists. The dilemma of over-aggressive treatment has proven difficult to balance with the risk of infertility. We hoped that elucidating the relationship between TTV and TVD could be useful in identifying patients who are at greater risk for infertility while decreasing the need for more intrusive testing, such as semen analysis, in an adolescent population. We looked at the direct relationship between low TTV and high TVD. In our population, there was a non-significant relationship between TTV < 30 cc and TVD ≥ 20% (p > 0.05) indicating that in adolescents with varicocele, TTV and TVD are independent variables. Our study limitations include the inherent user dependent bias of ultrasound measurements and data collection at a single institution with high ethnic diversity, possibly not comparable to all patient populations. Conclusions: Low TTV (< 30 cc) itself is not predictive of high TVD (≥ 20%) in adolescent boys with varicocele, despite their reported independent associations with impaired fertility in other studies.

A comparison of perinephric fat surface area and Mayo Adhesive Probability score in predicting malignancy in T1 renal masses.

INTRODUCTION: Recent studies have proposed that nearby fat deposits may have metabolic influence on kidney cancer pathobiology. Both fat quantity and quality may play unique roles in this complex relationship. As such, we investigated whether perinephric fat surface area (PFA), a quantitative measure of fat, or Mayo Adhesive Probability (MAP) score, a qualitative measure, were predictive of malignant pathology or Fuhrman grade in small renal masses. METHODS: A total of 317 patients undergoing minimally invasive partial nephrectomy between 2010 and 2016 for renal masses were retrospectively reviewed. Preoperative abdominal CT and MRI scans were measured for PFA and MAP scores. Multiple binary logistic regression models were created to identify predictive factors of malignant disease and Fuhrman grade. RESULTS: A total of 253 patients had malignant masses, while 64 had benign masses. A total of 189 of the malignant masses were T1a, while 64 were designated T1b. A total of 221 patients with malignant masses had reported Fuhrman grades. Of these 211 patients, 143 (64.7%) had low-grade and 78 (35.3%) had high-grade disease. Mean PFA was 18.0 ± 13.3 cm2, while mean MAP score was 2.6 ± 1.2. Binary logistic regression analysis yielded three variables in the best-fit model for predictors of malignant pathology: MAP score (OR = 1.374, 95% CI: 1.007-1.873, P = 0.045), male sex (OR = 2.058, 95% CI: 1.004-4.218, P = 0.049), and BMI (OR = 1.064, 95% CI: 0.998-1.135, P = 0.059). Neither MAP nor PFA was predictive of Fuhrman grade. CONCLUSIONS: MAP score, a measure of perinephric fat quality, but not PFA, a qualitative measure of fat quantity, was predictive of malignant pathology, raising the question whether fat quality rather than quantity may be involved in the pathophysiology of RCC in a large and diverse patient population. Understanding the increasing burden of obesity, further studies are needed to elaborate on these findings and to discern the exact relationship between perinephric fat deposits and renal tumorigenesis.

Does total testicular volume predict testicular volume difference in adolescent males with varicocele?

INTRODUCTION: We evaluated the relationship between total testicular volume (TTV) and testicular volume differential (TVD) in adolescent males with varicocele. Both low TTV and high TVD have been independently associated with higher incidences of infertility later in life, but a predictive relationship between TTV and TVD directly has yet to be described. MATERIALS AND METHODS: We retrospectively analyzed a database of Tanner 5 boys ages 16-21 who presented with varicocele at a single institution between 2009 and 2017. All patients had a scrotal sonogram prior to surgical intervention. TTV and TVD were calculated for each individual and four non-exclusive groupings of patients were created for statistical analysis. We chose 30 cc as a cut off value for low TTV based on prior studies. RESULTS: 209 patients met our inclusion criteria. Mean age was 18.3 years (16-21, SD 1.7) with a mean total testicular volume of 36 cc (13.5-78.2, SD 11.1). Cut off points of TVD of 20% and TTV of 30 cc were used to separate patients. There were 65 boys (31%) with TTV < 30 cc and 58 boys (28%) with TVD ≥ 20%. Among males with TTV < 30 cc, 23 (35%) had a TVD ≥ 20%. Among males with TTV ≥ 30 cc, 35 (24%) had a TVD ≥ 20%. The relationship between TVD and TTV was found to be non-significant (p > 0.05). DISCUSSION: Adolescent varicoceles continue to pose a challenge to pediatric urologists. The dilemma of over-aggressive treatment has proven difficult to balance with the risk of infertility. We hoped that elucidating the relationship between TTV and TVD could be useful in identifying patients who are at greater risk for infertility while decreasing the need for more intrusive testing, such as semen analysis, in an adolescent population. We looked at the direct relationship between low TTV and high TVD. In our population, there was a non-significant relationship between TTV < 30 cc and TVD ≥ 20% (p > 0.05) indicating that in adolescents with varicocele, TTV and TVD are independent variables. Our study limitations include the inherent user dependent bias of ultrasound measurements and data collection at a single institution with high ethnic diversity, possibly not comparable to all patient populations. CONCLUSIONS: Low TTV (< 30 cc) itself is not predictive of high TVD (≥ 20%) in adolescent boys with varicocele, despite their reported independent associations with impaired fertility in other studies.

Diagnosis and management of non-calcium-containing stones in the pediatric population.

Compared to adults, urolithiasis is less common in children, with a definite rise in incidence, especially among young adults (Tasian et al. in Clin J Am Soc Nephrol 11:488, 2016). In the last 25 years, the incidence in children has increased by approximately 6-10% annually, for reasons still unknown, with an associated significant increase in related health care-related expenditures (Hyams and Matlaga in Transl Androl Urol 3(3):278-83, 2014). It has been shown that there is twice as high a risk of chronic kidney disease (CKD) or end stage renal disease (ESRD) in stone formers compared to non-stone formers (Tasian et al. 2016). While calcium-containing stones are by far the most common category of stone encountered in both children and adults, non-calcium stones are more common in children than adults and have been shown in several studies to be associated with greater morbidity and lower renal function than calcium stones (Issler et al. in BMC Nephrol 18(1):136, 2017; Gambaro et al. in J Urol 198:268-273, 2017). This could be related to the challenges in the management of non-calcium-containing stones due to associated infection or metabolic derangements, further leading to recurrence and loss of renal function. There is currently a gap in our understanding of how to appropriately and effectively encounter and manage patients with non-calcium-containing stones, as such cases are encountered less frequently. Identification of stone composition and appropriate management is very important to reduce serious complications and recurrence, especially in non-calcium stones. We present a review of diagnosis and management of non-calcium-containing stones in the pediatric population, in hopes of providing more clarity to providers and promoting a consideration of non-calcium stone composition with all children presenting with urolithiasis.