Financial and Business Literacy Among Urology Residents: Is this a Problem and How Can We Better Prepare Residents for their Careers?

PURPOSE OF REVIEW: Although financial wellness is a predictor of physician burnout, we are yet to optimize financial education or wellness of Urology trainees. We assessed existing studies, compared them to those of other specialties, and discussed resources and methods to address this deficiency. RECENT FINDINGS: Urology residents tend to be less fiscally savvy (carry significant debt, and lack retirement savings or disability insurance), and 90% of trainees and young Urologists do not feel comfortable with the business of practice, including skills like coding and billing, contract negotiation, and self-value assessment. Financial and business literacy are deficiencies of Urology training, as in other specialties. Eventually, the goal should be universal adoption of a formal curriculum that is graded in nature. In the interim, we need to propose and endorse adoption of a formal curriculum, and we should support trainees by promoting a space for easily accessible and transparent information regarding best practices in personal finance and the business of healthcare.

A case report on the prolonged viability of postmortem human testicular sperm.

Objective: To report a case of postmortem sperm retrieval with prolonged viability and motility. Design: Case report. Setting: Hospital and Medical Examiner Department. Patients: A 44-year-old African American male patient with a history of recreational marijuana use and occasional alcohol consumption who died from a cardiac arrest because of drug overdose. Interventions: Multiple testicular biopsies and sperm analyses. Main Outcome Measures: Sperm viability and motility of testicular biopsies at serial time intervals. Results: Sperm obtained from the testis in the morgue remained viable and motile even at 106 hours (>4 days) postmortem. Conclusions: Our study found that sperm obtained from the testis remained viable and motile even after being thawed after cryopreservation, even when obtained up to 100 hours postmortem. This may have implications on the timeframe that postmortem sperm retrieval can be performed successfully several days after death.

Endourological management of multiple large bladder calculi over eroded mesh in an adult with augmented bladder and catheterisable continent appendicovesicostomy.

Migration of abdominal wall mesh in an augmented bladder is a rarely encountered complication leading to formation of bladder stones causing recurrent urinary tract symptoms. The usual management of this condition involves either open surgical or a percutaneous approach for removal of the stone and migrated portion of mesh. Diagnosis of a migrated mesh is usually made intraoperatively during cystolitholapaxy. Appropriate management results in symptomatic improvement. Endoscopic management through catheterisable continent appendicovesicostomy has not been described to manage this challenging condition. To the best of our knowledge, we describe herewith the first report of endoscopic management of a large bladder stone formed over migrated mesh which involved removal of migrated mesh with holmium laser via a Mitrafanoff.

Prevalence of post-prostatectomy erectile dysfunction and a review of the recommended therapeutic modalities.

Radical prostatectomy (RP) represents one of the most commonly used first-line treatment modalities in men with localized prostate cancer. One of the most feared post-surgical complications is erectile dysfunction (ED), usually caused by direct damage to the cavernous nerves or due to neuropraxia. Penile rehabilitation is an emerging concept that was proposed to stimulate and accelerate recovery of erectile function after RP. The goal is to improve blood flow to the penis, increasing cavernous oxygenation and avoiding fibrosis. The most common used modalities include oral phosphodiesterase type 5 inhibitors (PDE5-I), vacuum erection devices (VEDs), intracorporeal injection (ICI) therapy, medicated urethral system for erections (MUSE), and a combination of these treatments. For those patients with severe ED, ED refractory to medical therapy and/or seeking long term reliable results, the penile prosthesis implant remains an excellent alternative. We conducted a broad review of post-prostatectomy ED prevalence with different techniques and the success rates of the different therapeutic approaches.

Effect of Natesto on Reproductive Hormones, Semen Parameters and Hypogonadal Symptoms: A Single Center, Open Label, Single Arm Trial.

PURPOSE: To evaluate the effect of short-acting 4.5% nasal testosterone gel (Natesto) on serum testosterone, gonadotropins, total motile sperm count, health related quality of life and sexual function. MATERIALS AND METHODS: This was a single institution, open label, single arm trial conducted between November 2017 and September 2019 at the University of Miami. Men 18 to 55 years old diagnosed with symptomatic hypogonadism (total testosterone less than 300 ng/dl on 2 occasions) were included. Men with azoospermia, vasectomy or a total motile sperm count less than 5 million were excluded. Enrolled patients were treated with Natesto, a short-acting nasal testosterone (125 µl per nostril, 11.0 mg testosterone per dose, TID) for 6 months. RESULTS: In total, 60 men were enrolled in the study. Of these, 44 and 33 patients were evaluated for testosterone at 3 and 6 months, respectively. A total of 31 patients (90.9%) reached a normal testosterone level (greater than 300 ng/dl) at 6 months. Follicle stimulating hormone and luteinizing hormone levels were maintained within the normal range in 81.8% and 72.7% of patients at 6 months, respectively. Total motile sperm count was maintained with total motile sperm count greater than 5 million over the treatment period in 88.4% of men at 3 months and 93.9% at 6 months. There were statistically significant improvements on International Index of Erectile Function sexual desire and overall satisfaction domains at 6 months. CONCLUSIONS: Natesto appears to increase testosterone while maintaining semen parameters in a majority of men. Natesto has the potential to be a safe and effective treatment for men with functional hypogonadism who wish to preserve semen parameters. Long-term studies beyond 6 months are needed before we can safely prescribe nasal testosterone gel for men interested in fertility.

Comparison of PESA and MESA techniques for men with obstructive azoospermia.

DESIGN: Video presentation. SETTING: University hospital. PATIENTS: A 53-year-old male presents with a history of a vasectomy performed 7 years prior. His wife is 36 years-old and requests sperm extraction for in-vitro fertilization. On examination, his testicles were 20 cc bilaterally with a serum follicle-stimulating hormone of 5.3. INTERVENTIONS: Percutaneous Epididymal Sperm Aspiration (PESA) and Microscopic Epididymal Sperm Aspiration (MESA). MAIN OUTCOME MEASURES: Intraoperative technique highlighting the main steps for performing PESA and MESA, complications, and sperm retrieval outcomes. RESULTS: This video highlights the technique for performing both PESA and MESA. We demonstrate complications and outcomes associated with both procedures. Both PESA and MESA are viable options for sperm retrieval with varying complications and sperm quality outcomes. CONCLUSIONS: We demonstrate how to perform both PESA and MESA. Both are effective means for obtaining sperm for in-vitro fertilization with differences in technique, equipment required, complications and sperm quality outcomes.

Can serum 17-hydroxyprogesterone and insulin-like factor 3 be used as a marker for evaluation of intratesticular testosterone?

Serum testosterone values vary considerably with little correlation to intratesticular testosterone (ITT). ITT is approximately ~100 times that of serum testosterone and is critical for spermatogenesis. Unfortunately, the only method to accurately measure ITT is invasive testicular aspiration and therefore is not performed routinely. The identification of a serum biomarker for ITT would allow serial monitoring during hormonal manipulation and the ability to assess the effectiveness of a male contraceptive agent. Prior studies have evaluated several serum biomarkers for their ability to accurately reflect ITT with data supporting 17-hydroxyprogesterone (17-OHP) and insulin-like factor 3 (INSL3) as a potential marker. Because evaluation of serum 17-OHP is readily available through commercial laboratories, in this review, we present the evidence for 17-OHP and how it can play a pivotal role in the management of male infertility.

A Surgeon's Guide to the Various Antibiotic Dips Available During Penile Prosthesis Implantation.

PURPOSE OF REVIEW: Inflatable penile prosthesis (IPP) is a treatment for erectile dysfunction. IPPs have undergone improvements; however, post-surgical infections still occur. Furthermore, the type of pathogens infecting the implants has changed recently from Gram-positive to Gram-negative bacteria and fungi due to advances in antibiotic dips targeting the skin flora. To protect against infection, the AMS 700 is pre-coated with InhibiZone (mixture of Rifampin/Minocycline) and the Coloplast Titan, with several antibiotic dip options of differing efficacies. This review discusses strategies to decrease the infection rates in implant surgery, focusing on antibiotic dips. RECENT FINDINGS: Current research endorses the use of rifampin/gentamicin as the most studied combination; however, some studies have utilized different dips for additional coverage including the InhibiZone on the AMS 700. With the increasing prevalence of diabetes and Gram-negative organisms, there is a need to develop strategies for increased coverage against infections. Controlled studies with different antibiotic combinations are needed to identify the ideal cocktail to decrease infection.