Outcomes of a Standardized Pain Pathway for Transgender Patients Undergoing Vaginoplasty and Vulvoplasty.

OBJECTIVE: To establish and evaluate a multimodal, opioid-minimizing pathway for gender-affirming vaginoplasty (GAVa) and vulvoplasty (GAVu) in treating postoperative pain. METHODS: A standardized pain pathway including opioids, non-opioid analgesics, and patient counseling was implemented at a single academic institution with a center for transgender care. Postoperative pain levels, analgesia methods, and opioid use for 84 GAVa and 64 GAVu patients were prospectively gathered during inpatient postoperative days 2-4 and outpatient follow-up at 2 weeks. Pertinent patient, operative, and medication administration data were extracted from patient charts and outpatient pain was measured with the Brief Pain Inventory short form (BPI-sf). RESULTS: On average, GAVa patients used 89.3 MME and GAVu patients used 41.8 MME during inpatient stay. MME decreased daily for both groups. There was no difference in MME between open and robotic GAVa. Forty-nine percent of GAVa patients and 54% of GAVu patients used ketorolac with decreasing daily inpatient use. Postoperative pain levels were similar between GAVa and GAVu patients. Fifty percent of respondents denied postoperative pain in the 24 hours preceding the survey. Forty-four percent of GAVa and of GAVu patients did not use any opioid medications in the outpatient setting, while 81% of GAVa and 83% of GAVu patients used fewer than 20 of 30 prescribed opioid tablets. Ibuprofen and acetaminophen were rated the most effective outpatient analgesics among GAVa and GAVu patients, respectively. CONCLUSION: The multimodal pathway demonstrated effective postoperative pain control for GAVa and GAVu patients while minimizing opioid use and has changed institutional prescribing practice.

Interest In and Prior Receipt of Counseling on Fertility Preservation in Transgender Patients Presenting for Gender-affirming Orchiectomy.

OBJECTIVE: To describe the characteristics of patients presenting for gender-affirming bilateral simple orchiectomy including interest in and prior education on reproductive options prior to gonad removal. METHODS: A retrospective chart review evaluated patients seeking gender-affirming bilateral orchiectomy. Data collected included age, family history, history of fertility preservation education prior to gender-affirming hormone therapy initiation, prior fertility preservation, interest in fertility preservation, and postorchiectomy surgical pathology results where applicable. RESULTS: The cohort included 78 patients. 22% (n = 17) indicated reproductive options were not discussed prior to surgical consultation. 85% (n = 66) were not interested in fertility preservation. Reasons included not having an interest in biological children (74%), not wanting to delay transition (47%), and cost (36%). Patients who were married or in long-term relationships had a higher interest in fertility preservation compared to patients who were not in long-term relationships. 40% of patients with pathology data available had at least some level of spermatogenesis present in their testicular tissue. CONCLUSION: Fertility preservation counseling prior to surgical referral was lower than expected. This lack of counseling could result in patients not wanting to sperm bank prior to orchiectomy as it could delay their surgical care. Increased adherence to the WPATH guidelines may improve fertility preservation interest. Our data shows a low utilization and interest in sperm preservation for transwomen and nonbinary patients seeking bilateral simple orchiectomy at our institution. Improving counseling regarding fertility preservation options earlier in transition could improve utilization of sperm cryopreservation.

Minimizing opioids after gender affirming orchiectomy - a multimodal pain pathway.

INTRODUCTION: To evaluate the effectiveness of a standardized multimodal pain pathway for gender affirming orchiectomy (GAO) in adequately addressing postoperative pain while reducing the prescribing of unnecessary opioids. MATERIALS AND METHODS: A standardized discharge pain pathway for GAO +/- scrotectomy or testicular implants was implemented between May 2020 and March 2022. A retrospective analysis was performed on all consecutive patients who underwent GAO with a single surgeon. Patients answered five questions on postoperative pain management at their 3 week follow up. RESULTS: A total of 69 patients were included in the study. Mean age was 34.3 years (SD ± 10.5; IQR 26-39) with a mean body mass index (BMI) of 27.1 (SD ± 7.5; IQR 22.3-31). No patients were taking narcotics preoperatively. Mean 4.7 tablets (SD ± 4.5; range 0-30) oxycodone tablets taken by GAO patients without concurrent procedures, with 33 patients (47.8%) taking fewer than 4 tablets. Thirteen patients (18.8%) required no narcotics. Four patients (5.8%) requested an additional narcotic prescription, none of whom underwent a concurrent procedure. There was no significant association between BMI and the number of oxycodone tablets taken. All patients used at least one recommended alternative therapy (acetaminophen, ibuprofen and ice packs) with 41 patients (59.4%) using all three. CONCLUSION: Most patients achieved adequate postoperative pain control as requests for additional narcotic prescriptions were low. Almost half of patients used < 4 tablets, and all patients employed at least one alternative non-narcotic analgesic. Based on these findings, we plan to decrease the quantity of opioids on discharge.

Addressing Burnout in Urology: A Qualitative Assessment of Interventions.

INTRODUCTION: We characterized physician burnout among urologists to determine the prevalence and efficacy of specific burnout interventions utilized and to determine involvement of workplaces in effective burnout interventions. METHODS: The Western Section of the American Urological Association created an electronic, 29 question workforce survey. Several questions focused on assessing the level of urologist burnout, prevalence of work sponsored burnout interventions and efficacy of specific interventions. RESULTS: A total of 440 responses were received (25.9% response rate); 82.2% of responders were male. The majority of urologists noted some level of burnout (79.5%) with no significant difference between those who reported no burnout vs some level of burnout (p=0.30). The most commonly tried interventions to reduce burnout were participating in regular physical exercise (76.6%), reading nonmedical literature (67.1%) and decreasing or modifying work hours (52.3%). The interventions most frequently cited as "very effective" were hiring a scribe (62.5%), regular exercise (56.1%) and participating in 1-on-1 gatherings with colleagues outside of work (44.6%). There were no significant differences noted when comparing "very effective" interventions by gender. The interventions most frequently cited as not effective were stress or burnout seminars (26.9%) and meditation/mindfulness training (11.5%); 42.5% reported workplace interventions to help prevent or reduce burnout. CONCLUSIONS: Certain practice-changing and personal burnout interventions were noted to be "very effective" in decreasing burnout. Fewer than half of responders noted workplace sponsorship of interventions. Organizational support may lead to increased participation and effectiveness of burnout interventions.

Post-Surgical Complications After Bladder Outlet Reducing Surgery: An Analysis of The FDA Manufacturer and User Facility Device Experience (MAUDE) Database.

OBJECTIVE: To examine voluntary reports in the Food & Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database, categorize complications and assign device-related causality with transurethral resection of the prostate (TURP), prostatic urethral lift (PUL), and transurethral water vapor therapy (TWVT). METHODS: A review was performed using the terms "Urolift," "Rezum," and "transurethral resection of the prostate" between 01/01/2015 and 12/31/2019. Duplicate and incomplete reports were excluded. The Gupta system was used to report complications and device related causality.1 Pearson's Chi-square analysis was performed to compare minor (Level 1) versus major (Levels 2-4) complications. RESULTS: A total of 548 events were examined. After removal of duplicates (n = 60), irrelevant reports (n=65), and incomplete information (n = 14), we included 409 events (74.6%). Of the 409 events, 214 were for TURP, 112 for TWVT, and 83 for PUL. In aggregate, 39.4% of events were minor/Level 1 (n=161/409). The proportion of subjects with Level 2-4 complications versus Level 1 complications was significantly higher for PUL than TURP or TWVT [X2 (2, N = 408) = 41.4023, P < .00001]. Device causality was attributable to device malfunction in 60.4% of cases (n=247/409). CONCLUSION: Device malfunction was noted in all groups and 39.4% of these were minor (Level 1). However, the majority of PUL reports noted a Level 3 or 4 complication (50.6%, 42/83), primarily bleeding related. Previous studies have not revealed significant risk of bleeding and suggests a discrepancy between study data and real-world experience that may alter patient counseling practices.

National patterns of injury and outcomes of gunshot wounds to the penis: A Trauma Quality Programs retrospective cohort analysis.

AIM: Gunshot wounds (GSW) to the penis represent a rare type of traumatic injury in the civilian United States population. Although small, single-center studies have reported results of care for these types of injured patients, no national analyses have examined this group. METHODS: A cohort of patients with GSW to the penis was identified using the 2017 American College of Surgeons Trauma Quality Programs database, a comprehensive national database of 753 accredited trauma centers. RESULTS: Gunshot wounds to the penis occurred in 722 patients, which represents 1.7% of all GSW patients (n = 41,017). Gunshot wounds from altercations with law enforcement or accidental discharge of a firearm were rare; the vast majority (n = 655, 90.7%) occurred as a result of assault, intentional self-harm, attempted suicide, or attempted homicide. Patients with a major concomitant non-genitourinary injury comprised 119 (16.5%) patients of the cohort. Most patients (n = 499, 69.1%) underwent a genitourinary procedure during their trauma admission. Penile salvage was successful in most cases, with only 13 (1.8%) patients requiring completion penectomy. Most patients (87.8%) required admission with a median length of stay of 49.8 h. Most patients were treated at the initial trauma center without requiring transfer to another center, and complications during admission were rare. CONCLUSIONS: This analysis, the first national examination of care of patients with GSW to the penis, reveals overall favorable outcomes. Admission and surgical intervention were required in most patients, but penectomy was rare and length of stay was generally short. These results will guide resource utilization and quality improvement efforts in this patient cohort.

Sustained Glycemic Control Observed in Diabetic Men Who Improve Hemoglobin A1c Values to Allow for Elective Penile Prosthesis Placement.

OBJECTIVES: We hypothesize that men with diabetes mellitus whose inflatable penile prosthesis (IPP) implantation is delayed for unacceptably high hemoglobin A1c (HbA1c) will have durable improvements in their glycemic control after achieving acceptable HbA1c levels for surgery. METHODS: Per institutional protocol, an A1c <9% must be documented prior to IPP placement. After IRB approval, a single surgeon IPP database was retrospectively queried for data specific to diabetes mellitus management. Men without HbA1c values at ≥1-year follow-up were excluded. Univariate and multivariate statistical analyses were performed to assess associations with sustained HbA1c control. RESULTS: From January 2011 to March 2019, 138 diabetics undergoing IPP were identified. Thirty-seven were excluding for insufficient follow-up. Nineteen of the 101 analyzed men (18.8%) were delayed a median 4 months (range 2-17) for elevated HbA1c values (median 10.1, range 9.1-12.3). Following improvements, median preoperative HbA1c remained higher (8.2% vs 7.0%) in delayed men (P < .001). Among delayed recipients, 11 (58%) improved without medication changes while insulin was newly initiated (5) or dosage was increased (5) in 42%. At 32 months follow-up, a HbA1c <9% was similarly maintained in delayed and nondelayed men (74% vs 87%, P = .17). Delayed men more commonly required insulin therapy at follow-up (89.5% vs 54.9%, P = .008), but had a similar median change in BMI (+0.1 vs +0.1, P = .65). Device infection occurred in 1 nondelayed patient (0.7%). CONCLUSION: Men who improve HbA1c for IPP surgery are likely to demonstrate persistent improvement. IPP implantation appears to be safe in diabetic men with HbA1c <9%.

Hip Joint Pathology Among Men Referred to Urology for Chronic Orchialgia: A Source for Misdiagnosis and Opportunity for Quality Improvement.

OBJECTIVE: To evaluate the findings of magnetic resonance imaging (MRI) of the ipsilateral hip(s) as part of the workup of men with chronic orchialgia (CO). METHODS: Following IRB approval, a retrospective chart review was performed from a single surgeon database of all men with a diagnosis of CO from June 2018 to October 2019 who underwent subsequent hip MRI evaluation. RESULTS: Ten men were identified. Median age was 51 years and median duration of pain was 10 months. MRI was obtained after testis pathology was ruled out. Pain was noted in the groin (100%) and hip (50%). Hip MRI identified overt labral tears in 8 men (10/12 hips evaluated, 83%) and labral fraying in the remaining 2 (16.7%). Standard plain film radiography was performed in 6 men prior to MRI, all of which were negative. Following MRI, 5 men underwent hip injection with steroid and local analgesic with lasting resolution (2 men) or significant improvement in pain (2 men; 80%, follow-up 3-15 months). Two men had complete resolution of pain with 8 weeks of physical therapy. CONCLUSION: Hip MRI has a high rate of diagnosis of labral tear in appropriately selected men referred to the urologist for CO. Identification of orthopedic pathology may avoid unnecessary antibiotics, opiates, or urological surgery. Referrals to orthopedics and/or physical therapy for intervention may lead to resolution of pain.

A Quality Analysis of the Last Decade's Most Heavily Cited Data Relative to Outcomes After Penile Prosthesis Placement.

BACKGROUND: The penile prosthesis has been used for men with erectile dysfunction for nearly 5 decades. Although many articles examine various outcome measures, wide variability exists in the quality of these studies. AIM: We sought to critically evaluate the most referenced literature related to penile prosthesis outcomes over the last 10 years. METHODS: A PubMed search of the indexed English literature was performed using the search terms "prospective," "penile prosthesis," and "outcomes", and all relevant publications from 2009 to 2019 were reviewed. In addition, we performed a Google Scholar search for the same interval using the search term "penile prosthesis outcomes" to evaluate manuscripts which have been most commonly cited. The most heavily cited manuscripts were sorted for relevancy using Google's internal algorithm, and then, the articles were reviewed by the authorship team for appropriateness of the subject matter. Articles with less than 10 citations were excluded. We used the Oxford Center for Evidence-Based Medicine Criteria as part of our evaluation of the published data involving independent research, as opposed to review articles summarizing previously published findings. RESULTS: We evaluated the most-cited literature of the past decade relevant to penile prosthesis outcomes and reported the major findings in regards to infection, erosion, extrusion, device reliability, and satisfaction (both the patient and partner). The majority of these studies are retrospective in nature. CLINICAL IMPLICATIONS: From our review of the most commonly cited studies, there was no high-level evidence published in this area within the last 10 years. There are multiple barriers to producing these types of studies in the evaluation of penile prosthesis outcomes. STRENGTHS & LIMITATIONS: Using the most commonly cited articles allows us to understand the data that are being cited in other new publications. Focusing on the most cited articles on penile prosthesis outcomes in the last 10 years is a limitation as there have been many more studies published in this area. CONCLUSION: While many studies have examined penile prosthesis outcomes, most of the heavily cited literature consists of low-level evidence. Higher quality research is necessary to better assess penile prosthesis outcomes. Chouhan JD, Pearlman AM, Kovell RC, et al. A Quality Analysis of the Last Decade's Most Heavily Cited Data Relative to Outcomes After Penile Prosthesis Placement. J Sex Med 2020;17:861-869.

Burnout in the Urology Workforce: Voluntary Survey Results in the United States.

INTRODUCTION: Burnout among urologists is significant with studies estimating approximately 40% meet the criteria for burnout. This study sought to survey practicing urologists to identify factors associated with burnout and its implications. METHODS: A 16-question survey was created on SurveyMonkey.com and distributed to urologists by email via their American Urological Association section. Descriptive statistics and chi-square testing were used for analysis, and logistic regression was used for multivariate analysis to assess factors associated with burnout. RESULTS: There were 466 respondents of whom 460 were actively practicing. In all, 78% of respondents reported burnout with 45% reporting it as either moderate or severe. Respondents were 90% male and 41% fellowship trained. Females tended to report worse burnout with 4 times greater likelihood to report severe burnout on multivariate analysis (p=0.01). There was also a difference in reasons cited for burnout among genders. Females most often cited lack of personal time (51%) while males most often complained about insurance and regulations (62%). Initial analysis did not show a difference based on fellowship. Multivariate analysis revealed a possible protective role of fellowship training with nonfellowship trained urologists twice as likely to report moderate burnout (p=0.017). CONCLUSIONS: A large number of urologists are experiencing burnout. This affects patient interaction and planned time to retirement. Most urologists do not have interventions in place to assess or prevent/change their levels of burnout. Further investigation and intervention aimed at physician wellness need to occur to prevent the worsening of this trend.

Engineering of erectile tissue: the state and future of corporal restoration.

PURPOSE: To provide an overview of the state of tissue engineering relative to male erectile tissue and the implications for treatment of penile pathology. METHODS: A PubMed review of the relevant peer-reviewed literature pertaining to engineering of penile tissues was performed. RESULTS: There are multiple pathologies that threaten form and/or function of the penis. Management of disease rarely offers a path to true restoration. Historical efforts to correct structural defects have largely relied on synthetic materials, commercially prepared allograft or xenograft constructs, or autologous tissue substitutes. These approaches have traditionally suffered from less-than-optimal clinical outcomes and degrees of patient morbidity that may be preventable. Prior work in tissue engineering of corpora cavernosa has demonstrated the ability to produce functional tissue in small and large animal models. A human clinical trial is currently underway. CONCLUSIONS: Varied conditions pathologically affecting the penis warrant development of more sophisticated tissue-based solutions. Animal models have demonstrated efficacy in restoring functional corpora cavernosa, and upcoming clinical trials will serve to determine safety and efficacy in humans.

A User's Guide for Surgery Involving the Artificial Urinary Sphincter.

INTRODUCTION: The artificial urinary sphincter (AUS) has long been regarded as the gold standard for surgical correction of male stress urinary incontinence (SUI). Despite impressive rates of initial success for restoration of continence, durability may wane to the point of considering revision surgery. AIM: To provide a review of existing data as well as personal experience regarding patient selection, surgical technique, and postoperative troubleshooting for the AUS. METHODS: A systematic review of the peer-reviewed literature was performed to identify relevant and contemporary articles regarding perioperative and long-term management of the AUS. Additional input is presented based on clinical experience of the senior author. MAIN OUTCOME MEASURE: The main outcome measures are durability, patient satisfaction, mechanical failure, and urethral erosion. RESULTS: In addition to a thorough history and examination, preoperative screening should include office cystoscopy to rule out bladder neck contracture in patients with a history of radical prostatectomy. Perineal cuff placement appears superior to alternative approaches. Prior radiation and use of the 3.5-cm cuff are risk factors for future erosion. Newer findings suggest that subsequent recurrence of SUI may be due to restrictive encapsulation, rather than true atrophy, with implications for revision surgery. CONCLUSION: The AUS remains an excellent option for surgical correction of moderate to severe male SUI. Detailed preoperative evaluation and patient selection are critical. The challenge of downstream recurrent SUI after AUS can be effectively managed for most patients with a structured approach. Chouhan JD, Terlecki RP. A User's Guide for Surgery Involving the Artificial Urinary Sphincter. Sex Med Rev 2019;7:167-177.

Changes observed in prostate biopsy practices in an inner city hospital with a high risk patient population following the 2012 USPSTF PSA screening recommendations

ABSTRACT Introduction: We compared characteristics of patients undergoing prostate biopsy in a high-risk inner city population before and after the 2012 USPSTF recommendation against PSA based prostate cancer screening to determine its effect on prostate biopsy practices. Materials and Methods: This was a retrospective study including patients who received biopsies after an abnormal PSA measurement from October 2008-December 2015. Patients with previously diagnosed prostate cancer were excluded. Chi-square tests of independence, two sample t-tests, Mann-Whitney U tests, and Fisher's exact tests were performed. Results: There were 202 and 208 patients in the pre-USPSTF and post-USPSTF recommendation cohorts, respectively. The post-USPSTF cohort had higher median PSA (7.8 versus 7.1ng/mL, p=0.05), greater proportion of patients who were black (96.6% versus 90.5%, p=0.01), and greater percentage of biopsy cores positive for disease (58% versus 29.5%, p<0.001). Multivariable analysis supported that the increase in PSA was independent of the increase in the proportion of patients who were black. The proportion of patients who were classified as D'Amico intermediate and high-risk disease increased in the post-USPSTF cohort and approached statistical significance (70.1% versus 58.8%, p=0.12). Conclusions: Our study suggests that the USPSTF recommendations may have led to an increase in pre-biopsy PSA as well as greater volume of disease. Also, a greater proportion of patients were being classified with intermediate or high risk disease. While the clinical significance of these findings is unknown, what the data suggests is somewhat troubling. Future research should further examine these changes in a larger cohort as well as resultant long-term outcomes.

Changes observed in prostate biopsy practices in an inner city hospital with a high risk patient population following the 2012 uspstf psa screening recommendations.

INTRODUCTION: We compared characteristics of patients undergoing prostate biopsy in a high-risk inner city population before and after the 2012 USPSTF recommendation against PSA based prostate cancer screening to determine its effect on prostate biopsy practices. MATERIALS AND METHODS: This was a retrospective study including patients who received biopsies after an abnormal PSA measurement from October 2008-December 2015. Patients with previously diagnosed prostate cancer were excluded. Chi-square tests of independence, two sample t-tests, Mann-Whitney U tests, and Fisher's exact tests were performed. RESULTS: There were 202 and 208 patients in the pre-USPSTF and post-USPSTF recommendation cohorts, respectively. The post-USPSTF cohort had higher median PSA (7.8 versus 7.1ng/mL, p=0.05), greater proportion of patients who were black (96.6% versus 90.5%, p=0.01), and greater percentage of biopsy cores positive for disease (58% versus 29.5%, p<0.001). Multivariable analysis supported that the increase in PSA was independent of the increase in the proportion of patients who were black. The proportion of patients who were classified as D'Amico intermediate and high-risk disease increased in the post-USPSTF cohort and approached statistical significance (70.1% versus 58.8%, p=0.12). CONCLUSIONS: Our study suggests that the USPSTF recommendations may have led to na increase in pre-biopsy PSA as well as greater volume of disease. Also, a greater proportion of patients were being classified with intermediate or high risk disease. While the clinical significance of these findings is unknown, what the data suggests is somewhat troubling. Future research should further examine these changes in a larger cohort as well as resultant long-term outcomes.

High Grade Mucinous Urothelial Carcinoma of the Renal Collecting System: A Case Report.

High grade mucinous urothelial carcinoma is a rare pathological variant. There is still controversy as to its nomenclature and classification. We report the case of a 64 year old female with history of pelvic pain who was incidentally discovered to have a left upper pole renal mass. Left nephroureterectomy was performed and histopathological examination revealed high grade mucinous urothelial carcinoma. Accurate diagnosis of this distinct pathological entity will allow for better understanding of phenotypic behavior and inform best treatment strategies.

Ovotestis in Adolescence: 2 Case Reports.

We present 2 patients found to have ovotesticular disorder of sexual development (otDSD) in late adolescence. Two 15-year-old phenotypically male patients presented to a large pediatric hospital with different complaints: 1 with concern for testicular rupture after a straddle injury; 1 with gynecomastia. Further workup, including imaging and laboratory tests, was performed before surgical exploration. The first patient had unilateral ovotestis, contralateral testis, and SRY-negative 46,XX karyotype. The second patient with gynecomastia had unilateral ovotestis with hemi-uterus and fallopian tube, contralateral ovarian tissue, and 46,XX/47,XXY Klinefelter mosaic karyotype. Although rare, phenotypically normal male patients may present later with ovotesticular disorder of sexual development.

Retroperitoneal hemorrhage after ureteroscopy without laser lithotripsy: an extreme example of an underreported event?

Retroperitoneal hemorrhage and an associated hematoma are uncommon but potentially serious complications following ureteroscopy with laser lithotripsy. However, no reports of serious bleeding complications have been published regarding ureteroscopy without laser lithotripsy in the management of stone disease. We report of such a case here and then review the current literature in order to discuss the incidence, risk factors, and management of such events.