The Financial Burden of Applying to Urology Residency in 2020.

OBJECTIVES: To determine contemporary costs of preparing for and applying for a urology residency position for the 2019-2020 American Urological Association Match. METHODS: An electronic survey was emailed to all urology residency applicants who applied to Rutgers Robert Wood Johnson Medical School during the 2019-2020 application cycle; it was sent 2 weeks after the Match results were released. We collected information on applicant demographics, interview logistics, and estimated costs incurred applying to residency. RESULTS: A total of 26% (64/242) of subjects responded, representing all 8 the American Urological Association sections, international schools, and schools without urology programs. 62% were male, 75% were single, and 52% attended public medical school. Applicants paid for the interview trail using loans (67%), family donations (50%), previous or current income (36%), and scholarships (16%). Subjects completed a median of 2 visiting student rotations (IQR 2-3), applied to 80 programs (IQR 66-99), and attended 16 interviews (IQR 13-18.75). The median cost per applicant for the 2019-2020 Match was $9725 (IQR $6134-12,564). This estimate included expenditures on application fees, visiting student rotations, interview trail travel and lodging, research, interview attire, and professional photos. Subjects who attended public medical school were likely to spend $3546.31 (95% confidence interval: 5630.71-1461.916; P < .001) more than those attending private schools. CONCLUSION: Urology residency applicants spend almost $10,000 in pursuit of a residency position. These high costs not only contribute to student debt but also may deter applicants from entering the field of urology.

Beyond Arthritis: Understanding the Influence of Gout on Erectile Function: A Systematic Review.

OBJECTIVE: To review the evidence suggesting a significant association between gout and erectile dysfunction (ED) and evaluate possible underlying pathways that may explain this relationship. METHODS: English medical literature was searched from January 1, 2010, to January 1, 2020, for randomized or quasi-randomized controlled trials, cross-sectional studies, case-cohort studies, or meta-analysis evaluating the relationship between gout and ED. RESULTS: All nine gout studies included in the study found a significant association between gout and ED. ED pathophysiology in gout involves hyperuricemia, increased reactive oxygen species, decreased nitric oxide synthesis, and low-grade inflammation. CONCLUSION: The findings of this review suggest that the effect of urate-lowering therapy on the incidence of ED in gout patients should be studied. Additionally, we propose that all gout patients should be assessed for ED.

Comparing Outcomes of Medical Management and Minimally Invasive Surgical Techniques for Lower Urinary Tract Symptoms due to BPH.

PURPOSE OF REVIEW: Compare outcomes of medical therapy as compared to minimally invasive surgical therapy (MIST) for treatment of bladder outlet obstruction RECENT FINDINGS: Treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) remains largely driven by patient symptomatology with medical therapy or watchful waiting as the first-line management strategies. However, most patients are not adherent to prescribed medical therapies and are hesitant to accept the risks associated with more invasive therapies. Minimally invasive surgical therapies are treatments providing short-term symptom relief superior to medical therapies without the sequela of more invasive procedures. Though there are few direct comparisons, MIST seems to relieve LUTS/BPH symptoms at least as well as medical therapy without the need for daily adherence.

Scrotoplasty at Time of Penile Implant is at High Risk for Dehiscence in Diabetics.

INTRODUCTION: Scrotoplasty has become a common practice during insertion of penile prosthesis, improving patient perception of penile length. Previous reports on scrotoplasty outcomes have only focused on the perceived benefits. The risk of wound complications after scrotoplasty is unknown. AIM: Identify wound complications and associated risk factors of scrotoplasty with insertion of penile prosthesis. METHODS: A retrospective review of a single-surgeon series (T.S.K.) of patients who underwent scrotoplasty with initial insertion of inflatable penile prosthesis (IPP) was performed from 2009-2014. Surgical outcomes and wound complications after scrotoplasty were examined, along with patient information, including basic demographics, medical comorbidities, and perioperative data. MAIN OUTCOME MEASURES: Studied outcomes included rate of wound complications after scrotoplasty and IPP insertion and identification of risk factors for wound dehiscence. RESULTS: Of the 103 scrotoplasties performed during the study period, a total of 15 had mild, moderate, or major wound dehiscence. Of these 15 cases, 9 had mild dehiscence and 5 cases had moderate dehiscence and required stitches to be placed in clinic to reinforce the closure. 1 patient had a major dehiscence requiring a return to the operating room for a washout, with exchange of IPP to malleable prosthesis. Multiple risk factors for wound dehiscence were found, including diabetes (odds ratio 6.1, CI 1.5, 25.0, P = .0129) and scrotoplasty technique (odds ratio 4.9, CI 1.2, 8.6, P = .003). Other examined variables, including patient age, Peyronie's disease, hypertension, intraoperative penile modeling, smoking, and device manufacturer, were not associated with wound dehiscence. CLINICAL IMPLICATIONS: Patients with diabetes and scrotoplasties performed via V-Y plasty are more likely to experience wound dehiscence. STRENGTHS & LIMITATIONS: Strengths include a single surgeon, thus lending continuity of skill and technique, a consecutive series, and 100% short-term follow-up. Limitations include retrospective design, single institution series, and lack of long-term follow-up. CONCLUSION: Although scrotoplasty can improve patient satisfaction with IPP, scrotoplasty can lead to increased patient morbidity. Diabetic patients are at increased risk for wound complication after scrotoplasty. Gupta NK, Sulaver R, Welliver C, et al. Scrotoplasty at Time of Penile Implant is at High Risk for Dehiscence in Diabetics. J Sex Med 2019;16:602-608.

New and Emerging Technologies in Treatment of Lower Urinary Tract Symptoms From Benign Prostatic Hyperplasia.

INTRODUCTION: Lower urinary tract symptoms (LUTS) from bladder outlet obstruction from benign prostatic hyperplasia (BPH) occur in a large percentage of urologic patients. Treatment of this condition with medical and surgical therapy provides symptom relief but has serious adverse effects and causes sexual dysfunction. New technologies to treat BPH-associated LUTS aim to effectively treat urinary symptoms and minimize side effects and sexual dysfunction. AIM: To review the efficacy of new and emerging therapies for treatment of LUTS from BPH. METHODS: A literature search was performed to identify therapies for LUTS from BPH with early outcomes data within the past 5 years. MAIN OUTCOME MEASURES: Improvement in International Prostate Symptom Score (IPSS) and effect on sexual functions such as erectile and ejaculatory functions as measured on the International Index of Erectile Function and the Male Sexual Health Questionnaire. RESULTS: Technologies introduced within the past 5 years include techniques using intraprostatic injectables, mechanical devices, and prostatic tissue ablation. Most technologies remain in the development phase and have only phase I and II studies available that show promising alleviation of urinary symptoms. Injectables have not typically surpassed placebo or sham effects, although special cohorts could be exceptions. Thus far, convective water vapor ablation therapy and prostatic urethral lift have shown the most promise, with short- and medium-term data available on phase III studies demonstrating significant improvement in IPSS with minimal impact on sexual function. Many of these technologies are limited in their potential treatment population by prostate size and conformation, whereas other therapies might be more generalizable. CONCLUSION: Many new technologies aim to treat LUTS from BPH and minimize sexual side effects. Most therapies remain experimental, although prostatic urethral lift and water vapor ablation therapy have been brought to market and show promise. Long-term durability of symptom relief remains to be demonstrated. Gupta NK, Gange SN, McVary KT. New and Emerging Technologies in Treatment of Lower Urinary Tract Symptoms From Benign Prostatic Hyperplasia. Sex Med Rev 2018;7:491-498.

Is Sexual Function Better Preserved After Water Vapor Thermal Therapy or Medical Therapy for Lower Urinary Tract Symptoms due to Benign Prostatic Hyperplasia?

BACKGROUND: Men often experience deterioration of sexual function after the use of α-blockers and 5-α reductase inhibitors for the treatment of lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia. Thus, an alternative treatment with water vapor thermal therapy (Rezum System, Boston Scientific, Marlborough, MA, USA) which is an efficacious minimally invasive surgical treatment that preserves sexual function was examined. AIM: To compare sexual function over 3 years after continuous daily treatment with pharmaceutical agents in the Medical Therapy of Prostatic Symptoms (MTOPS) study vs a single thermal therapy procedure (Rezum study) in subjects with matched criteria for LUTS severity and prostate size. METHODS: We used sexual function data from sexually active cohorts in the MTOPS study (1,209) randomized to doxazosin, finasteride, combination drugs and placebo, and sexually active men who received thermal therapy (86). MTOPS study participants completed the Brief Male Sexual Function Inventory; men in the Rezum trial completed the International Index of Erectile Function and Male Sexual Health Questionnaire. MAIN OUTCOME MEASURE: Estimated mean changes from baseline for sexual function variables were compared using a linear mixed repeated measures model with fixed effects for treatment and follow-up visits. RESULTS: With continued daily drug use, men experienced significant worsening of sexual desire, erectile and ejaculatory function with finasteride and combination drug therapy, and reduced desire and erectile function with doxazosin. Thermal therapy was not associated with significant negative changes in sexual function throughout 3 years after treatment. CLINICAL IMPLICATIONS: Water vapor thermal therapy can result in greater LUTS improvements than either doxazosin or finasteride alone, whereas combination drug therapy may equal that of this Rezum procedure, but all drug therapies did have a significant negative impact on sexual function in contrast to the preservation of libido, erectile, and ejaculatory function after thermal therapy. STRENGTH & LIMITATIONS: The report includes high-quality data from 2 large randomized controlled trials in subjects with similar baseline inclusion criteria for LUTS severity and prostate size. It is the first longitudinal assessment of sexual function domains restricted to sexually active men treated with drugs or a single minimally invasive surgical treatment with the Rezum procedure. A limitation of the study is the use of 2 different, although validated sexual function inventories (Brief Male Sexual Function Inventory and International Index of Erectile Function). CONCLUSION: A single water vapor thermal therapy procedure for targeted prostate tissue ablation for LUTS/ benign prostatic hyperplasia had no deleterious effect on 4 sexual function domains compared with appreciable worsening of sexual function after long-term single or combination drug use. McVary KT, Rogers T, Mahon J, et al. Is Sexual Function Better Preserved After Water Vapor Thermal Therapy or Medical Therapy for Lower Urinary Tract Symptoms due to Benign Prostatic Hyperplasia? J Sex Med 2018;15:1728-1738.

The penoscrotal surgical approach for inflatable penile prosthesis placement.

Optimizing outcomes with placement of inflatable penile prostheses (IPPs) can be challenging, especially in inexperienced hands. In this article, we outline Dr. Köhler's penoscrotal penile prosthesis surgical approach. We also highlight patient selection, post-operative care and complications.