A contemporary systematic review of penile lengthening procedures with penile prosthesis.

Background: Penile prosthetic devices are the standard treatment for erectile dysfunction (ED) after failure of maximum medical therapy and conservative options. Several penile lengthening procedures (PLPs) can be performed concurrently with penile prosthesis (PP) insertion in patients with severe ED, penile shortening, and/or Peyronie's disease to help combat negative emotional and psychological concerns from penile length loss with penile prosthetic device placement. Methods: An extensive, systematic literature review of the various pre-, intra-, and post-operative techniques that can be applied to preserve, restore or enhance penile length at the time of penile prosthetic implantation. Results: Numerous pre-operative and post-operative inflation protocols exists with vacuum erection devices and penile traction therapy. Intraoperative surgical techniques include cavernosal sparing and channeling without dilatation, subcoronal incision with circumferential penile degloving and grafting, the sliding technique, the modified sliding technique, the multiple-slit technique, the tunical expansion procedure (TEP), modified TEP, and the auxetic expansion procedure. These approaches can be meaningful to restore and/or preserve length for patients undergoing PP insertion. Conclusions: PLPs can be performed by surgeons who have extensive penile reconstruction experience and have been trained to do these procedures, as there is significant risk to the patient and limitations to what can be expected. Each patient must be counseled in detail about the risks and benefits of these procedures and have their expectations managed as the average postoperative penile length recovery is around 3 cm and can range from 0-4.0 cm. Future research is needed to identify the appropriate candidate for each approach, and how much length gain the patient can expect.

Trends and Costs of Minimally Invasive Surgery for Kidney Cancer in the US: A Population-based Study.

OBJECTIVE: To analyze temporal trends and costs associated with the use of minimally invasive surgery (MIS) for kidney cancer in the US over the past decade. To examine the impact of social determinants of health (SDOH) on perioperative outcomes. METHODS: The PearlDiver Mariner, a national database of insurance billing records, was queried for this retrospective observational cohort analysis. The MIS population was identified and stratified according to treatment modality, using International Classification of Diseases and current procedural terminology codes. SDOH were assessed using International Classification of Diseases codes. Negative binomial regression was used to evaluate the overall number of renal MIS and Cochran-Armitage tests to compare the utilization of different treatment modalities, over the study period. Multivariable logistic regression analysis identified predictors of perioperative complications. RESULTS: A total of 80,821 MIS for kidney cancer were included. Minimally invasive partial nephrectomy adoption as a fraction of total MIS increased significantly (slope of regression line, reg. = 0.026, P <.001). Minimally invasive radical nephrectomy ($26.9k ± 40.9k) and renal ablation ($18.9k ± 31.6k) were the most expensive and cheapest procedures, respectively. No statistically significant difference was observed in terms of number of complications (P = .06) and presence of SDOH (P = .07) among the treatment groups. At multivariable analysis, patients with SDOH undergoing minimally invasive radical nephrectomy had higher odds of perioperative complications, while renal ablation had a significantly lower probability of perioperative complications. CONCLUSION: This study describes the current management of kidney cancer in the US, offering a socioeconomic perspective on the impact of this disease in everyday clinical practice.

Experience With Extra-Tunical Grafting and Tunica Albuginea Plication for Correction of Indentation Deformity in Men With Peyronie's Disease.

OBJECTIVE: To further evaluate extra-tunical grafting (ETG), a relatively new surgical option to treat corporal indentation in those with Peyronie's disease without buckling or hinge effect, we report our experience, patient satisfaction, and surgical outcomes. METHODS: Retrospective review of patients following ETG, including pre-operative deformity, type of graft, graft location (under or over Buck fascia), patient characteristics, and satisfaction. Overall cosmetic satisfaction with deformity correction between patients undergoing 2 different ETG locations and 3 different types of grafts, as well as perceived bother of graft visibility and palpability were assessed. RESULTS: From 2018-2023, 35 patients underwent ETG and tunica albuginea plication (TAP) with 89.6% of patients having persistent correction on office examination at a median (interquartile range) follow-up of 23.5 (15.2) months. Overall satisfaction with penile appearance by grafting location via patient-reported questionnaires showed no statistical difference (P = .47). Patients undergoing TAP and ETG were satisfied with their erect appearance regardless of graft material. Patients reported grafting tissue was palpable (74.3%) and visible (48.6%) in the flaccid state as compared to the erect state (8.6% and 5.7%). CONCLUSION: ETG presents a less invasive surgical option than traditional approaches to correct indentation deformities not associated with instability. Our experience shows high patient satisfaction rate following correction of indentation using graft tissue when placed under or over Buck fascia. At a median follow-up of almost 2 years, patients had persistent correction, and while some report visibility of the graft and palpability in the flaccid state, this tends to disappear in the erect state.

A contemporary assessment of the evaluation and management of patients presenting to a tertiary medical center with Peyronie's disease.

Peyronie's disease continues to be poorly understood. We characterize the presenting features of Peyronie's disease within a large cohort and elucidate the factors that correlate with surgical intervention. Univariate and multivariate analyses were performed on 1483 consecutive patients to assess pre-operative predictors of surgical intervention for Peyronie's disease. Overall, 1263 patients met inclusion criteria. Mean age was 55.4 ± 11.1 years with a mean duration of disease at presentation of 33.2 ± 42.5 months. Mean primary curvature was 49.8 ± 20.8°. Primary ventral curvature was present in 11.4% and 36.5% of patient had a multiplanar curvature. During penile duplex ultrasound evaluation indentation/narrowing deformities were appreciated in 76.0%, hourglass deformity in 10.1%, and hinge effect in 33.0% of patients. Calcification was seen in 30.1% of patients. Operative intervention occurred in 35.3% of patients. Degree of primary curvature (1.03 OR, p < 0.001), hourglass deformity (1.82 OR, p = 0.01), decreased tunical elasticity (1.20 OR, p = 0.03), and prior intralesional collagenase clostridium histolyticum injections (2.94 OR, p < 0.001) predicted surgical correction on multivariate analysis. Compared to historical studies, we found a higher incidence of severe degree of curvature (27.5% >60°), indentation deformities, hinge-effect, multiplanar curvature and penile calcifications. Ultimately, predictors of surgical intervention included those with worse erectile function and more severe characteristics.

Predictors of hinge effect in patients with Peyronie's disease.

BACKGROUND: Patients with Peyronie's disease present with a variety of penile deformities. Those with hinge effect can experience bothersome buckling of the erection and instability during penetrative sex; however, the actual characteristics and clinical implications are not fully understood. AIM: To determine the factors that cause hinge effect and to assess the role on surgical intervention. METHODS: This retrospective review included 1223 consecutive patients who were examined by a single surgeon and had a complete penile duplex evaluation with curvature and hinge assessment. Baseline demographics, penile duplex findings, and clinical outcomes were used to assess for predictors of hinge effect. OUTCOMES: Analyses were performed to assess preoperative predictors of hinge effect and surgical intervention. RESULTS: Hinge effect was observed at the time of penile duplex Doppler examination in 33% of patients. Circumferential girth discrepancy at point of indentation (odds ratio [OR] 1.82; P < .001), rigidity of erection (OR, 0.82; P = .002), and degree of primary curvature (OR, 1.03; P < .001) predicted the presence of hinge effect. When controlling for rigidity, a girth discrepancy >1 cm did appear to be associated with a hinge. CLINICAL IMPLICATIONS: Circumferential girth discrepancy >1 cm, regardless of erectile rigidity, can be associated with hinge effect. STRENGTHS AND LIMITATIONS: As a strength, this study included the largest cohort of patients with Peyronie's disease, all of whom were examined in a rigorous and uniform manner via the same operative counseling. However, the study is limited by its retrospective nature and potential for selection and observer bias, given that the treating physician was also assessing all penile deformities as well as performing operative intervention. CONCLUSIONS: The presence of hinge effect can cause instability of erections during penetrative sex. Multiple factors may predispose patients to a hinge effect, including the quality of erection and severity of curvature. But when controlling for rigidity, a girth discrepancy >1 cm did appear to be associated with a hinge. While many factors, such as baseline erectile dysfunction and severity of curvature, are important in determining the optimal surgical intervention, assessing for preoperative hinge effect also influenced the surgical approach.

Genital monkeypox superimposed on co-incident sexually transmitted infections in AIDS patient; a case report.

Monkeypox outbreaks were, until recently, mostly confined to Africa but a currently expanding worldwide outbreak has recently been designated a global emergency by the World Health Organization. Genital manifestation is common and can be confused with sexually transmitted infection (STI), posing a diagnostic challenge. We herein report a case of genital monkeypox superimposed on multiple co-incident STIs in a HIV patient and describe characteristic clinical findings and management.

The monetary costs of pediatric upper urinary tract stone disease: Analysis in a contemporary United States cohort.

INTRODUCTION: The prevalence of upper urinary tract stone disease (USD) in the United States is rising among both adults and children. Studies on the contemporary economic burden of USD management in the pediatric population are lacking. OBJECTIVE: To comprehensively analyze the economic impact of USD in a contemporary United States pediatric cohort, and to evaluate drivers of cost. STUDY DESIGN: A retrospective cohort study of pediatric patients (aged 0-17), diagnosed with USD between 2011 and 2018 were identified from PearlDiver-Mariner, an all-payer claims database containing diagnostic, treatment and prescription data provided in all treatment settings. Relevant International Classification of Disease (ICD-9 and ICD-10) and Current Procedural Terminology (CPT) codes were used for identification, and only patients with claims recorded for at least one year before and after entry of a diagnosis code for USD were selected (N = 10,045). Patients were stratified into those undergoing operative vs. non-operative management and for each patient, total 1-year healthcare costs following USD diagnosis, including same day and non-same day encounters, were analyzed. Factors associated with increased spending, as well as economic trends were analyzed. RESULTS: Overall, 8498 (85%) patients were managed non-operatively, while 1547 (15%) underwent a total of 1880 procedural interventions. Total overall cost was $117.1 million, while median annual expenditure was $15.8 million. Proportion of spending for outpatient, inpatient and prescription services was 52%, 32% and 16%, respectively (Table). Outpatient management accounted for 67% of overall spending. The proportion of patients managed non-operatively increased significantly over time, in parallel with spending for non-operative care. Comorbidity burden, treatment year and geographic region were among predictors of costs. DISCUSSION: Our study is the first to report actual insurance reimbursements for pediatric USD management using actual reimbursement data, examined across all treatment settings. We found that majority of the costs were for outpatient services and for non-operative management, with a rising tendency toward non-operative management over time. Regional variation in expenditures was evident. Specific reasons underlying these observed patterns could not directly be discerned from our dataset, but merit further investigation. CONCLUSION: Non-operative and outpatient management for pediatric USD are increasingly common, resulting in parallel shifts in spending. Notably, 52% of overall spending was for outpatient care. These insights into the contemporary economic burden of pediatric USD could provide value in shaping future healthcare policy.

Aspiration and Sclerotherapy: A Minimally Invasive Treatment for Hydroceles and Spermatoceles.

OBJECTIVE: To describe our contemporary experience with aspiration and sclerotherapy (AS) as a non-surgical alternative for patients with symptomatic hydrocele and spermatocele who prefer non-surgical treatment. MATERIALS AND METHODS: Patients were identified by billing diagnosis code for hydrocele or spermatocele from 2015 to 2019. Patients underwent AS with doxycycline (200-400 mg). Physical examination, ultrasound and aspirate microscopy were used to differentiate hydrocele from spermatocele. Baseline and follow-up data were recorded. RESULTS: In total, 65 patients underwent AS, 54/65 (83%) for hydrocele and 11/65 (17%) for spermatocele with mean aspirate volumes 307 mL (SD 238 mL) and 138 mL (SD 112 mL), respectively. Follow-up data was available for 38/54 (70%) hydroceles and 8/11 (73%) spermatoceles with median follow-up 28 (IQR 23-41) and 22 (IQR 18.5-30.5) months respectively. Relief of patient reported bother associated with scrotal size occurred in 29/38 (77%) hydroceles and 8/9 (89%) spermatoceles. 2/54 (4%) hydrocele patients developed hematoma managed with in-office aspiration. Immediate post-procedural pain occurred in 2/56 (4%) hydroceles and 2/10 (20%) spermatocele. Post-procedural pain requiring more than 5 tablets of hydrocodone/acetaminophen 5mg/325mg occurred in 2/57 (3%) hydroceles and 2/10 (20%) spermatoceles. Surgical repair was ultimately pursued in 3/38 (8%) and 1/9 (11%) patients with persistent hydrocele and spermatocele respectively. CONCLUSION: AS is a safe and effective treatment alternative for hydrocele and spermatocele for patients wishing to avoid surgery.

Postoperative Urinary Retention After Bariatric Surgery: An Institutional Analysis.

BACKGROUND: Postoperative urinary retention (POUR) can impact quality outcomes, leading to urinary tract infections, longer lengths of stay, and increased healthcare costs. The incidence of POUR in bariatric patients is unknown. Our primary objective was to determine the incidence and risk factors contributing to POUR in primary bariatric surgery. METHODS: A retrospective review was conducted on patients who underwent a laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2013 to 2017. POUR was defined as the inability to urinate postoperatively, requiring urinary catheterization. Univariate and multivariate analyses were performed on perioperative variables and their correlation with POUR. RESULTS: During the study period, 603 patients underwent surgery: 317 (52.6%) LSG and 286 (47.4%) LRYGB. Overall, 49 (8.1%) patients developed POUR. There were no significant differences in preoperative demographics between patients with and without POUR. Patients who underwent an LSG had an increased incidence of POUR compared with LRYGB (P = 0.002). In both procedures, POUR was associated with decreased neostigmine, isolated nondepolarizing muscle relaxant, and reduced intraoperative fluid. LSG and congestive heart failure, as well as LSG and body weight, were independently associated with POUR. Female patients who experienced POUR had significantly increased length of stay. CONCLUSIONS: Risk factors associated with POUR after primary bariatric surgery include LSG, less intraoperative neostigmine and intravenous fluids, and isolated nondepolarizing muscle relaxants. These risk factors can help educate patients and providers, as well as identify quality initiatives that focus on perioperative and anesthetic management to reduce POUR and length of hospital stay.

Postoperative urinary retention after laparoscopic total extraperitoneal inguinal hernia repair.

BACKGROUND: Postoperative urinary retention (POUR) after laparoscopic inguinal hernia repair has an incidence of 2%-30%. POUR can lead to increased length of stay, decreased patient satisfaction, and increased health-care costs. The objective of this study was to determine the patient risk factors at our institution contributing to POUR after laparoscopic total extraperitoneal (TEP) inguinal hernia repair. METHODS: A retrospective chart review of patients who underwent a laparoscopic TEP inguinal hernia repair at our institution from 2009 to 2016. POUR is defined as the inability to urinate requiring urinary straight or indwelling catheterization in the postoperative period. Univariate analyses were performed on perioperative variables and their correlation with POUR. RESULTS: In total, 578 laparoscopic TEP inguinal hernia repair patients were included in the study: 277 (48%) indirect, 144 (25%) direct, 6 (1%) femoral, and 151 (26%) combination of direct, indirect, and/or femoral hernias. Of these, 292 (51%) were bilateral, and 286 (49%) were unilateral. Overall, 64 (11.1%) of the 578 patients developed POUR. POUR was significantly associated with benign prostatic hyperplasia, age 60 y or older, urinary tract infection within 30 d, and decreased body mass index. CONCLUSIONS: Patients aged greater than 60 y, with benign prostatic hyperplasia, and a decreased body mass index (≤25.8 kg/m2) were more likely to develop POUR after laparoscopic TEP inguinal hernia repair. In addition, these patients were more likely to develop a urinary tract infection within 30 d. Future quality initiatives can be explored to minimize the incidence of POUR in high-risk patient populations.