Perception from students regarding online synchronous interactive teaching in the clinical year during COVID-19 pandemic.

AIM: The global pandemic of COVID-19 has led to extensive practice of online learning. Our main objective is to compare different online synchronous interactive learning activities to evaluate students' perceptions. Moreover, we also aim to identify factors influencing their perceptions in these classes. METHODS: A cross-sectional, questionnaire-based study focusing on clinical year medical students' perceptions and feedback was conducted between February 2021 -June 2021 at the University of Hong Kong. Online learning activities were divided into bedside teaching, practical skill session, problem-based learning (PBL) or tutorial, and lecture. A questionnaire based on the Dundee Ready Education Environment Measure (DREEM) was distributed to 716 clinical year students to document their perceptions. RESULTS: One hundred responses were received with a response rate of 15.4% (110/716, including 96 from bedside teaching, 67 from practical skill session, 104 from PBL/tutorial, and 101 from lecture). For the mean score of the DREEM-extracted questionnaire, online PBL/tutorial scored the highest (2.72 ± 0.54), while bedside scored the lowest (2.38 ± 0.68, p = 0.001). Meanwhile, there was no significant difference when we compared different school years (p = 0.39), age (p = 0.37), gender (p = 1.00), year of internet experience (<17 vs ≥17 years p = 0.59), or prior online class experience (p = 0.62). When asked about students' preference for online vs face-to-face classes. Students showed higher preferences for online PBL/tutorial (2.06 ± 0.75) and lectures (2.27 ± 0.81). Distraction remains a significant problem across all four learning activities. A multivariate analysis was performed regarding students' reported behavior in comparison with their perception through the DREEM-extracted questionnaire. The results showed that good audio and video quality had a significant and positive correlation with their perception of online bedside teaching, practical skill sessions, and PBL/tutorial. It also showed that the use of the video camera correlated with an increase in perception scores for lectures. CONCLUSION: The present analysis has demonstrated that students' perception of different online synchronous interactive learning activities varies. Further investigations are required on minimizing distraction during online classes.

Describing characteristics clinicians believe predictive of patient reported outcomes after adult's ankle fracture - A modified Delphi study.

BACKGROUND: Despite explanatory studies have identified a wide range of modifiable and non-modifiable characteristics, uncertainty persists as to what characteristics are predictive of patient reported outcome following ankle fracture in adults, therefore hindering the selection of candidate variables in prognostic models without compromising the accuracy. OBJECTIVE: To establish consensus-based characteristics which clinicians believe are predictive of patient reported outcomes following ankle fracture. DESIGN: Three-round online modified Delphi survey. METHODS: In Round 1, participants provided responses to open-ended questions, as to what characteristics within the first eight weeks following ankle fracture are predictive of short- (<6 months), medium- (6 months-2 years) and long-term (>2 years) patient reported outcome. Rounds 2 and 3 presented consensus and gathered agreement on statements. RESULTS: Twenty participants answered the open-ended questions, including 13 physiotherapists and seven orthopaedic/trauma surgeons. Participants reached consensus for fracture characteristics and agreement for age, recovery of signs and symptoms, fracture management complexity, medical comorbidities, mental health status and patient journey at the short-term timepoint; agreement for age, engagement in recovery process, recovery of signs and symptoms, fracture characteristics, medical comorbidities and socioeconomic status at the medium-term timepoint; agreement for engagement in recovery process, fracture characteristics and medical comorbidities at the long-term timepoint. CONCLUSION: Clinicians believed in certain modifiable and non-modifiable characteristics predictive of patient reported outcome following ankle fracture. Our findings may provide insights about characteristics which can be selected in prognostic model development and future explanatory studies, allowing targeting adults at risk of developing long-standing symptoms and disability.

Papillary cystadenoma of the epididymis.

Background: Papillary cystadenoma is a rare benign neoplasm of the epididymis. It may occur sporadically or in association with von Hippel-Lindau disease (VHLD). Papillary cystadenoma of the epididymis (PCE) is a benign mimic of metastatic clear cell renal cell carcinoma (CCRCC) given their histologic similarities. Case presentation: Herein, we present the case of a 40-year-old man with a four-year history of microhematuria and a recently detected right paratesticular mass. A testicular sonogram revealed a hypoechoic, hypervascular solid mass in the right epididymal head treated by surgical excision. Histopathological examination demonstrated a 1.1 cm papillary cystadenoma of the epididymis. Genetic testing performed later showed no signs of VHLD. However, heterozygous mutations in three genes - CASR, POT1, and RAD51D - were found which have never been reported in PCE before. Conclusions: Papillary cystadenoma of the epididymis should always be considered in the differential diagnosis of epididymal lesions, especially those that are cystic. The mainstay of treatment remains surgical excision, which provides an excellent prognosis.

The association between person and fracture characteristics with patient reported outcome after ankle fractures in adults: A systematic review.

BACKGROUND: The incidence of ankle fractures is increasing and the clinical outcome is highly variable. QUESTION: What person and fracture characteristics are associated with patient reported outcomes after surgically or conservatively managed ankle fractures in adults? DATA SOURCES: Medline, EMBASE, and Allied and Complimentary Health Medical Database (AMED) databases were searched from the earliest available date until 16th July 2020. STUDY SELECTION: Prognostic factors studies recruiting adults of age 18 years or older with a radiologically confirmed ankle fracture, and evaluating function, symptoms and quality of life by patient reported outcome measures, were included. STUDY APPRAISAL/SYNTHESIS METHODS: Risk of bias of individual studies was assessed by the Quality in Prognostic Factors Studies tool. Correlation coefficients were calculated and data were analysed using narrative synthesis. RESULTS: Fifty-one phase 1 explanatory studies with 6177 participants met the inclusion criteria. Thirty-one studies were rated as high risk of bias using the Quality in Prognostic Factors Studies tool. There was low quality evidence that age, body mass index, American Society of Anesthesiologists classification and pre-injury mobility were associated with function, and low to moderate quality evidence that age, smoking and American Society of Anesthesiologists classification were associated with quality of life. No person characteristics were associated with symptoms and no fracture characteristics were associated with any outcomes. CONCLUSION: There was low to moderate quality evidence that person characteristics may be associated with patient reported function and quality of life following ankle fracture. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number CRD42020184830.

Papillary cystadenoma of the epididymis

ABSTRACT Background Papillary cystadenoma is a rare benign neoplasm of the epididymis. It may occur sporadically or in association with von Hippel-Lindau disease (VHLD). Papillary cystadenoma of the epididymis (PCE) is a benign mimic of metastatic clear cell renal cell carcinoma (CCRCC) given their histologic similarities. Case presentation Herein, we present the case of a 40-year-old man with a four-year history of microhematuria and a recently detected right paratesticular mass. A testicular sonogram revealed a hypoechoic, hypervascular solid mass in the right epididymal head treated by surgical excision. Histopathological examination demonstrated a 1.1 cm papillary cystadenoma of the epididymis. Genetic testing performed later showed no signs of VHLD. However, heterozygous mutations in three genes - CASR, POT1, and RAD51D - were found which have never been reported in PCE before. Conclusions Papillary cystadenoma of the epididymis should always be considered in the differential diagnosis of epididymal lesions, especially those that are cystic. The mainstay of treatment remains surgical excision, which provides an excellent prognosis.

A Case Report of Large Bowel Obstruction in a Patient With an Inflatable Penile Prosthesis.

INTRODUCTION: Inflatable penile prostheses (IPP) consist of 2 cylinders implanted into the corpora cavernosa, a pump placed in the scrotum, and a saline-filled reservoir traditionally placed in the space of Retzius. IPPs are used to treat refractory erectile dysfunction with few rare, but serious, complications. Cases of reservoirs causing erosion into the bladder, small bowel obstructions, vascular compression, and inguinal herniation have been described. AIM: We highlight the importance of keeping a broad differential diagnosis when assessing patients with bowel obstructions. METHODS: A 68-year-old man with a previous IPP placement presented with left lower quadrant abdominal pain, constipation and obstipation for 5 days. On exam, he was afebrile, and noted to have a firm, distended, tympanic abdomen. CT scan showed a distended cecum at 11 cm, narrowing of the proximal sigmoid with adjacent inflammatory changes, and minimal peri-colonic air, suggestive of a localized perforation. The IPP reservoir was seen in the left iliac fossa, coinciding with the lead point of the obstruction, suggesting that the reservoir may have itself caused the obstruction. The patient was taken to the operating room for an emergent exploratory laparotomy, which revealed a mass in the colon abutting the IPP reservoir. MAIN OUTCOME MEASURES: Considerations for IPP component explantation, factors considered for reintervention, and preservation of penile length with avoidance of penile fibrosis. RESULTS: A left colectomy with transverse colostomy was successfully performed and the IPP reservoir was explanted. Intraoperative frozen section revealed adenocarcinoma. Upon initial review of the imaging, it was thought that the IPP reservoir may have caused the obstruction, but intraoperatively, the colonic tumor was found to be the culprit. CONCLUSION: Although complications related to IPPs, including bowel obstructions, have been previously described in the literature, treatment for large bowel obstructions must take into account all possible etiologies, including malignancy. Atri E, Mallory C, Perez A, et al. A Case Report of Large Bowel Obstruction in a Patient With an Inflatable Penile Prosthesis. Sex Med 2021;9:100391.

Sexual Dysfunction Among Men Who Have Sex with Men: a Review Article.

PURPOSE OF REVIEW: The goal of this review article is to evaluate sexual dysfunction among men who have sex with men (MSM). RECENT FINDINGS: Men who have sex with men are commonly affected by sexual dysfunction. Often sexual dysfunction in MSM will significantly impact their psychological well-being perhaps even more than their heterosexual counterparts. Despite the frequency and high impact of sexual dysfunction in MSM, access to appropriate care may be limited. It is important for urologists, especially sexual medicine clinicians, to be aware of and comfortable with differences in sexual practices of MSM. Penile pathology in this patient population will negatively affect their quality of life and well-being. Therefore, it is important to properly assess and treat these patients.

Melanotan Tanning Injection: A Rare Cause of Priapism.

Melanotan II, an injectable melanocortin analog, is illicitly available on the internet to generate a sunless tan through melanocyte induction. It is also used as a sexual stimulant in unlicensed performance enhancement clinics, and has been investigated as a possible treatment agent in erectile dysfunction. We describe in this case report a patient presenting with acute ischemic priapism after subcutaneous injection of melanotan II. The patient was initially managed with cavernosal aspiration and irrigation, and intracavernous injection of phenylephrine without achieving detumescence. After failing initial management, the patient underwent operative management with penoscrotal decompression, a promising alternative technique for the management of refractory ischemic priapism. Priapism after melanotan II injection has only been reported in the literature twice before. This case report highlights a rare presentation of acute ischemic priapism after melanotan II use, managed with surgical decompression. Future therapeutic applications of these agents and updated management guidelines should consider priapism as a possible side effect. CW. Mallory, DM Lopategui, BH. Cordon. Melanotan Tanning Injection: A Rare Cause of Priapism. Sex Med 2021;9:100298.

Favourable multi-institutional experience with penoscrotal decompression for prolonged ischaemic priapism.

OBJECTIVES: To report our multi-institutional experience using penoscrotal decompression (PSD) for the surgical treatment of prolonged ischaemic priapism (PIP). MATERIALS AND METHODS: We retrospectively reviewed clinical records for patients with PIP treated with PSD between 2017 and 2020. Priapisms were confirmed as ischaemic based on clinical presentations and cavernosal blood gas abnormalities. Treatment with irrigation and injection of α-agonists in all patients had failed prior to PSD. Patient characteristics, peri-operative variables and outcomes, and changes in International Index of Erectile Function (IIEF) scores were evaluated. RESULTS: We analysed 25 patients who underwent a total of 27 PSD procedures. The mean duration of priapism at initial presentation was 71.0 h. Irrigations and injections in all patients had failed, while corporoglanular shunt treatment in 48.0% of patients (12/25) had also failed prior to PSD. Of the 10 patients who underwent unilateral PSD, two (20.0%) had priapism recurrence. Both were treated with bilateral PSD, with prompt and lasting detumescence. Among the 15 patients undergoing primary bilateral PSD, none had priapism recurrence. Of the 15 patients with documented sexual function status at last follow-up, nine (60%) reported spontaneous erectile function adequate for penetration, while six (40%) reported erectile dysfunction. The median (interquartile range) decrease in IIEF-5 score was 3.5 (0-6.75) points after PSD. Two patients underwent uneventful inflatable penile prosthesis placement following PSD. CONCLUSIONS: Penoscrotal decompression presents a simple, safe, highly effective and easily reproducible procedure for resolution of PIP. PSD should be considered as a viable salvage or alternative strategy to corporoglanular shunt procedures.

PacBio Amplicon Sequencing Method To Measure Pilin Antigenic Variation Frequencies of Neisseria gonorrhoeae.

Gene diversification is a common mechanism pathogens use to alter surface structures to aid in immune avoidance. Neisseria gonorrhoeae uses a gene conversion-based diversification system to alter the primary sequence of the gene encoding the major subunit of the pilus, pilE Antigenic variation occurs when one of the nonexpressed 19 silent copies donates part of its DNA sequence to pilE We have developed a method using Pacific Biosciences (PacBio) amplicon sequencing and custom software to determine pilin antigenic variation frequencies. The program analyzes 37 variable regions across the strain FA1090 1-81-S2 pilE gene and can be modified to determine sequence variation from other starting pilE sequences or other diversity generation systems. Using this method, we measured pilin antigenic variation frequencies for various derivatives of strain FA1090 and showed we can also analyze pilin antigenic variation frequencies during macrophage infection.IMPORTANCE Diversity generation systems are used by many unicellular organism to provide subpopulations of cell with different properties that are available when needed. We have developed a method using the PacBio DNA sequencing technology and a custom computer program to analyze the pilin antigenic variation system of the organism that is the sole cause of the sexually transmitted infection, gonorrhea.

Investigation of the Optic Nerve Head Morphology Influence to the Optic Nerve Head Biomechanics - Population Specific Model.

Glaucoma is an eye disorder potentially leading to permanent blindness through the damage of optic nerves at the optic nerve head (ONH). As a critical region of optic nerve damage, the porous Lamina Cribrosa (LC) in the ONH plays a critical role in determining whether optic nerves passing through will experience apoptosis in response to shear stress. The primary cause of shear stress to the LC is the increase in intraocular pressure (IOP). Since morphology governs how mechanical stresses distributes, LC morphology could be an important factor in determining the risks of glaucoma development and progression. The current project aims at investigating how anterior LC surface morphology impacts its response to shear stress caused by IOP. Results of the current study show that steeper LC morphologies could be associated with increased average shear stress on the anterior LC surface. The effect of LC morphology was comparable to that of IOP. This highlights the potential significance of LC morphology on the distribution of IOP-induced shear stress and calls for further investigation in this area.

The Rear Tip Extender for Inflatable Penile Prostheses: Introduction of "Rigidity Factor" and Review of the Literature.

INTRODUCTION: Rear tip extenders (RTEs) are often used in penile prosthesis surgery, and their value and use have varied with the evolution of penile prostheses. AIM: To review the literature addressing RTEs and to introduce a new term, rigidity factor, which quantifies the ratio of inflatable to non-inflatable component of the cylinders. METHODS: The urologic literature was reviewed for all mention of RTEs. In addition, literature regarding penile prostheses was explored for mention of RTEs. MAIN OUTCOME MEASURE: A search on PubMed for "rear tip extender" resulted in 17 publications. These publications were reviewed, and references were also explored for related publications. RESULTS: The history of the development of RTEs, complications associated with the use of RTEs, and current practices in the use of RTEs are all discussed. In addition, recent publications regarding RTEs were examined in detail. RTEs were introduced in the 1980s to improve mechanical survival of prostheses. They were thought to decrease input tubing wear. Although the trend recently has been to place more rear tips, evidence has surfaced suggesting a link to increased need for reoperation with additional RTEs. In addition, we believe that increased length of RTEs can decrease erectile quality. Rigidity factor, defined as the ratio of the live (inflatable) portion of cylinder to the total cylinder length, can be used to quantify the effect of RTE on erectile strength. However, the effects of RTEs on biomechanical properties of the penis when fully inflated are still not fully understood. CONCLUSION: The use of RTEs is a relatively underexplored area of penile prosthesis placement. Further laboratory and in vivo work will allow for a better understanding of the optimal role of RTEs in penile prosthesis surgery. Thirumavalavan N, Cordon BH, Gross MS, et al. The Rear Tip Extender for Inflatable Penile Prostheses: Introduction of "Rigidity Factor" and Review of the Literature. Sex Med Rev 2019;7:516-520.

Excision and Primary Anastomosis Reconstruction for Traumatic Strictures of the Pendulous Urethra.

OBJECTIVES: To present a multi-institutional experience with functional and patient-reported outcomes among men undergoing excision and primary anastomosis (EPA) urethroplasty for pendulous urethral strictures. METHODS: We describe the technique and present our experience with EPA for focal penile strictures. Patients undergoing urethroplasty (2004-2017) at 2 tertiary referral centers were reviewed, of whom 14 (0.7%) underwent EPA of radiographically confirmed pendulous urethral strictures. Validated questionnaires were utilized to evaluate overall improvement (Patient Global Impression of Improvement), urinary bother (International Prostate Symptom Score), and sexual function (International Index of Erectile Function-5). Treatment success was defined as urethral patency without need for subsequent reconstruction. RESULTS: Among 14 men undergoing penile EPA, 13/14 (93%) had durable treatment success over a median follow-up of 43 months. No patient reported penile curvature postoperatively. Stricture etiology in most cases was posttraumatic (12/14), of which 4 had a history of urethral disruption secondary to penile fracture and 8 iatrogenic trauma. Median age was 51 years (IQR 30-60) and stricture length 1.0 cm (IQR 1.0-1.4). Erectile function was normal in 8/14 patients preoperatively, and postoperative median International Index of Erectile Function was 21. Most men reported significant global improvement in condition (median Patient Global Impression of Improvement 2, IQR 1-3) and most had only mild urinary bother (median International Prostate Symptom Score 4, quality of life 1). The single treatment failure had a history of hypospadias with multiple prior urethral procedures. CONCLUSION: For men with short strictures of the pendulous urethra, EPA has a high success rate, without adverse sequelae such as erectile function or penile curvature.

Contemporary surgical and non-surgical management of Peyronie's disease.

Numerous treatments have been proposed for Peyronie's disease (PD). As the evidence base has expanded, the field of operative and non-operative options for patients has narrowed. Collagenase clostridium hystolyticum (CCH) injection now comprises the medical option, and surgical possibilities entail penile plication, plaque incision/excision and grafting, and prosthesis implantation. Still, questions abound regarding the optimal approach and indication for each of these treatments. We conducted a review of literature exploring the contemporary management of PD with a particular focus on work since the last American Urologic Association's (AUA) guidelines update for PD. Recent results and discussion indicate trends toward minimal invasiveness, toward a more holistic approach to the PD patient, and away from algorithmic management, galvanized, in part, by data challenging long-held beliefs.

The Hemodynamic Effects of Intracavernosal Phenylephrine for the Treatment of Ischemic Priapism.

AIM: We sought to evaluate whether the administration of phenylephrine (PE) at concentrations higher than those described in guidelines resulted in any significant changes in vital signs or impacted outcomes. METHODS: After receiving institutional review board approval, we retrospectively reviewed the charts of patients presenting to our emergency department between May 1, 2014, and August 15, 2016, using International Classification of Diseases, Ninth Edition and Internation Classification of Disease, Tenth Edition diagnosis codes for priapism. Treatment was reviewed, including corporal aspiration/irrigation, injection of PE, and shunt procedures. Vital signs were compared before and after treatment with PE. Baseline variables were explored with categorical data analysis (chi-squared tests, t-tests, and Mann-Whitney nonparametric tests). Where feasible, linear regression was used to evaluate outcomes. MAIN OUTCOME MEASURE: Detumescence and changes in blood pressure and heart rate. RESULTS: We identified 74 different patient encounters of acute priapism. The median age was 36.5 years (interquartile range [IQR] = 27-47), and the median time to presentation was 5.4 hours (IQR = 4.0-9.6). 62 percent of cases were due to drug-induced priapism. In 58 (74%) encounters, patients received PE. The median dose of PE given was 1000 µg (IQR 500-2,000). Univariate regression found no association between PE dose and change in patient heart rate or blood pressure. A statistically significant decrease in heart rate (HR) (-4.2 BPM), systolic blood pressure (BP) (-1.8 mm Hg), and diastolic BP (-5.4 mm Hg) was noted. Fifty-three of 58 (91%) patients receiving PE experienced detumescence at the bedside, 2 required shunting in operating room, and 3 refused treatment and left against medical advice. No adverse events occurred. CONCLUSION: We frequently treat patients with high doses of PE and seldom notice adverse effects, typically resulting in resolution of priapism without any additional procedures. Careful administration of high doses of intracavernosal PE in patients presenting with priapism does not appear to significantly affect heart rate or blood pressure and may help prevent further ischemic damage and achieve detumescence effectively and efficiently. Sidhu AS, Wayne GF, Kim BJ, et al. The hemodynamic effects of intracavernosal phenylephrine for the treatment of ischemic priapism. J Sex Med 2018;15:990-996.

Rear Tip Extenders and Penile Prosthesis Rigidity: A Laboratory Study of Coloplast Prostheses.

BACKGROUND: Rear tip extenders (RTEs) are used commonly in penile prostheses, but their effect on erectile rigidity has not been extensively studied. AIM: To determine whether RTEs affect erectile rigidity in inflatable penile prostheses and determine what length of RTE should be used for a given corporal length-in this case, 22 cm. METHODS: To assess the effect of RTEs on erectile rigidity, we created a penile model simulating 2 corpora cavernosa that accommodated cylinders of varying lengths. Once the cylinders were inflated, a 200-g weight was then uniformly placed on the tip of the cylinders and deflection was measured using a ruler. Measurements were repeated for varying cylinder/RTE lengths to total 22 cm of overall corporal length. OUTCOMES: Differences in rigidity and angular deflection based on RTE length were assessed. RESULTS: Increasing the length of RTEs increased the deflection in our model, indicative of decreased axial rigidity. CLINICAL TRANSLATIONS: The current work implies that having additional RTEs may decrease penile rigidity and in turn, patient satisfaction. STRENGTHS AND LIMITATIONS: Though assessing effect of RTEs on erectile rigidity is novel, the exact ability of our model to predict in-vivo behavior is unknown. CONCLUSION: An inflatable penile prosthesis represents a heterogeneous beam given that it is composed of a non-inflatable rear combined to an inflatable cylinder. In this model greater bending deflection was associated with more RTE length. Greater RTE length decreases the size of the inflatable device that can be implanted. The erect penis is subject to axial stress and bending deflection. Though further work is needed, these data support the notion that maximizing inflatable length by minimizing RTEs will improve overall erectile rigidity dynamics. Thirumavalavan N, Cordon BH, Gross MS, et al. Rear Tip Extenders and Penile Prosthesis Rigidity: A Laboratory Study of Coloplast Prostheses. J Sex Med 2018;15:1030-1033.

Sexual Health Care Practitioners' Evaluation of Men Who Have Sex With Men.

BACKGROUND: The Institute of Medicine Report and Department of Health and Human Services Healthy People 2020 Initiative have called for steps to address health disparities facing sexual minorities. AIM: We sought to characterize the practice patterns of sexual health specialists as they relate to men who have sex with men (MSM). METHODS: Surveys were electronically mailed to 696 members of the Sexual Medicine Society of North America (SMSNA). Responses were compared using descriptive statistics and χ2 analysis with Yates correction where appropriate. OUTCOMES: Outcomes were SMSNA members' demographics, their assessment of their patients' sexual orientation, and adaptation of care to address the specific needs of their MSM patients. RESULTS: 92 (13.2%) Members responded. While 93.3% of respondents reported treating MSM patients, only 51.7% routinely asked about sexual orientation. Of those that do not ask, 41.9% responded that sexual orientation is irrelevant to their patients' care and 25.6% responded that patients will disclose this information if the patient thinks it is important. Practitioners inquiring about sexual orientation were more likely to practice in urban settings; more likely to inquire about a greater number of sexual behaviors; more likely to tailor their care to lesbian, gay, bisexual, and transgender needs; and more likely to endorse the notion that homosexual/bisexual patients have unique sexual dysfunction concerns. CLINICAL TRANSLATION: Limited and uneven inquiry about sexual orientation necessitates efforts aimed at tailoring care to the needs of sexual minority patients. STRENGTHS & LIMITATIONS: This survey addresses a gap in the literature by investigating predictors and practical consequences of practitioner inquiry about sexual orientation. Limitations include a low response rate, disparate study population, the potential influence of respondent social desirability biases, and spurious associations due to a multiplicity of statistical tests. CONCLUSION: Only about half of surveyed SMSNA members ask their patients' sexual orientation; inquiry about sexual orientation was associated with practice setting and with provider practice patterns and attitudes. Saheb Kashaf M, Butler PR, Cordon-Galiano BH, et al. Sexual Health Care Practitioners' Evaluation of Men Who Have Sex With Men. J Sex Med 2018;15:942-946.

Peyronie's penile plication.

Penile plication has become the preferred surgical technique for Peyronie's disease (PD) as it can be performed efficiently, safely, with a high success rate, low morbidity and a low complication rate. Here in we describe two modern plication techniques in detail: the Kiels Knot plication and the minimally invasive penoscrotal plication. Benefits of the techniques include no palpable sutures for the Kiels Knot Plication and less surgical trauma for the penoscrotal plication. Plication has a low rate of failure. However, when it does occur it is usually secondary to under-correction. Failures typically present early postoperatively and a contributing factor to underestimating the deformity is a poor intraoperative artificial erection. Complex, severe, or multiplanar deformities will require more sophisticated intraoperative decision-making, but can be managed effectively with penile plication nonetheless.

Low Testosterone Levels Result in Decreased Periurethral Vascularity via an Androgen Receptor-mediated Process: Pilot Study in Urethral Stricture Tissue.

OBJECTIVE: To compare expression of androgen receptor (AR) and angiopoietin 1 receptor TIE-2 and vessel density of urethral stricture tissue among eugonadal and hypogonadal men to identify a pathophysiological basis for our observations that low testosterone is associated with urethral atrophy. METHODS: Among 1200 men having urethroplasty at our institution, we retrospectively identified 11 patients with testosterone levels drawn within 2 years of surgery. Low testosterone was defined as <280 ng/dL and detected in 5 of 11 (45.5%) patients. Urethral tissue samples were analyzed using immunohistochemistry for AR, TIE-2 (a downstream target of activated AR linking it to angiogenesis), and CD31 expression. RESULTS: Mean testosterone was 179.4 ng/dL for patients classified as having low testosterone and 375.0 ng/dL for controls (P = .003). We found a significant decrease of AR expression (1.11%high power field [HPF] vs 1.62, P = .016), TIE-2 expression (1.84%HPF vs 3.08, P = .006), and vessel counts (44.47 vessels/HPF vs 98.33, P = .004) in men with low testosterone. Expression levels of AR and TIE-2 were directly correlated to testosterone levels (rho: 0.685, P = .029, and rho: 0.773, P = .005, respectively). We did not find a difference in age, radiation, or comorbidities among patients with normal or low testosterone levels, with the exception of higher body mass index in the latter. CONCLUSION: Men with low testosterone levels demonstrate decreased AR and TIE-2 expression and lower vessel counts in periurethral tissue samples of urethral strictures. Our results provide a rationale for a mechanistic relationship between low testosterone levels and decreased periurethral vascularity that may contribute to urethral atrophy in patients with urethral strictures.