Assessing Attitudes and Confidence in Managing Erectile Dysfunction Among Urology, Internal Medicine, and Family Medicine Providers.

OBJECTIVE: To assess and contrast attitudes and confidence regarding erectile dysfunction (ED) treatment among urologists (GU) and primary care providers (PCPs), identifying areas for collaboration, practice improvement, and additional training to enhance men's healthcare (MH) quality and access. METHODS: An anonymous survey with 25 questions on ED treatment, rated on a 5-point Likert scale, was conducted among our institution's providers in GU, internal medicine (IM), and family medicine (FM). Data were analyzed using descriptive statistics and Fisher's exact test. RESULTS: 138 providers responded, including 58 IM, 47 FM, and 33 GU. FM and IM responses generally overlapped with some differences. IM were more positive regarding vacuum erection device (VED) and inflatable penile prosthesis (IPP) satisfaction and risk. Comparing GU to FM + IM, GU displayed greater confidence and knowledge about ED. Notably, 63% of GU used the validated International Index of Erectile Function (IIEF) compared to 3% of FM + IM. Additionally, 100% of GU strongly/agreed that good options remained after pills failed vs 83% of FM + IM. Significant differences in GU vs FM + IM perspectives on IPP included patient willingness to undergo surgery for ED (67% vs. 12%), patient satisfaction (91% vs. 28%), partner satisfaction (79% vs. 26%) and willingness to recommend/repeat surgery (82% vs. 17%). Notably, 82% of GU vs 10% of FM + IM were aware that Medicare covered implants. CONCLUSION: This survey reveals significant knowledge gaps in ED treatment between GU and PCPs. Targeted provider education, particularly about penile prostheses, could optimize patient care.

The Film Room: Using Artificial Intelligence to Facilitate Video Review for Urology Trainees.

Video-based educational programs offer a promising avenue to augment surgical preparation, allow for targeted feedback delivery, and facilitate surgical coaching. Recently, developments in surgical intelligence and computer vision have allowed for automated video annotation and organization, drastically decreasing the manual workload required to implement video-based educational programs. In this article, we outline the development of a novel AI-assisted video forum and describe the early use in surgical education at our institution.

Lessons learned from the Sexual Medicine Society of North America fellowship bootcamp.

BACKGROUND: Sexual Medicine Society of North America (SMSNA) fellowships offer variable experience in sexual health domains: erectile dysfunction, Peyronie's disease, male infertility, male hypogonadism (low testosterone), reconstruction (including male incontinence), benign prostatic hyperplasia, gender affirmation surgery, sexual mental health, and female sexual dysfunction. AIM: To evaluate baseline and postbootcamp understanding and trust in these domains. METHODS: In 2023, 28 of 31 urologists currently enrolled in SMSNA-endorsed fellowships participated in a 3.5-day training bootcamp in Minneapolis, Minnesota. Participants were asked to complete pre- and postbootcamp surveys. The bootcamp curriculum offered American Urological Association guidelines and case-based lectures, hands-on clinical training with cadavers (penile surgery) and models (collagenase training), and interaction with industry. OUTCOMES: Changes in knowledge, independence, and trust in performing the procedures, as well as billing issues and feedback for future bootcamps. RESULTS: Prebootcamp surveys revealed vastly varied residency experience. Reported time with an expert faculty member was greatest for benign prostatic hyperplasia and least for female sexual dysfunction, gender affirmation surgery, and low testosterone. The lowest prebootcamp confidence in performing surgery independently was for penile grafting procedures and elevating the neurovascular bundle. Postbootcamp results revealed several areas of significant improvement in confidence (P ≤ .03): intralesional injections for Peyronie's disease, manual modeling, penile plication, penile grafting procedures, and elevating the neurovascular bundle. There was a trend for improved confidence with the insertion of inflatable (P = .05) and semirigid (P = .08) penile prostheses. Nonsignificant improvement occurred in artificial urinary sphincter surgery (P = .12). Participants graded the bootcamp very highly and requested that next year's bootcamp have more content on female sexual dysfunction, male incontinence, and low testosterone, as well as more hands-on skills sessions and case-based lecture formats. CLINICAL IMPLICATIONS: Offering a bootcamp with hands-on instruction could significantly improve urologists' knowledge and confidence. STRENGTHS AND LIMITATIONS: As the main strength, this study was the first specialized bootcamp for urologists in the subject of men's health, taking into account hands-on and cadaver laboratories, as well as highlighting industrial and pharmaceutical products. The small sample size was the major limitation. CONCLUSIONS: Current SMSNA fellows present with varied levels of experience and confidence across sexual health domains. Notable confidence improvements were seen with topics that combined didactic lectures with hands-on trainings.

The Utilization of Fine-Needle Vasography to Localize Obstruction of the Male Reproductive Tract.

OBJECTIVE: To report our experience using fine-needle vasography (FNV) to identify a site of obstruction and determine candidacy for reconstructive procedures in patients presenting with suspected obstructive azoospermia (OA) or cryptozoospermia. METHODS: We report a multi-institutional case series of patients with suspected complete or partial OA. Patients that were included had azoospermia or cryptozoospermia, presence of palpable vasa, testicles ≥12 mL, and FSH <7.6 IU/L. All patients underwent testicular biopsy prior to or at the time of FNV to confirm spermatogenesis. FNV was performed using a 25-gauge angiocatheter, with radio-opaque dye visualized under fluoroscopy. Descriptive statistics are reported as median and interquartile range (IQR). RESULTS: A total of 16 patients underwent vasography from 2014 to 2022 with 3 surgeons. Twelve patients presented with azoospermia, and 4 with cryptozoospermia. A total of 7 (44%) men were found to have distal obstruction on FNV. Of the 8 men with prior inguinal hernia repairs, 2 were confirmed to have an obstruction at the level of the inguinal canal. Of the 6 patients with a history of genitourinary infection, 4 had an obstruction at the level of the epididymis (with normal FNV), while 2 had atresia of the vas deferens in the pelvis. CONCLUSION: FNV is an effective, minimally invasive way to identify the site of complete or partial obstruction in patients presenting with suspected OA/cryptozoospermia. It additionally permits identification of men who are candidates for epididymovasostomy reconstruction and helps to differentiate between ejaculatory duct obstruction (EDO) and other causes of blockage.

Glans hypermobility scale (GHS): A simple grading scale and description of a modified glanspexy technique.

Glans hypermobility (GH) is a well-described clinical entity that can have significant implications for cosmesis and function, resulting in sexual dissatisfaction, penile pain, and early device erosion, with an estimated incidence of 0.04% to 10%. We developed a novel grading scale to assess GH severity intraoperatively during primary inflatable penile prosthesis (IPP) placement and describe a modified glanspexy technique to correct GH when encountered during IPP placement. 530 patients who underwent primary IPP placements from two high-volume prosthetic surgeons between February 2018 - November 2019 were retrospectively reviewed in order to identify the incidence of GH. Of these, 139 (26.2%) had hypermobility. Employing our new scaling system, grade 1, 2, and 3 GH was seen in 86 (16.2%), 29 (5.5%), and 24 (4.5%) cases, respectively. Increased implant size correlated with a decreased likelihood of GH incidence. Each increase in implant size by 1 cm decreased the incidence of detecting GH by 11.0% (OR = 0.89; p = 0.015). 11 patients underwent primary GH repair using our described technique. At one-year follow-up, one patient required repeat glanspexy for recurrent bothersome GH and a second patient developed a suture granuloma at the glanspexy incision requiring unilateral cylinder explant. Our modified glanspexy technique can be used to correct GH in any direction and is a useful tool for the prosthetic surgeon's armamentarium.

The Discontinuation Rate With Collagenase Clostridium histolyticum for Peyronie's Disease in a High-volume Practice Is Unexpectedly High: Identifying Opportunities for Patient Care Improvement.

OBJECTIVE: To elucidate reasons for premature discontinuation of Collagenase Clostridium histolyticum (CCH) injections for the treatment of penile curvature associated with Peyronie's disease. METHODS: A database of men who underwent CCH injections at a single institution was queried to identify men who completed fewer than 8 injections. Chart review was conducted to identify reasons for treatment discontinuation. When this could not be identified, patients were contacted first via the online patient portal and next by phone. RESULTS: Of 406 patients who underwent CCH treatment, 133 did not complete 8 injections (32.8%). The most common reasons for discontinuation were satisfactory curve reduction (27%), unsatisfactory curve reduction (21%), bothersome side effect (15%), and pursuit of surgery (12%). Other less common reasons included other health concerns, pausing treatment due to the COVID-19 pandemic, high cost, transferring care elsewhere, and lack of awareness that more injections were indicated. CONCLUSION: We present the largest series of patients to date dedicated to evaluation of CCH discontinuation. We find that up to 1/3 of patients who begin CCH injections will not complete the full treatment course. Understanding the reasons for discontinuation can help providers better stratify patients for CCH treatment vs other modalities. In addition, as previous studies indicate curvature improvements are equally likely to be seen in the final four injections as the first four, our data points to the potential impact of improved patient education for individuals who discontinue due to unsatisfactory curve reduction.

Assessing psychiatric risk with a focus on optimizing patient satisfaction with penile prosthesis placement-a narrative review.

Background and Objective: Treatment for medication-refractory erectile dysfunction (ED) is based on a shared decision-making model. The gold standard treatment for medication refractory ED is penile prosthesis (PP) placement. Patient satisfaction rates with PP are high with adequate counseling and expectation-setting. However, as with any elective surgery, patient selection is key to minimizing complications and ultimately patient dissatisfaction. Psychological well-being is an important consideration in the preoperative evaluation and postoperative management of patients undergoing PP placement. Methods: We performed a PubMed literature review to identify pertinent studies for this narrative review. Specifically, we sought describe preoperative evaluation including appropriate counseling and patient selection as well relevant intraoperative and postoperative factors for patients undergoing PP placement with a specific focus on optimizing preoperative psychiatric factors and treatment-related patient satisfaction to identify pertinent articles describing ways to optimize patient satisfaction with PP. Key Content and Findings: A patient's psychological state can influence the degree of understanding of their condition, affect perception of their treatment team, and limit their ability to cope with complications. All patients should undergo a thorough medical history and physical examination to screen for psychiatric health disorders, substance abuse, and chronic pain conditions. Establishing patient expectations with regards to treatment-related outcomes during the preoperative consultation will ensure congruency between the patient and performing surgeon. Patients with a more significant psychiatric distress related to their underlying sexual dysfunction may require additional evaluation and counseling preoperatively. Conclusions: PP placement is associated with high levels of overall satisfaction in appropriately screened patients. Specific considerations during preoperative counseling and careful patient selection, intraoperative decision making to avoid or anticipate possible complications, and postoperative cares are necessary to ensure the best result for an individual patient.

Significant Geographic Variation in Access to Certified Collagenase Clostridium histolyticum Injectors for Peyronie's Disease Throughout the United States.

INTRODUCTION: We characterize the geographic distribution of providers trained to inject Clostridium histolyticum and identify areas with low provider availability. METHODS: We utilized a publicly available search tool to identify clinical sites offering Clostridium histolyticum in the US The data gathered included the provider's name, specialty, address, and whether the site was considered high-volume (ie, administer ≥20 Clostridium histolyticum injections per year). Data were compared to the AUA Census. RESULTS: In total, 2,388 clinical sites offering Clostridium histolyticum were identified. A total of 894 sites (37%) were high-volume sites. The mean number of locations offering Clostridium histolyticum per 100,000 state residents was 0.69 (SD 0.27). Georgia (1.28), Rhode Island (1.13), and Alaska (1.10) had the highest number, whereas New Mexico (0.10), Maine (0.22), and Delaware (0.30) had the lowest. The mean proportion of urologists providing Clostridium histolyticum to total urologists was 0.17 (SD 0.07). The 3 states with the highest proportion were Georgia (0.37), Alaska (0.31), and Utah (0.30), whereas New Mexico (0.03), Maine (0.05), and Vermont (0.06) had the lowest. CONCLUSIONS: States with low numbers of clinical sites offering Clostridium histolyticum per 100,000 residents relative to other states also had a low total ratio of urologists offering Clostridium histolyticum as a treatment. There is room for urologists in these states and others to expand their practice to offer Clostridium histolyticum and improve patient access to this important nonsurgical treatment option.

Comparison of Collagenase Clostridium histolyticum to Surgery for the Management of Peyronie's Disease: A Randomized Trial.

PURPOSE: Since Food and Drug Administration approval of collagenase Clostridium histolyticum for Peyronie's disease, there has been significant debate regarding its role and comparable efficacy to surgery. MATERIALS AND METHODS: A randomized, controlled trial was performed of Peyronie's disease men treated with either collagenase C histolyticum + RestoreX penile traction therapy + sildenafil or penile surgery + RestoreX penile traction therapy + sildenafil, with 3-month data presented. Primary objectives were overall satisfaction, subjective changes in erectile function, penile sensation, penile length, and changes in the International Index of Erectile Function-Erectile Function Domain score. Secondary outcomes included objective changes in length, curve, adverse events, and other standardized and nonstandardized questionnaires. RESULTS: A total of 40 men were enrolled, with 38 (collagenase C histolyticum group = 19, surgery group = 19) completing treatment and having 3-month data available. All demographic and clinicopathological variables were similar between groups. Following treatment, 50% of men in the collagenase C histolyticum group reported being very satisfied (vs 21% in the surgery group, P = .08) and noted better subjective erectile function (100% vs 68%, P = .03) and penile length (88% vs 16%, P < .0001), lesser impacts on penile sensation (75% vs 11% no change, P < .001), and similar International Index of Erectile Function-Erectile Function Domain changes (+1.5 vs +2.5, P = .91). Objectively, men in the surgery group had greater curve improvements (84% vs 54%, P < .01) and higher rates of adverse events (50 vs 13 events, P < .001) but decreased penile length (-0.5 cm vs +1.0 cm, P < .01). CONCLUSIONS: At 3 months posttreatment, collagenase C histolyticum + RestoreX penile traction therapy + sildenafil results in lesser curve improvements but greater penile length and fewer adverse events, including impacts on subjective erectile function and sensation, than men treated with surgery.

Perceived influence of medical school sexual health education on specialty selection in young urologists specializing in sexual dysfunction.

Background: To determine effects of sexual health curriculum (SHC) in medical school and mentorship on future specialty/subspecialty selection, we sought to evaluate the experiences of urology trainees and practicing urologists. Methods: Residents, fellows, and practicing urologists completed a 15-question survey regarding their exposure to a SHC during medical school, topics covered, and the influence of mentors in their career choice. Summary statistics were used to identify trends based on survey responses. Results: Ninety-four respondents, primarily post-graduate training year 4 and 5 (46%), completed the survey. Approximately 50% recalled a dedicated SHC during medical school with 46% planning to pursue fellowship training in sexual medicine/reconstruction. Topics commonly covered included reproductive anatomy/physiology and sexual history-taking, while respondents rarely recalled topics such as sexual aids/toys and pornography. Only 25% felt their SHC provided an adequate fund of knowledge to address sexual health concerns in patients, and only 14% felt that exposure to a SHC influenced their decision to pursue urology. Individuals intending to pursue fellowship were more likely to have an attending mentor, a mentor with expertise in sexual dysfunction, and considered their mentor as important or very important in their decision to subspecialize (P<0.05). Conclusions: Most urology trainees do not have strong exposure to a SHC during medical school and cite mentorship as a more important role in the decision to pursue subspecialty training. These data support the need for a standardized formal SHC and continued exposure to sexual health experts during training to ensure continued interest in sexual medicine/reconstruction fellowship.

The clinical significance of imperfection: is idiopathic corporal asymmetry related to curvature during penile prosthesis placement?

Patient satisfaction after inflatable penile prosthesis (IPP) has been linked to preexisting curvature; however the association with intraoperative asymmetric corporal measurements (ACM) has not been well described. We sought to identify incidence of ACM during IPP surgery, and relationship to penile curvature. A retrospective review of all patients undergoing primary IPP placement between 6/2019 and 6/2021 was performed. Logistic regression analysis was performed to identify factors associated with ACM and need for adjunct straightening techniques. A total of 273 patients underwent primary IPP. 27.8% had Peyronie's disease (PD) diagnosed preoperatively or detected intraoperatively. ACM was identified in 20.1% (55/273) patients. There was no significant difference in ACM in PD versus non-PD patients (p = 0.55). Most patients with ACM (78.2%, 43/55) underwent placement of asymmetric device. ACM did not predict need for invasive straightening maneuvers (p = 0.12). However ACM patients were significantly more likely to have mild residual curvature than those with symmetry (p < 0.0001). Our study is first to address management of idiopathic ACM and association with curvature, providing new insight into a common situation. While ACM was detected in 20%, it did not predict need for adjunct straightening techniques. Our findings may provide reassurance to urologists troubleshooting idiopathic ACM during corporal dilation during IPP surgery.

Efficacy of collagenase Clostridium histolyticum in men with congenital penile curvature.

BACKGROUND: Collagenase Clostridium histolyticum (CCH) has been proven effective in multiple subpopulations of PD men; however, no studies have evaluated its role with congenital penile curvature (CPC). AIM: To evaluate the safety and efficacy of CCH in men with CPC. METHODS: A prospective registry was queried of men undergoing CCH injections at our institution. Beginning in 2016, CCH was administered to CPC men using a similar protocol to PD. A comparative analysis was performed between cohorts to evaluate the safety and efficacy of therapy. OUTCOMES: Objective measures included penile length and curvature, while subjective outcomes included standardized (International Index of Erectile Function and Peyronie's Disease Questionnaire) and non-standardized assessments. Curvature outcomes were categorized as follows: 1 - included all men, with the most recent assessment considered final, and 2 - only men who had completed eight CCH injections or stopped early due to satisfaction. RESULTS: From 2014 to Oct 2021, a total of 453 men (408 PD, 45 CPC) underwent one or more CCH injections. In comparing cohorts, CPC men were younger (33 vs 58 years, p<0.0001), had lesser baseline curvatures (52.5 vs 65°, p<0.01), more ventral curves (25.7 vs 9.2%, p<0.01), and longer penile lengths (12.5 vs 12.0 cm, p=0.04). Following treatment, both cohorts experienced similar curvature improvements. Specifically, PD men experienced 20-25° or 33-35% improvements depending on definition compared to 25-30° or 40-50% in CPC men (all p-values >0.05). CPC and PD men also demonstrated similar changes on standardized questionnaires, with the exception of the Psychological and Physical subdomain, which was more improved in CPC men (-11 vs -4, p<0.01). Baseline curvature was positively correlated with greater absolute (degree) and relative (percent) improvements. Adverse events were similar between groups after controlling for confounders. CLINICAL IMPLICATIONS: CCH may be safely and effectively administered in men with CPC. These data provide the first evidence for the efficacy of a non-surgical therapeutic option in this cohort. STRENGTHS AND LIMITATIONS: Strengths - large, prospective series with standardized assessments; Limitations - non-randomized study, short-term follow-up, and lack of standardized method to differentiate CPC from PD. CONCLUSIONS: CCH may be safely and effectively administered to men with CPC, with similar success rates compared to PD. Increasing curvature was associated with greater absolute (degree) and relative (percent) improvements, supporting the role for CCH in men with mild, moderate, or severe curvatures. External validation is warranted prior to routine implementation.

Testicular Pain - Not Always What it Seems: A Cross-Sectional Assessment of Patients Presenting for Chronic Scrotal Content Pain at a Tertiary Care Center.

OBJECTIVE: To review historical and examination findings in patients presenting to a tertiary care center for evaluation of Chronic Scrotal Content Pain (CSCP) defined by persistent/bothersome pain present for > 3-months. METHODS: We performed a retrospective chart review of all patients presenting to our medical center for evaluation of CSCP. Pertinent information collected included historical data, physical examination findings, laboratory and imaging results, and treatments recommended by the assessing physician. The data was summarized to present a cross-sectional representation of patients presenting for CSCP. RESULTS: 110 patients were identified. 80 patients (73%) had seen at least one prior urologist. 26 patients (24%) had undergone a prior unsuccessful surgical intervention for CSCP. Reproducible tenderness was present in 67% of patients including testicular tenderness in 50 (45%), epididymal tenderness in 60 (55%), and spermatic cord tenderness in 31 patients (28%). 33% of patients did not have any reproductible scrotal content tenderness on physical examination. Surgery was recommended in 57/110 patients (52%), including microdenervation in 22%. Musculoskeletal etiologies were suspected based on specific aspects of the history and physical examination in 43 patients (39%), prompting additional evaluation and/or referrals. CONCLUSION: CSCP presents with a wide array of symptoms and many patients do not have reproducible findings on examination, suggesting alternative sources of pain such as referred pain from musculoskeletal causes. The history and physical examination should include assessments for concurrent abdominal, back, hip, and other genital/pelvic pain that may suggest alternative diagnoses and referrals for appropriate treatment.

Improved Peyronie's Disease Curvature Outcomes Using a Novel Collagenase Administration Protocol.

OBJECTIVE: To report outcomes of a novel collagenase clostridium histolyticum (CCH) injection protocol. METHODS: A prospective, sequential database was maintained of all Peyronie's men undergoing CCH injections since 2015. Our protocol has evolved to include changes with injection technique, timing, aggressive modeling/traction, and wrapping. Results of the "traditional" and "novel" techniques were compared using two definitions: "most recent" assessment and final assessments among men who "completed eight (injections) or were satisfied." RESULTS: A total of 509 men underwent greater than or equal to 1 CCH series (traditional, n = 280; novel n = 229). Baseline demographic/clinicopathologic characteristics were similar between groups. Results demonstrated significantly greater curve improvements with the novel technique ("most recent" median 30° vs 20° or 46% vs 28%; "completed eight or satisfied" 34° vs 20° or 58% vs 30%). Using the "completed eight or satisfied" definition, 94% vs 66% of men achieved greater than or equal to 20% improvement (odds ratio 7.6), and 60% vs 24% achieved greater than or equal to 50% improvements (odds ratio 5.0) in the novel cohort (all P < .0001). Importantly, the International Index of Erectile Function Erectile Function Domain score was unchanged, and subjective erectile function (50% vs 5%, P < .0001) and sensation improved (17% vs 8% improved, P = .01) with the new protocol. The novel cohort also reported higher rates of surgery prevention (53% vs 18%), restored/facilitated penetration (57% vs 21%), and hematomas (56% vs 26%), necessitating changes to wrapping procedures (all P < .0001). CONCLUSIONS: Use of the novel CCH protocol results in significant improvements with curvature without negatively impacting erectile function or sensation. Given its specialized nature, it is not recommended for low-volume CCH injectors.

Current Landscape of Andrology Fellowship Programs and the Effect of Gender on Post-Fellowship Practice Patterns.

OBJECTIVE: To evaluate the current landscape of andrology fellowships, characteristics of past fellows, and post-fellowship career paths of fellowship graduates. MATERIAL AND METHODS: The websites of the American Urological Association (AUA), Society for the Study of Male Reproduction (SSMR), and Sexual Medicine Society of North America (SMSNA) were reviewed for sponsored fellowships. Program coordinators, institutional websites, and Google were queried for information about each program in a stepwise fashion. Descriptive statistics and t-tests were used to compare outcomes by gender. RESULTS: The SMSNA endorsed 73% of programs, and SSMR 48%, while only 45% of all programs participated in the 2021 AUA match. Nearly all programs (93%) were affiliated with an academic institution. Only 20% programs had any female andrology faculty. From 1982-2020, 324 andrology fellows were identified, 16.4% of whom were female. Of the fellows identified, 54.5% of women pursued academia versus 45.5% of men (P = .39). Men and women were equally likely to advertise an exclusive andrology practice, 65.4 and 61.4%, respectively (P = .78). There was an increase in the proportion of female fellows from 8.1%-20.7% when comparing fellows who began training prior to 2010 to those who began training in 2010 or later (P = .0038). CONCLUSION: National societies have taken steps towards standardizing andrology fellowship training, but much of the fellowship information is not readily available, restricting the interpretation of gender-based differences in practice environment. However, we found that there was no negative impact in female andrologists' ability to practice andrology or enter academic careers despite being in a male-dominated subspecialty.

Vasectomy Reversal Online Marketing Practices: What Are We Putting Out There?

OBJECTIVE: To determine characteristics of providers marketing vasectomy reversal (VR) online, degree of information available online, the ease with which patients can compare providers, and the differences in VR practice patterns between academic and private practices. MATERIALS AND METHODS: We identified VR practices operating within the top 50 most populous metropolitan areas in the US. Practice websites were reviewed to obtain information such as provider educational background, level of magnification, ability to perform vasoepididymostomy, surgical volume, and cost. Based on information available, providers were assigned a novel REVERSAL score created by the authors. Descriptive statistics were used to compare results. RESULTS: Of the 107 providers identified (29 academic, 78 private), the majority were male urologists with a Doctor of Medicine degree. Academic providers were more likely to have fellowship training than private practice providers, 96.6 vs 43.6%, respectively (P = 0.00001). Compared to non-urologists, urologists were less likely to purchase online ads or disclose cost. Non-urologists charged significantly less than urologists, $3,584 ± 1,554 and $6,591 ± 1,518, respectively (P = 0.00001). Only one provider provided complete information as defined by REVERSAL score of 12, with the majority (61.7%) of providers achieving score ≤6. CONCLUSION: There is significant lack of transparency in publicly available information from VR practices. Practices should implement measures to improve dissemination of information to the public, so that patients can more easily compare providers and make informed decisions regarding VR.

A narrative review of the management of benign prostatic hyperplasia in patients undergoing penile prosthesis surgery.

Penile prosthesis surgery is an effective and durable treatment modality for patients who have failed conservative management for erectile dysfunction (ED). Thorough patient counseling and appropriate preoperative workup lay the foundation for a successful outcome. While the risk of infection of penile prosthesis is rare, it is a dreaded complication with dire consequences. The goal of the prosthetic surgeon is to minimize the risk of preventable complications. Given the common prevalence of benign prostatic hyperplasia (BPH) in this patient population, it is essential that providers are familiar with the implications and nuances of managing both conditions in order to maximize the chances of a favorable result. Due to the relatively infrequent nature of complications associated with the management of BPH in the setting of a penile prosthesis, literature regarding this topic is scarce. In this narrative review we present our own case series illustrating some of the most common scenarios that a prosthetic surgeon may encounter. We have included our suggestions for management in these difficult situations based on our clinical experience. In the following review we have highlighted the importance of identifying and treating BPH in penile implant candidates to reduce postoperative morbidity and to offer critical insights into managing BPH-related complications this population.