The Impact of Physician Productivity Models on Access to Subspecialty Care: A White Paper From the Society for the Study of Male Reproduction and the Society for Male Reproduction and Urology.

Male infertility is a common disease. Male infertility is also a core competency of urology training and clinical practice. In this white paper from the Society for the Study of Male Reproduction and the Society for Male Reproduction and Urology, we identify and define different physician productivity plans. We then describe the advantages and disadvantages of various physician productivity measurement systems for male infertility practices. We close with recommendations for measuring productivity that we hope urologists and administrators can use when creating productivity plans for male infertility practices.

Is there a rationale for penile rehabilitation following radical prostatectomy?

Erectile function recovery after radical prostatectomy (RP) is an increasingly prominent quality-of-life outcome following surgery. Following RP many men, despite the advent of cavernous nerve-sparing surgical technique, have moderately or significantly impaired erectile function (EF). The term penile rehabilitation (PR) is used to define interventions that maintain the health of erectile tissue in the context of nervous, vascular, and structural tissue injury. The goal of PR is to regain, as closely re-approximate, preoperative erectile function. PR is based on an increasing volume of preclinical and clinical data, but conclusive evidence of efficacy has not been established, and therefore the concept of PR remains controversial. The optimal PR regimen has not been established, but all strategies rely on one or more erectile dysfunction treatments to be administered on a regular basis regardless of actual use for sexual activity. This review highlights recent studies and evidence related to PR.

Use of a preoperative checklist reduces risk of penile prosthesis infection.

PURPOSE: Infection of a penile prosthesis is a devastating complication that necessitates the removal of all device components. Many aspects of preoperative and intraoperative infection prophylaxis practices have been examined but the specific relevant factors remain unknown. We determined whether use of a mandatory checklist of perioperative practices believed to reduce the risk of prosthesis infection would impact patient safety. MATERIALS AND METHODS: We retrospectively reviewed men with erectile dysfunction who underwent penile prosthesis insertion. Only patients who had not previously undergone penile prosthesis surgery were included in the study. After an outbreak of infections, a mandatory checklist comprised of best infection prophylaxis practices was developed and was required for all subsequent implant surgeries. Patient cohorts were divided into 3 groups of baseline period, outbreak period and intervention period. Statistical analysis was performed using the chi-square test, Fisher's exact test and ANOVA. RESULTS: During the baseline period 2 of 68 (2.9%) inflatable penile prosthesis devices became infected. During the outbreak period 6 of 11 (54.5%) devices became infected, representing an incidence risk ratio 18.55 times that of the baseline period. After the implementation of the preoperative checklist the incidence risk ratio decreased to 0.0 in the intervention period with 0 of 52 devices (0%) becoming infected. CONCLUSIONS: After an outbreak of an unusually high number of penile prosthesis infections, implementation of a required checklist brought the rate down to zero. Although the specific factors that led to the infection outbreak and subsequent cessation of infections are unknown, we have shown that use of a checklist was associated with a dramatic impact on patient safety.

Reproductive sequelae of diabetes in male patients.

Diabetes mellitus (DM) is an increasingly prevalent public health concern. A recent study projected the number of people worldwide with DM to increase from 171 million in 2000 to 366 million in 2030. Although DM is a systemic disease that often leads to end-organ dysfunction of multiple body systems, the effects of the condition on male fertility are often not fully appreciated. DM is associated with multiple risk factors for reduced male fertility potential, including erectile dysfunction, various manifestations of ejaculatory dysfunction, and hypogonadism.

Update on vasectomy protocol.

Vasectomy is a commonly practiced form of male contraception with over half a million procedures performed annually. Among urologists who perform the procedure, there is considerable variation in pre-procedure patient counseling, vasectomy technique, and post-procedure practices regarding confirmation of sterility. We report an overview of the vasectomy literature published within the past year with a focus on guidelines that have been recently published by two major organizations, the American Urological Association (AUA) and the European Association of Urology (EAU).

Management of ejaculatory disorders in infertile men.

Ejaculatory dysfunction is a highly prevalent clinical condition that may be classified along a continuum that ranges from premature ejaculation (PE), through retarded or delayed ejaculation (DE), to complete anejaculation (AE). Retrograde ejaculation (RE) represents a distinct entity in which ejaculate is expelled either partially or completely into the bladder. While DE and PE are significant sources of sexual dissatisfaction among men and their partners, patients with these disorders retain normal fertility in most cases. Conversely, men with AE and RE are unable to deliver sperm into the female genital tract and are therefore rendered subfertile. Therefore, in reviewing ejaculatory disorders as they relate to fertility, this paper will primarily focus on the diagnosis and management of AE and RE. Physiology, diagnostic strategies, pharmacological treatments, and procedural interventions relevant to AE and RE are discussed.

Other work has highlighted the limitations of using histopathology to predict success after varicocelectomy.

The morbidity associated with performing testicular biopsy on all men before varicocele repair appears to outweigh the benefit of any prognostic information obtained.

Resume fraud: unverifiable publications of urology training program applicants.

PURPOSE: We examined the incidence of resume fraud among urology residency applicants by determining the rate of misrepresented publications listed in applications to a urology residency program. MATERIALS AND METHODS: Applications from all 147 urology residency applicants to a program from the 2007 application cycle were analyzed. Verification of listed publications was attempted by querying PubMed, Google Scholar and MEDLINE. Univariate analysis was conducted to assess associations between unverifiable publications and applicant demographics. RESULTS: Of the applicants who submitted publications 19% (14 of 71) had at least 1 unverifiable publication, which represented 9% (14 of 147) of the entire applicant pool. There were no statistically significant associations between misrepresented publications and applicant demographics. CONCLUSIONS: Applicants had a low but still unacceptable rate of misrepresented publications and this trend in academic medicine is of great concern.

Factors predicting successful microsurgical vasectomy reversal.

A man who desires restoration of fertility after vasectomy has two main treatment options for having his genetic child: vasectomy reversal or sperm extraction with subsequent in vitro fertilization with intracytoplasmic sperm injection. Microsurgical reconstructive techniques and their widespread availability have made vasectomy reversal a realistic option for many couples; however, vasectomy reversal outcomes are varied because there are many factors that alter the chance of success. Some of these factors become known preoperatively, whereas others can only be ascertained at the time of surgery. Intraoperatively, the urologist must identify factors and understand how they will affect the decision to proceed. This article systematically reviews each of these phases of decision-making and management.

Outcomes of varicocelectomy treatment: an updated critical analysis.

This article provides an updated analysis of the varicocele literature published since 1994. The present authors have followed the format of the previous review and have included a summary of the results from the 1994 article at the end of each section.

Systemic antibiotic prophylaxis not needed for microsurgical varicocelectomy.

OBJECTIVES: Although systemic antibiotic prophylaxis is not recommended for class I (clean) cases according to the Centers for Disease Control and Prevention guidelines, they are often used for varicocelectomy. This study was designed to determine whether antibiotic prophylaxis is necessary for varicocelectomy. METHODS: We conducted a retrospective review of 278 patients who had undergone microsurgical varicocelectomy. No antibiotics were used. All patients were seen within 4 weeks of surgery and evaluated for signs of infection. RESULTS: Only 2 patients developed culture-positive infection. Five additional patients had signs of infection as defined by the Centers for Disease Control and Prevention. CONCLUSIONS: The results of this study have shown that antibiotic prophylaxis is not warranted for patients undergoing varicocelectomy.

Presentation of a functional pituitary adenoma as a significant decrease in prostate-specific antigen level in a patient followed for prostate cancer.

The stimulatory role of testosterone in the production and release of prostate-specific antigen (PSA) has been well characterized. Testosterone production by the testes is dependent on a functional hypothalamic-pituitary-gonadal axis. High prolactin levels have been shown to disrupt this axis, resulting in decreases in gonadotropins and testosterone levels. We report a patient with prostate cancer and elevated PSA levels followed with "watchful waiting" for several years who experienced a precipitous decrease in PSA level over a 3 month period. The patient was found to have an asymptomatic prolactin-secreting pituitary macroadenoma.

Radionuclide imaging in urology.

Radiopharmaceutic tracers are used commonly to diagnose and monitor benign and malignant conditions of the genitourinary system. Most often, these tracers assess renal function and obstruction in "normal" and transplanted renal units. More recently, especially with the advent of positron emission tomography (PET)/CT, the role of nuclear pharmaceutics in the staging and monitoring of malignancies has expanded.