American Urological Association Guidelines Research Articles

Is Reddit a reliable source for information on erectile dysfunction treatment?

Patients may turn to social media websites, such as Reddit, for information on erectile dysfunction prior to seeking care from a physician. We sought to identify, characterize, and assess the quality of the erectile dysfunction treatments discussed on the highly influential Reddit website. We assessed 2634 comments from two subreddits, r/AskMen and r/ErectileDysfunction, for positive and negative statements regarding treatments for erectile dysfunction. A total of 45 unique treatments were discussed and consisted of changes in sexual behavior (30%), lifestyle changes (29%), medical interventions (23%), talking with a partner about ED (10%), and use of supplements (8%). Only 24.4% of all treatments discussed are in line with current American Urological Association guidelines. Only 43.8% of all positive statements made endorsed a guidelines-based treatment, indicating a high rate of self-proclaimed success with alternative therapies. Our results indicate that there is active discussion of erectile dysfunction treatment on Reddit with a wide range of therapies recommended, however, the majority of the recommendations are not supported by strong clinical evidence.

Are neutrophil–lymphocyte and platelet–lymphocyte ratios useful for determining active phase of Peyronie’s disease?

Background: Management options for Peyronie’s disease (PD) are determined by the phase of the condition. Experts counsel against surgical intervention during the active phase of PD. Patients with chronic phase of PD are offered either collagenase injections or surgical intervention. Accurately characterising a patient’s phase of PD is crucial in determining the appropriate treatment option. Objective: To investigate neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR) as possible predictors for the determination of acute or chronic phase of PD. Methods: This study retrospectively queried all patients who presented for initial diagnosis of PD from 2016 to 2020 and had complete blood count (CBC) laboratory values before initial therapy. PD phase was defined per the American Urological Association guidelines. The active phase of PD was defined as a changing penile curvature and/or growing palpable plaque. The chronic phase of PD was defined as a stabilised penile curvature. All statistical analyses were two-tailed, using a significance level of 0.05. Results: One hundred nine patients met inclusion: 27 (25%) active phase and 82 (75%) chronic phase patients. Demographic and erectile characteristics were not statistically different between the two groups. NLR and PLR values between active and chronic phase patients were comparable ( p > 0.05). A linear regression evaluated correlations between the duration of PD and either NLR or PLR. Neither NLR nor PLR was correlated with PD duration on Spearman, Pearson, or Kandall tests. In addition, NLR and PLR were not noted to be predictors of PD phase on multiple logistic regression. Finally, a receiver operator characteristic curve was generated. NLR and PLR yielded an area under curve of 58% and 57.8%, respectively. Conclusions: Two recent studies suggested NLR and PLR could be used to predict the phases of PD. However, after evaluating a cohort of 109 men from our institution, our data do not support the use of peripheral blood PLR or NLR to determine the phase of PD.

Evaluation of periprocedure antibiotics and infection-related hospitalizations after transrectal prostate biopsies

Background: Prostate cancer is the leading cancer diagnosis and the second leading cause of cancer deaths in men. Definitive diagnosis is made by prostate biopsy. This procedure poses a risk of infection and, rarely, sepsis. Studies have found the incidence of symptomatic urinary tract infection (UTI) after biopsy to be 2%–3%, and the rate of infection-related hospitalization (IRH) to be 0.6%–4.1%. An initial review at our facility found the IRH rate to be 3.7%. The primary purpose of this study was to determine the incidence of IRH following prostate biopsy in patients at the Memphis VA Medical Center (VAMC) after initial review and education. Methods: All transrectal prostate biopsies performed at the Memphis VAMC from October 2017 through May 2021 were analyzed. Patients were excluded if they had a spinal cord injury or concomitant procedure. The primary outcome was IRH occurring within 30 days of the procedure. Variables collected included risk factors, antibiotic choice and duration, and details of postprocedural infections. Analyses were performed on a per-procedure basis. Results: Overall, 601 procedures were identified; 13 were excluded, for a total of 588 transrectal prostate biopsies on 533 patients. All patients were given antibiotics. Oral antibiotics alone were provided for 306 procedures (52%) for an average duration of 3 days. A combination of both oral and intramuscular antibiotics were provided for 282 (48%) procedures. The most common oral antibiotics used were cefuroxime (538, 91.4%), ciprofloxacin (17, 2.9%), amoxicillin–clavulanate (16, 2.7%), and sulfamethoxazole–trimethoprim (12, 2%). Intramuscular antibiotics included ceftriaxone (263, 93.3%) and gentamicin (19, 6.7%). An infectious complication occurred in 29 patients (4.9%): 26 (3.4%) were urogenital and 5 (0.8%) required hospitalization. Of the procedures complicated by a postprocedure infection, 22 (75.9%) received an oral antibiotic alone, 21 (95.4%) of which were cefuroxime, and 7 (24.1%) received both an intramuscular and an oral agent. Conclusions: In our initial review, the most common antibiotics used were fluroquinolones, with an average duration of 3 days periprocedure and an IRH rate of 3.7%. These findings were used to reinforce practices compliant with American Urological Association (AUA) guidelines. This follow-up review reveals that the first-line choice changed from fluroquinolones to cephalosporins, with average duration remaining at 3 days. Although the overall infection rate was 4.9%, the IRH rate decreased from 3.7% to 0.8%.Funding: NoneDisclosures: None

MP13-16 THE AUA GUIDELINES: AN EVALUATION OF EVIDENCE GRADE BACKING STATEMENTS

You have accessJournal of UrologyCME1 May 2022MP13-16 THE AUA GUIDELINES: AN EVALUATION OF EVIDENCE GRADE BACKING STATEMENTS Chris Du, Kuemin Hwang, John Hill, and Howard L. Adler Chris DuChris Du More articles by this author , Kuemin HwangKuemin Hwang More articles by this author , John HillJohn Hill More articles by this author , and Howard L. AdlerHoward L. Adler More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002542.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: As part of its mission to provide the highest standards of clinical care, the American Urological Association (AUA) publishes guidelines on numerous urologic topics to assist clinical decision making. These guidelines are written after a systematic review and meta-analysis of research and advancements in the topic of interest. We sought to evaluate the caliber of evidence used establish the currently available AUA guidelines. METHODS: All AUA guideline statements on the AUA website were reviewed for their level of evidence and recommendation strength. Statistical analysis was performed to identify any differences between oncological and non-oncological topics, newer versus older guidelines, and statement pertinence to diagnosis, treatment, and followup. All statistical analysis was performed via SPSS statistical software. RESULTS: We identified guidelines available for 32 urologic topics. One guideline did not offer levels of evidence and was excluded. 938 statements were analyzed for this study. 39 (4.2%) were backed by Grade A evidence, 188 (20%) Grade B, 297 (31.6%) Grade C, 185 (19.7%) Clinical Principle, and 230 (24.5%) Expert Opinion. Of the recommendations made, 169 Strong, 191 Moderate, and 156 Conditional were made. There was a statistically significant association of Grade A (36, p<0.01) and B (103, p<0.01) evidence backing Strong Recommendations. There was a significant association of oncology guidelines (6% vs 3%, p=0.021) having more grade A evidence and less Grade C Evidence (24% vs 35%, p=0.002). Guidelines published in the last 3 years vs. older guidelines had less Grade A Evidence (3% vs 7%, p<0.01) and more Expert Opinion backing (27% vs 22%, p=0.038). Statements pertaining to diagnosis and evaluation were more likely backed by Clinical Principle (31% vs 14% vs 15%, p<0.01), while treatment statements were backed by B (26% vs 13% vs 11%, p<0.01) and C (35% vs 30% vs 17%, p<0.01) grade evidence, and followup statements by Expert Opinion (53% vs 23% vs 24%, p<0.01). CONCLUSIONS: The majority of evidence for the AUA guidelines is not high grade. While topics such as oncology are more likely to have higher grade evidence, there appears to be a recent trend toward weaker evidence statements as well as less evidence backing diagnosis and followup statements. More research is needed to modify and enhance the guidelines to deliver evidence based urologic care. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e228 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chris Du More articles by this author Kuemin Hwang More articles by this author John Hill More articles by this author Howard L. Adler More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP35-05 COST ANALYSIS OF DIRECT-TO-CONSUMER TELEHEALTH PLATFORMS OFFERING TESTOSTERONE THERAPY

You have accessJournal of UrologyCME1 May 2022MP35-05 COST ANALYSIS OF DIRECT-TO-CONSUMER TELEHEALTH PLATFORMS OFFERING TESTOSTERONE THERAPY Erin Jesse, Nicholas Sellke, Wade Muncey, Ramy Abou Ghayda, Aram Loeb, and Nannan Thirumavalavan Erin JesseErin Jesse More articles by this author , Nicholas SellkeNicholas Sellke More articles by this author , Wade MunceyWade Muncey More articles by this author , Ramy Abou GhaydaRamy Abou Ghayda More articles by this author , Aram LoebAram Loeb More articles by this author , and Nannan ThirumavalavanNannan Thirumavalavan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002589.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Direct-to-consumer (DTC) telehealth platforms now offer treatment for testosterone deficiency (TD). We sought to compare the cost of undergoing treatment with testosterone therapy (TTh) via DTC platforms to the cost for similar care at a tertiary center. METHODS: Google was queried to identify DTC platforms offering TTh. Platforms that did not provide transparency of services and prices were excluded. Information regarding the type of services offered as well as the cost for the initial evaluation and for 12 months of treatment were gathered. The cost of evaluation and treatment for TD per the American Urological Association (AUA) guidelines at a tertiary center were estimated using a single institution’s cost estimator for a patient with no insurance, private insurance, and Medicare. RESULTS: Three DTC platforms met inclusion criteria: Hone, Regenex, and TRT Nation. The services provided by these platforms for the evaluation and follow up of patients on TTh were similar to the AUA guidelines (Table 1). The cost of the initial evaluation was lowest for the patient with Medicare at a tertiary center ($0) and via the DTC platform Hone ($165.00) (Table 2). The cost for 12 months of treatment was lowest among the patient with Medicare ($131.16) and the patient with private insurance ($777.96) at the tertiary center (Table 3). The cost of ongoing treatment was higher via all 3 platforms as compared to the tertiary center. CONCLUSIONS: While DTC telehealth platforms may offer a cost benefit to some patients in the initial evaluation for TD, the cost of ongoing treatment with TTh via these platforms exceeds that which may be encountered at a tertiary care center. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e588 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Erin Jesse More articles by this author Nicholas Sellke More articles by this author Wade Muncey More articles by this author Ramy Abou Ghayda More articles by this author Aram Loeb More articles by this author Nannan Thirumavalavan More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP54-07 A URINE-BASED MOLECULAR ASSAY REFINES THE RISK STRATIFICATION OF THE RECENT AMERICAN UROLOGICAL ASSOCIATION GUIDELINE ON HEMATURIA

You have accessJournal of UrologyCME1 May 2022MP54-07 A URINE-BASED MOLECULAR ASSAY REFINES THE RISK STRATIFICATION OF THE RECENT AMERICAN UROLOGICAL ASSOCIATION GUIDELINE ON HEMATURIA Joep de Jong, Olga Pijpers, Kim van Kessel, Joost Boormans, Wim van Criekinge, Ellen Zwarthoff, and Yair Lotan Joep de JongJoep de Jong More articles by this author , Olga PijpersOlga Pijpers More articles by this author , Kim van KesselKim van Kessel More articles by this author , Joost BoormansJoost Boormans More articles by this author , Wim van CriekingeWim van Criekinge More articles by this author , Ellen ZwarthoffEllen Zwarthoff More articles by this author , and Yair LotanYair Lotan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002633.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: According to the recent American Urological Association (AUA) Guideline on Hematuria, patients are stratified into low, intermediate and high-risk groups. These risk groups are based on clinical risk factors and do not incorporate urine-based tumor markers. Previously, we validated a urine-based molecular assay in a large prospective cohort of patients referred for gross- or microscopic hematuria. Here, we applied the updated AUA guidelines onto this prospective cohort, integrating both clinical and molecular parameters for refined urothelial cancer risk prediction. METHODS: We selected all patients with complete biomarker status from a previously published prospective Dutch hematuria cohort, including 838 patients of whom 112 were diagnosed with urothelial cancer. Patients were stratified into AUA risk category low, intermediate or high risk based on sex, age and type of hematuria. Biomarker status included mutation status of the FGFR3, TERT and HRAS genes and methylation status of the OTX1, ONECUT2 and TWIST1 genes, as assessed on urinary patient DNA. The primary end point was the diagnostic model performance for different hematuria risk groups as indicated by the AUC. Further analyses assessed the pre- and post-test cancer probability within hematuria subgroups using Fagan’s nomograms. RESULTS: Overall, 65 patients (7.8%) were classified as low risk, 106 (12.6%) patients intermediate risk, and 667 patients (79.6%) were classified as high risk. The urothelial cancer incidence differed significantly between gross (21%, 98/457) and microscopic (4%, 14/381) hematuria subgroups (P <0.001). Notably, all cancer cases were among the high risk AUA category with an incidence of 16.8% (112/667). Application of the diagnostic model revealed robust performance among all evaluated hematuria risk groups (AUC’s 0.929-0.971), showing consistent sensitivities of >90%. However, specificity of the assay was only 53% for gross hematuria patients, while microscopic hematuria risk groups had consistent specificities of >90%. Depending on the evaluated hematuria risk group, a negative urine assay was associated with a post-test cancer probability of 0.3-2% and a positive urine assay was associated with a post-test cancer probability of 31-42%. CONCLUSIONS: This study suggests efficiency for incorporating a urine-based molecular assay after AUA guideline stratification based on clinical risk factors for evaluation of hematuria patients. The AUA high risk stratification is accurate and detects all urothelial cancer cases. In AUA low/intermediate risk categories, patients with a negative assay may be able to safely avoid cystoscopy. Furthermore, AUA high risk patients with a positive assay should have expedite evaluation. Source of Funding: Supported by MDxHealth and powered by Health Holland, Top Sector Life Sciences & Health © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e928 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joep de Jong More articles by this author Olga Pijpers More articles by this author Kim van Kessel More articles by this author Joost Boormans More articles by this author Wim van Criekinge More articles by this author Ellen Zwarthoff More articles by this author Yair Lotan More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP16-08 MAJOR SHIFT IN ANTIBIOTIC PROPHYLAXIS PATTERNS FOLLOWING IMPLEMENTATION OF GUIDELINES BASED CYSTOSCOPY SURVEY

You have accessJournal of UrologyCME1 May 2022MP16-08 MAJOR SHIFT IN ANTIBIOTIC PROPHYLAXIS PATTERNS FOLLOWING IMPLEMENTATION OF GUIDELINES BASED CYSTOSCOPY SURVEY Kelly R. Pekala, Danielle Sharbaugh, Jonathan G. Yabes, Adam J. Sharbaugh, Michelle Yu, Valentina Grajales, Oluwaseun Orikogbo, Hermoon Worku, Jordan M. Hay, Toby S. Zhu, Kody M. Armann, Chandler N. Hudson, Benjamin J. Davies, and Bruce L. Jacobs Kelly R. PekalaKelly R. Pekala More articles by this author , Danielle SharbaughDanielle Sharbaugh More articles by this author , Jonathan G. YabesJonathan G. Yabes More articles by this author , Adam J. SharbaughAdam J. Sharbaugh More articles by this author , Michelle YuMichelle Yu More articles by this author , Valentina GrajalesValentina Grajales More articles by this author , Oluwaseun OrikogboOluwaseun Orikogbo More articles by this author , Hermoon WorkuHermoon Worku More articles by this author , Jordan M. HayJordan M. Hay More articles by this author , Toby S. ZhuToby S. Zhu More articles by this author , Kody M. ArmannKody M. Armann More articles by this author , Chandler N. HudsonChandler N. Hudson More articles by this author , Benjamin J. DaviesBenjamin J. Davies More articles by this author , and Bruce L. JacobsBruce L. Jacobs More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002549.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inappropriate antibiotic administration has a host of well-defined deleterious downstream effects. The American UrologicalAssociation (AUA) released antibiotic guidelines for cystoscopy in June 2019 that recommended oral antibiotics only if there is a break in the mucosal barrier and fluoroquinolones were no longer the antibiotic of choice. As a result, we created a novel clinic-based rapid survey to increase AUA antibiotic guideline adherence. METHODS: To obtain baseline data, we retrospectively reviewed the urology clinic schedule for three-months and identified all patients who underwent cystoscopy. We then completed a literature review and designed a cystoscopy survey based on previous protocols and AUA guidelines to identify patients at high risk of infection. We then implemented a multi-pronged intervention for a twelve-month period where we provided a ‘formal’ grand rounds presentation, ad hoc emails with individual updates, monthly progress reports, edited the electronic health record cystoscopy order set, educated clinic staff, and started using the cystoscopy survey. We then recorded antibiotics given for prophylaxis at time of procedure, individual patient risk factors for infection, 30-day infection outcomes, and urine culture data both pre-intervention and post-intervention. RESULTS: We identified 473 cystoscopies pre-intervention, 2,137 cystoscopies in the intervention, and 417 cystoscopies post-intervention. There was a 30% decrease in the total amount of antibiotics administered and infection rates did not increase. We found that 99% of patients were administered antibiotics pre-intervention, the majority of which were fluoroquinolones. During and after the intervention phase, fluoroquinolone use decreased significantly to 15% and 6.5% respectively. (Figure 1) The utilization rates of recommended antibiotics increased to 91% and persisted post-intervention. CONCLUSIONS: We found that implementation of a cystoscopy survey enabled rapid adoption of new AUA guidelines on antibiotic prophylaxis for cystoscopy, which resulted in a drastic reduction in the amount of antibiotics administered without a spike in infection rates. The use of recommended antibiotics improved dramatically during the intervention period and persisted post-intervention. Source of Funding: Bruce L. Jacobs, MD, MPH is supported in part by the Shadyside Hospital Foundation © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e277 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kelly R. Pekala More articles by this author Danielle Sharbaugh More articles by this author Jonathan G. Yabes More articles by this author Adam J. Sharbaugh More articles by this author Michelle Yu More articles by this author Valentina Grajales More articles by this author Oluwaseun Orikogbo More articles by this author Hermoon Worku More articles by this author Jordan M. Hay More articles by this author Toby S. Zhu More articles by this author Kody M. Armann More articles by this author Chandler N. Hudson More articles by this author Benjamin J. Davies More articles by this author Bruce L. Jacobs More articles by this author Expand All Advertisement PDF DownloadLoading ...

PD11-03 ACCURACY AND RACIAL/ETHNIC REPRESENTATION OF PROSTATE CANCER SCREENING VIDEOS ON YOUTUBE AND TIKTOK

You have accessJournal of UrologyCME1 May 2022PD11-03 ACCURACY AND RACIAL/ETHNIC REPRESENTATION OF PROSTATE CANCER SCREENING VIDEOS ON YOUTUBE AND TIKTOK Max Abramson, Nathan Feiertag, Darius Javidi, Stacy Loeb, and Kara Watts Max AbramsonMax Abramson More articles by this author , Nathan FeiertagNathan Feiertag More articles by this author , Darius JavidiDarius Javidi More articles by this author , Stacy LoebStacy Loeb More articles by this author , and Kara WattsKara Watts More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002537.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Black men have higher incidence and mortality from prostate cancer than white men, and Hispanic men have an increased risk of advanced stage disease. Health-related videos on social media have increased markedly in recent years, and a vast majority of Black and Hispanic adults use social media. We investigated the content quality and racial/ethnic representation of prostate cancer screening videos on YouTube and TikTok. METHODS: The top 50 videos for the search term “prostate cancer screening” on both YouTube and TikTok were retrieved in a cache-cleared browser. Three reviewers analyzed all videos using validated criteria for the quality of consumer health information (DISCERN and PEMAT). High quality was defined as: DISCERN ≥4, PEMAT understandability ≥75%, and PEMAT actionability ≥75%. Additionally, a published Likert scale was used to demonstrate the level of misinformation compared to American Urological Association and National Comprehensive Cancer Network guidelines. Perceived race and ethnicity of people in the videos were assessed by consensus approach. RESULTS: Median number of views was lower on YouTube than TikTok (909, range: 12-221,003 vs 23,150, range: 640-13,900,000). Perceived Black and Hispanic representation was present in 10% and 6% of YouTube videos, and 20% and 12% of TikTok videos, respectively. High-risk racial/ethnic groups were explicitly discussed in 46% of YouTube videos and 8% of TikTok videos. 98% of YouTube videos and 100% of TikTok videos had low to moderate quality consumer health information, and 88% of YouTube videos and 100% of TikTok videos had moderate to high levels of misinformation based on screening guidelines. CONCLUSIONS: Social media videos about prostate cancer screening are widely viewed but do not provide quality consumer health information. Black and Hispanic men remain underrepresented on both platforms, and high-risk racial groups were not discussed in most videos despite the importance for screening criteria. The low understandability, low actionability, significant misinformation, and a lack of diversity in online videos may contribute to disparities in prostate cancer screening. Source of Funding: Funding for SL: Department of Defense Health Disparity Research Award, the Prostate Cancer Foundation and the Edward Blank and Sharon Cosloy-Blank Family Foundation © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e189 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Max Abramson More articles by this author Nathan Feiertag More articles by this author Darius Javidi More articles by this author Stacy Loeb More articles by this author Kara Watts More articles by this author Expand All Advertisement PDF DownloadLoading ...

V12-12 PENOSCROTAL DECOMPRESSION OF REFRACTORY ISCHEMIC PRIAPISM: SURGICAL TECHNIQUE

You have accessJournal of UrologyCME1 May 2022V12-12 PENOSCROTAL DECOMPRESSION OF REFRACTORY ISCHEMIC PRIAPISM: SURGICAL TECHNIQUE Nicholas Ottaiano, Ganesh Sanekommu, Christopher Koller, Wayne Hellstrom, Allen Morey, and Omer Raheem Nicholas OttaianoNicholas Ottaiano More articles by this author , Ganesh SanekommuGanesh Sanekommu More articles by this author , Christopher KollerChristopher Koller More articles by this author , Wayne HellstromWayne Hellstrom More articles by this author , Allen MoreyAllen Morey More articles by this author , and Omer RaheemOmer Raheem More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002638.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Outcomes after distal shunting have low rates of success in cases of refractory ischemic priapism lasting more than 48 hours. Current American Urological Association (AUA) guidelines recommend proximal shunting following a failed distal shunt; however, proximal shunting is no longer common practice due to the technically challenging nature of the procedure. METHODS: A 43 year old African American male presented to our institutional hospital from an outside hospital for refractory ischemic priapism lasting longer than 72 hours. Corporal blood gas analysis confirmed priapism of ischemic nature, penile duplex ultrasound confirmed an absence of blood flow. The remaining lab work (CBC, urine toxicology, and Hb electrophoresis) was negative. Corporal decompression via a penoscrotal approach was then performed in hopes of preserving the patient's erectile function. RESULTS: Penoscrotal decompression proved to be an effective and safe way of managing refractory ischemic priapism. The technique showed to produce favorable results while maintaining adequate sexual function. Longer follow up periods and a larger patient size is needed for future evaluation. CONCLUSIONS: Corporal decompression via a penoscrotal incision has recently emerged as a viable alternative to proximal shunting with favorable outcomes in select patients. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e970 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicholas Ottaiano More articles by this author Ganesh Sanekommu More articles by this author Christopher Koller More articles by this author Wayne Hellstrom More articles by this author Allen Morey More articles by this author Omer Raheem More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP46-08 COST AND UTILIZATION OF CONCURRENT VS STAGED TESTICULAR IMPLANT FOR RADICAL ORCHIECTOMY

You have accessJournal of UrologyCME1 May 2022MP46-08 COST AND UTILIZATION OF CONCURRENT VS STAGED TESTICULAR IMPLANT FOR RADICAL ORCHIECTOMY Arman Walia, Joshua Horns, Niraj Paudel, Aditya Bagrodia, Jim Hotaling, and Tung-Chin Hsieh Arman WaliaArman Walia More articles by this author , Joshua HornsJoshua Horns More articles by this author , Niraj PaudelNiraj Paudel More articles by this author , Aditya BagrodiaAditya Bagrodia More articles by this author , Jim HotalingJim Hotaling More articles by this author , and Tung-Chin HsiehTung-Chin Hsieh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002612.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: American Urological Association guidelines recommend testicular prosthesis discussion prior to orchiectomy. Utilization may be low. We investigated outcomes and care utilization between concurrent implant (CI) and staged implant (SI) insertion after radical orchiectomy. METHODS: The MarketScan Commercial claims database (2008-2017) was queried for men >18-years-old who underwent radical orchiectomy for testicular tumor, stratified as orchiectomy with no implant, CI, or SI (any time post-orchiectomy). 90-day outcomes included rate of reoperation, readmission, emergency department (ED) presentation, and outpatient visits. Regression models provided rate ratio comparison. RESULTS: 8803 (8564 no implant, 190 CI, 49 SI) patients were identified with no difference in age, Charlson comorbidity index, benefit plan, additional cancer treatment, or metastasis. Median perioperative cost at orchiectomy (+/- implant) for no implant, CI, and SI were $5682 (3648-8554), $7823 (5403-10973), and $5380 (4130-10521), respectively (p<0.001). Median perioperative cost for SI at implantation was $8180 (4920-14591) for a total cost (orchiectomy + implant) of $13560 (5380 + 8180). Total postoperative costs stratified by additional cancer treatment (chemotherapy, radiation, retroperitoneal surgery) are in Table 1. 90-day care utilization is in Table 2. CI patients were more likely to have follow-up (OR 2.48, p=0.006) with more visits (OR 1.54, p=0.030) compared to the SI group post-implantation, but had similar follow-up (OR 1.93, p=0.065) and less visits (OR 1.29, p=0.025) compared to the SI patients’ post-orchiectomy period. No difference in cost or rate of ED visits, readmission, or reoperation was identified.Overall explant rates were 4.7% (9) for CI and 14.3% (7) for SI (p=0.04) with a median time to explant of 166 (135-210) and 40 (9.5-141.5) days, respectively (p=0.06). Median cost of removal was $2060 (IQR 967-2880). CONCLUSIONS: CI placement has less total perioperative cost, lower explant rate, and similar postoperative utilization compared to SI. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e775 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arman Walia More articles by this author Joshua Horns More articles by this author Niraj Paudel More articles by this author Aditya Bagrodia More articles by this author Jim Hotaling More articles by this author Tung-Chin Hsieh More articles by this author Expand All Advertisement PDF DownloadLoading ...

An Approach to the Management of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia.

Benign prostatic hyperplasia (BPH) is a condition that affects up to 50% of men over the age of 50; the condition’s prevalence increases with age, particularly after the age of 40. BPH can lead to lower urinary tract symptoms (LUTS) which can have a significant negative impact on health-related quality of life (HRQoL). Men presenting with a gradual onset of LUTS are often suspected to have BPH. However, the clinician must recognize that LUTS possess many different aetiologies. This article aims to provide medical students with a stepwise approach to the diagnosis and management of LUTS that are secondary to BPH. The outlined approach describes the differential diagnoses, required investigations, and management-related details for LUTS that are secondary to BPH. This approach is based off of relevant Canadian, American, and European urological association guidelines.

Cost Analysis of Online Telehealth Platforms Offering Testosterone Therapy

ABSTRACT Introduction Online telehealth platforms are becoming increasingly common across several areas of medicine, including those related to men's health conditions. These ventures now offer virtual services for the evaluation of testosterone deficiency and treatment via the online sale of testosterone therapy (TTh). Objective We sought to compare the cost of undergoing virtual evaluation and treatment with TTh via online telehealth platforms, as compared to what may be offered by a board-certified urologist following the American Urologic Association (AUA) guidelines at a tertiary care center. Methods Google was queried to identify platforms that offer an online consultation and prescription service for TTh. Platforms that did not provide transparency of services including details of the initial consultation, laboratory work, type of medication offered, and associated fees on the company website were excluded. Information regarding the type of providers used, services and laboratory work included in the initial consultation, and price for the evaluation and three months of treatment with TTh were gathered. These were compared to the services and prices that a board-certified urologist at a tertiary care center may offer while following the AUA guidelines for the evaluation and management of testosterone deficiency. Costs for services at the tertiary care center were estimated using a single institution's online cost estimator1 for a patient with no insurance, a patient with basic employee insurance, and a patient with Medicare. Results A total of three online platforms met inclusion criteria: Hone, Regenex Health, and TRT Nation. The services provided for the initial evaluation and for follow up of patients on TTh were similar between the online platforms and those suggested by AUA guidelines (Table 1). The cost of the initial consultation including laboratory services were lowest for the patient with Medicare at a tertiary center ($0) and via the online platform, Hone ($45.00) (Table 2). The estimated cost for three months of treatment with TRT including follow up was lowest among the patient with Medicare ($32.79) and the patient with basic employee insurance ($192.58) at the tertiary center (Table 3). The cost of three months of treatment and follow up was highest via the online platform Regenex Health ($1,059.00). Conclusions While online telehealth platforms may offer a cost benefit in the initial consultation and evaluation for TRT for some patients, the cost of ongoing treatment greatly exceeds that which may be obtained at a tertiary care center for patients with basic insurance plans or Medicare. Patients without insurance may encounter a high cost of initial evaluation at a tertiary center, however, ongoing follow up and medication costs for these patients is likely similar between select online platforms and a tertiary center. Disclosure No

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Minimizing Antibiotic Use in Urethral Reconstruction.

There are no established guidelines regarding management of antibiotics for patients specifically undergoing urethral reconstruction. Our aim was to minimize antibiotic use by following a standardized protocol in the pre-, peri- and postoperative setting, and adhere to American Urological Association antibiotic guidelines. We hypothesized that prolonged suppressive antibiotics post-urethroplasty does not prevent urinary tract infection and/or wound infection rates. We prospectively treated 900 patients undergoing urethroplasty or perineal urethrostomy at 11 centers over 2 years. The first-year cohort A received prolonged postoperative antibiotics. Year 2, cohort B, did not receive prolonged antibiotics. A standardized protocol following the American Urological Association guidelines for perioperative antibiotics was used. The 30-day postoperative infectious complications were determined. We used chi-square analysis to compare the cohorts, and multivariate logistic regression to identify risk factors. The mean age of participants in both cohorts was 49.7 years old and the average stricture length was 4.09 cm. Overall, the rate of postoperative urinary tract infection and wound infection within 30 days was 5.1% (6.7% in phase 1 vs 3.9% in phase 2, p=0.064) and 3.9% (4.1% in phase 1 vs 3.7% in phase 2, p=0.772), respectively. Multivariate logistic regression analysis of patient characteristics and operative factors did not reveal any factors predictive of postoperative infections. The use of a standardized protocol minimized antibiotic use and demonstrated no benefit to prolonged antibiotic use. There were no identifiable risk factors when considering surgical characteristics. Given the concern of antibiotic over-prescription, we do not recommend prolonged antibiotic use after urethral reconstruction.

Growth kinetics and progression rates of cystic renal masses on active surveillance.

298 Background: The Bosniak classification is used to risk stratify the probability of cancer among cystic renal masses using CT or MRI and assigns a class ranging from I-IV. Bosniak III and IV masses have the highest probabilities of cancer and are treated similarly to solid renal masses per 2021 American Urological Association (AUA) Guidelines. The purpose of this study was to determine the growth kinetics and progression rates of unresected Bosniak III and IV masses defined by Bosniak Classification, version 2019 (v2019). Methods: In this retrospective and IRB-approved study, CT and MRI images of 107 cystic renal masses from 100 patients (34 women, 66 men; range 28-92 years) with unresected Bosniak III and IV masses from 2005-2021 were reviewed. Cystic renal masses on baseline imaging were assigned a category based on v2019 by two abdominal radiologists, with discrepancies resolved by a third, such that each mass had a single Bosniak class assignment. Mass dimensions over serial imaging were measured using orthogonal planes by a radiologist with 3D laboratory training. Linear growth rate (mm/year) and volumetric growth rate (mL/year) were calculated. “Progression” off of active surveillance was defined as any of the following: linear growth rate &gt; 5 mm a year, volume doubling rate ≤ 1 year, or increased stage based on TNM. Results: 107 cystic renal masses were categorized as 51 Bosniak III and 56 Bosniak IV masses on baseline exam. Median follow-up time was 406 days. Linear growth rate for Bosniak III masses was 0.4 ± 4.3 mm/year while linear growth rate for Bosniak IV masses was 2.3 ± 4.9 mm/year (p = 0.036; Student’s t-test). 12/51 (24%) Bosniak III masses progressed based on above definitions while 26/56 (46%) Bosniak IV masses progressed (p = 0.016; Fisher’s exact test). 13 masses upgraded from a Bosniak III to IV during surveillance, but category upgrades were not associated with progression (p = 0.131; Fisher’s exact test). 2 patients developed lung metastases; both masses were Bosniak IV and were biopsy proven papillary and clear cell renal cell carcinomas. Conclusions: Although currently treated similarly by AUA Guidelines, unresected Bosniak IV masses grow faster than Bosniak III masses and are more likely to progress off of active surveillance.

Long-term follow-up of intravesical gemcitabine and docetaxel as rescue therapy for nonmuscle-invasive bladder cancer.

573 Background: Intravesical bacillus Calmette-Guérin (BCG) is the first-line treatment for high-risk non-muscle invasive bladder cancer (NMIBC). Unfortunately, disease recurrence/progression is common and associated with increased risk of death from bladder cancer. While radical cystectomy remains the preferred treatment for BCG unresponsive NMIBC, many patients are either unwilling or unfit to undergo surgery. Previous retrospective studies have demonstrated the efficacy of intravesical gemcitabine and docetaxel (Gem/Doce) for treating NMIBC after BCG failure. However, the long-term outcomes of this cohort are unknown. We report 5-year survival outcomes of patients treated with intravesical Gem/Doce after BCG failure. Methods: We retrospectively identified patients at our institution who were treated with Gem/Doce for high-risk NMIBC after BCG failure between 2009 and 2017. Patients received six weekly intravesical Gem/Doce instillations. Initial responders received monthly maintenance instillations for 2 years. Surveillance was performed according to American Urological Association guidelines. Survival time was measured from start of Gem/Doce induction. Outcomes included high-grade recurrence-free survival (HG-RFS), progression-free survival (PFS), cystectomy-free survival (CFS), cancer-specific survival (CSS) and overall survival (OS). Recurrence was defined as pathologically confirmed tumor relapse in the bladder or prostatic urethra. Progression was defined as recurrence of disease with stage T2 or greater, cystectomy or death due to bladder cancer. Survival probabilities were calculated with the Kaplan-Meier method. Results: A total of 97 patients with a median age of 73 years were treated with Gem/Doce after BCG failure. Median follow-up was 49 months. BCG failure was further stratified as BCG unresponsive (35%), BCG relapsing (38%), BCG intolerant (11%) or unspecified (16%). 71% and 21% of patients had carcinoma in-situ and high-grade T1 disease, respectively. Complete response at initial surveillance was 74% and median duration of response was 26 months. Overall HG-RFS at 1, 2 and 5 years was 60%, 51% and 31%, respectively. HG-RFS was similar among BCG unresponsive patients and the overall cohort (see table). During follow-up, 18 patients (19%) underwent radical cystectomy and 28 patients (29%) experienced disease progression. PFS, CFS, CSS and OS at 5 years was 68%, 75%, 91% and 64%, respectively. Conclusions: Intravesical Gem/Doce for high-risk NMIBC after BCG failure offers long-term efficacy and substantial durability of response with a high likelihood of bladder preservation at five years after induction. Future prospective trials assessing Gem/Doce are warranted.[Table: see text]

Ethical Considerations for the Workup of the Microhematuria Patient. Letter.

No AccessJournal of UrologyLetters to the Editor1 May 2022Ethical Considerations for the Workup of the Microhematuria Patient. Letter. Jacob M. Gaines, Eric J. Macdonald, and Simon J. Hall Jacob M. GainesJacob M. Gaines https://orcid.org/0000-0003-1949-0225 Smith Institute for Urology at Northwell Health of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York More articles by this author , Eric J. MacdonaldEric J. Macdonald Smith Institute for Urology at Northwell Health of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York More articles by this author , and Simon J. HallSimon J. Hall * E-mail Address: [email protected] Smith Institute for Urology at Northwell Health of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002468AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Ethical Considerations for the Workup of the Microhematuria Patient. Letter.." The Journal of Urology, 207(5), pp. 1161–1162 REFERENCES 1. : Diagnostic and cost implications of the 2020 AUA microhematuria guidelines: modeling impact in a large public health care system. J Urol 2022; 207: 52. Link, Google Scholar 2. : Microhematuria: AUA/SUFU guideline. J Urol 2020; 204: 778. Link, Google Scholar 3. : Evaluation of the new American Urological Association guidelines risk classification for hematuria. J Urol 2021; 205: 1387. Link, Google Scholar 4. : Comparison of microscopic hematuria guidelines as applied in 1018 patients with microscopic hematuria. Urology 2021; 154: 28. Google Scholar 5. : Psychological distress associated with active surveillance in patients younger than 70 with a small renal mass. Urol Oncol 2020; 38: 603.e17. Google Scholar 6. : Mental health implications in bladder cancer patients: a review. Urol Oncol 2019; 37: 97. Google Scholar 7. : Delays in diagnosis and bladder cancer mortality. Cancer 2010; 116: 5235. Google Scholar 8. : Non-maleficence and the ethics of consent to cancer screening. J Med Ethics 2020; 47: 510. Google Scholar © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue 5May 2022Page: 1161-1162 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jacob M. Gaines Smith Institute for Urology at Northwell Health of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York More articles by this author Eric J. Macdonald Smith Institute for Urology at Northwell Health of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York More articles by this author Simon J. Hall Smith Institute for Urology at Northwell Health of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York * E-mail Address: [email protected] More articles by this author Expand All Advertisement PDF DownloadLoading ...

A0228 - A urine-based molecular assay refines the risk stratification of the recent American Urological Association guideline on hematuria

A0228 - A urine-based molecular assay refines the risk stratification of the recent American Urological Association guideline on hematuria

Evaluating Patient Preferences in Benign Prostatic Hyperplasia Treatment Using Conjoint Analysis

ObjectiveTo quantify benign prostatic hyperplasia (BPH) patient preferences to promote guidelines-compliant, patient-centered care. Discordance between patient and urologist priorities for the treatment of BPH hinders patient-centered care. Physician assumptions regarding patient preferences lead to dissatisfied patients; a poor outcome in any quality of life surgery. American Urologic Association guidelines urge urologists to consider patient preferences when recommending a BPH treatment. MethodsIn this cross-sectional, online survey study using researchmatch.org, participants were required to decide between theoretical BPH treatments in a balanced, choice-based conjoint analysis. The treatments had varying levels of four attributes: efficacy, recovery difficulty, risk of complications (Clavien-Dindo 2+), and risk of de novo ejaculatory dysfunction. Demographic information and International Prostate Symptom Score were collected and analyzed using comparative statistics. Each attribute was analyzed using a conditional logit model, and attribute importance (range in utility between attribute-levels) was calculated. ResultsOut of 1235 recruited participants, 812 (66%) completed the study. Median International Prostate Symptom Score and age was 6 (IQR 3-12) and 56 (IQR 38-67), respectively. Complication risk was the most important attribute, followed by efficacy, recovery difficulty, and risk of ejaculatory dysfunction. In a subgroup analysis of age quartiles, participants age <38 and >67 held efficacy (31%) and complication risk (47%) to the highest relative importance, respectively. ConclusionMales valued BPH treatments that minimize complication risks, while ejaculatory dysfunction was least impactful. Variation in results between age subgroups emphasizes the need for individualized care to maximize patient satisfaction.

Statička i dinamska komponenta opstrukcije kod benigne hiperplazije prostate

Introduction / Goal: Benign prostatic hyperplasia (BPH) is the most common benign neoplasm that occures in male population with an incidence of 45 to 90% between 50 and 80 years of age. BPH can cause an increase in output resistance, or an increase in resistance to urine flow, with its static and dynamic components. In clinical practice, the most common pharmacological treatment of lower urinary tract symptoms (LUTS) in patients with BPH is based on monotherapy with alpha-blockers, 5-alpha-reductase inhibitors or combination therapy. The aim of this review is to determine the main therapeutic and side effects of the most common pharmacological therapy and the recommended approaches of the European Association of Urology (EAU) and the American Urological Association (AUA) in the diagnosis of benign prostate obstruction (BPO). Method: Selective literature search with additional examination of EAU and AUA guidelines and meta-analysis. Results: The treatment of patients with BPH is complex. The factors on the basis of which treatment decisions are made are based on the patient's subjective perception of symptoms and quality of life due to LUTS and in relation to the presence of subvesical obstruction. Urodynamic pressureflow studies are the basis for the definition of BPO due to BPH or other etiology. Non-invasive uroflowmetry, determination of residual urine after urination (PVR) and non-invasive ultrasound tests are of great use in the diagnosis of BPO. Treatment with alpha1 receptor inhibitors (alpha-blockers), or 5-alpha-reductase inhibitors may be considered in patients with predominantly urinary dysfunction. Conclusion: Standard pharmacological medical treatment for BPH / LUTS is still based on alphablockers, 5-alpha-reductase inhibitors or a combination thereof. In the future, BPH / LUTS treatment is expected to become individualized, according to the type of symptoms, the presence of sexual dysfunction and the risk of BPH progression.