Short-Term Changes in Vasectomy Consults and Procedures Following Dobbs v Jackson Women's Health Organization

INTRODUCTION

On June 24, 2022, the US Supreme Court issued its decision on Dobbs v Jackson Women's Health Organization (Dobbs). This decision had major implications on female reproductive choices, but also had potential implications on their male counterparts. We sought to determine the association of Dobbs with the number and characteristics of men seeking vasectomy.

METHODS

A retrospective review was performed to determine the number of vasectomy consults and procedures completed at a single Michigan health system in the 6 months following Dobbs (June 24, 2022-December 24, 2022) vs the same 6-month time frame between 2019 and 2021. Another retrospective review was conducted in the 3 months following Dobbs (June 24, 2022-September 24, 2022) vs the same days in 2021 to determine the number of vasectomy consults completed and to evaluate for differences in the characteristics of these men.

RESULTS

In the 6 months after Dobbs, there was a 150% and 160% increase in vasectomy consults and procedures completed, respectively, compared to a similar time frame in 2019 to 2021. In the 3 months after Dobbs, there was a 225% increase in new vasectomy consults compared to a similar time frame in 2021. There were no differences in the age, race, religion, median household income, or insurance type of men seeking vasectomy consult pre- vs post-Dobbs. Partnerless men (odds ratio 3.66) and those without children (odds ratio 2.85) were more likely than married men and those with 3 or more children, respectively, to seek vasectomy consult post-Dobbs.

CONCLUSIONS

Dobbs was associated with a marked increase in vasectomy consultations and procedures at our institution in the state of Michigan. Future studies are needed to determine the long-term implications of Dobbs on vasectomy practices and determine if vasectomy practices differ by states and their respective abortion laws.

Epididymectomy Is an Effective Treatment for Chronic Epididymal Pain

INTRODUCTION

Chronic scrotal pain is difficult to manage, and epididymectomy is a treatment option for a subset of men with pain localized to the epididymis. We sought to evaluate the efficacy of epididymectomy at our institution.

METHODS

Between 2000 and 2020, 225 men underwent epididymectomy at our institution for pain localized to the epididymis and not part of a greater constellation of pelvic pain or urinary symptoms. Our primary outcome measure was change in pain after epididymectomy, categorized as cured/improved or no change/worsened. Multivariable logistic regression compared the impact of pain duration, and surgical and psychiatric histories on postoperative pain.

RESULTS

Patients in both outcome categories-cured/improved and no change/worsened-were similar in age and BMI. Overall, 162 patients (72%) reported cured/improved pain at the last documented follow-up visit. Median follow-up time was 12 (IQR 1-364) weeks. About half of the cohort (n = 117, 52%) had a prior vasectomy, and there was no difference in outcome based on vasectomy history on multivariate analysis (OR 0.625, P = .3). Men with pain duration > 1 year (OR 0.46, P = .03), diagnosed psychiatric conditions (OR 0.44, P = .04), or prior scrotal/inguinal/abdominal surgeries other than vasectomy (OR 0.47, P = .03) had decreased odds of pain relief after epididymectomy.

CONCLUSIONS

This 20-year analysis is the largest review of postepididymectomy outcomes reported. Among carefully screened men, 72% had resolution or improvement of scrotal pain. Epididymectomy is most effective for men with < 1 year of focal epididymal pain, with no history of psychiatric conditions or scrotal/inguinal/abdominal surgery other than vasectomy.

Assessment of neophallus length following metoidioplasty

Background

An increasing number of gender diverse individuals are presenting for gender affirming care. An option for genital gender affirming surgery (gGAS) in transmasculine individuals is metoidioplasty, creating a small neophallus from enlarged clitoral tissue following prolonged testosterone exposure. The goal of this study is to understand factors which contribute to greater exposed neophallus length following metoidioplasty.

Methods

We performed a retrospective chart review on patients presenting to a single academic institution who underwent a metoidioplasty. All operations were performed using the Belgrade technique with or without urethral lengthening depending on patient preference.

Results

Twenty-seven patients underwent metoidioplasty from 2017-2022. Sixteen had recorded stretched clitoral length (pre-operatively) and exposed neophallus length (post-operatively). The median length of time on testosterone therapy was 4.6 years. The median stretched clitoral length was 5.8 cm, and exposed neophallus length was 6 cm. There was a strong correlation between pre-operative length and post-operative length (ρ=0.9; P<0.0001). There were no correlations between pre-operative length or exposed neophallus length and BMI (ρ=-0.02, P=0.93; ρ=0.05, P=0.83, respectively). Time on testosterone does not correlate with stretched clitoral length nor exposed neophallus length (ρ=-0.28, P=0.15; ρ=-0.35, P=0.18, respectively).

Conclusions

Patients considering metoidioplasty often wonder how large their neophallus will be. We found that patients can expect exposed neophallus length to be about 0.6 cm longer than their pre-operative stretched clitoral length. No evidence of association of time on testosterone nor BMI with exposed neophallus length was found. This information is crucial for gender diverse patients to make informed decisions about gGAS.

Endoscopic management of a spontaneous rectus sheath hematoma causing bladder perforation

Rarely pelvic hemorrhage events can lead to bladder perforation. We present a 48-year-old female who developed a spontaneous rectal sheath hematoma which perforated her bladder. Her case was monitored with serial MRI imaging and managed with two endoscopic clot resections which demonstrated new epithelialization of the bladder wall across the hematoma point of entry. We conclude that the bladder has an impressive potential to heal and select cases of symptomatic invasive bladder hematomas may be monitored with serial imaging and managed endoscopically.

Men's Health: Scrotal and Testicular Conditions

Scrotal and testicular conditions include benign masses, infections, testicular torsion, and testicular cancer. Common palpable benign scrotal masses include spermatocele, varicocele, and hydrocele. Most patients with these masses require no treatment. Some varicoceles are associated with impaired fertility, probably due to an increase in scrotal temperature that leads to testicular hyperthermia, oxidative stress, and reduced spermatogenesis. Patients with documented infertility or scrotal pain should be referred to a urology subspecialist for consideration of surgical management. Epididymitis and epididymo-orchitis are caused by infection with Neisseria gonorrhoeae, Chlamydia trachomatis, or enteric bacteria. Antibiotics and supportive measures (eg, scrotal elevation, bed rest) are recommended for management of acute epididymitis. Testicular torsion is a urologic emergency that requires rapid surgical exploration and orchidopexy to reduce the risk of testicular loss due to ischemia. Salvage rates exceed 90% when surgical exploration is performed within 6 hours of symptom onset. Testicular cancer commonly manifests as a painless, incidentally discovered mass in a single testis. Ultrasonography is recommended to confirm the diagnosis. The recommended primary intervention for a suspected malignant testicular tumor is radical inguinal orchiectomy.

Men's Health: Prostate Cancer Screening

Prostate cancer is the second most common nondermatologic cancer in males in the United States. The median age at diagnosis is 66 years and median age at death is 80 years, with most patients diagnosed between ages 55 and 74 years. Black men are at greatest risk of developing and dying of prostate cancer. The U.S. Preventive Services Task Force (USPSTF) and American Urological Association (AUA) guidelines recommend shared decision-making in consideration of screening for men ages 55 to 69 years. Currently, digital rectal examination alone is not recommended for prostate cancer screening. The serum prostate-specific antigen (PSA) test remains the most common screening tool. Novel formulas and algorithms, including the Prostate Health Index (phi) and the 4Kscore, which use total PSA, free PSA, and other information to estimate risk, have shown greater predictive values for detection than the PSA test. Risk assessment with magnetic resonance imaging (MRI) study with or without MRI/transrectal ultrasonography (TRUS) targeted biopsy requires fewer biopsy specimens than traditional TRUS-guided biopsy, and is associated with higher detection rates. Studies of specific lifestyle modifications to minimize prostate cancer risk have shown inconclusive results; however, high carbohydrate and animal fat intakes may increase the risk.

Masculinizing Genital Gender Confirmation Surgery

INTRODUCTION

This article is the third in a 3-part series focused on the comprehensive treatment of gender dysphoria. Multidisciplinary gender dysphoria care may involve a combination of counseling, social gender transition, hormone therapy, and gender confirmation surgery (GCS) to maximize physical characteristics congruent with a patient's gender identity. Nonoperative management of gender dysphoria was covered in part 1. The focus of part 2 was feminizing GCS. In part 3, surgical considerations for masculinizing GCS are summarized, including a review of different phalloplasty techniques. This installment also includes information about adjunctive procedures, therapies, and products used by transgender men and women to express their gender identity.

AIM

To provide an overview of both genital and nongenital masculinizing gender confirmation procedures. To review phalloplasty techniques, preoperative considerations, complications, and outcomes. To summarize ancillary services and procedures available to transgender patients to facilitate their gender presentation.

METHODS

A review of relevant literature through May 2017 was performed via PubMed.

MAIN OUTCOME MEASURES

To summarize ancillary products and services used by transgender patients and to review surgical considerations for masculinizing genitoplasty.

RESULTS

A variety of nonsurgical ancillary services exist for transgender patients to aid their transition. A variety of phalloplasty procedures have been developed for transgender men who seek genital GCS. Most surgeons prefer radial forearm phalloplasty, including the authors whose surgical technique is described. Each phalloplasty approach is associated with its own benefits, drawbacks, and complications.

CONCLUSION

A variety of ancillary services and procedures that help transgender men and women communicate their gender identity in society is available and is an important adjunct to medical or surgical treatment of gender dysphoria. Pre-operative, intra-operative, and post-operative considerations of masculinizing genital gender confirmation procedures were reviewed. Hadj-Moussa M, Agarwal S, Ohl DA, et al. Masculinizing Genital Gender Confirmation Surgery. Sex Med Rev 2019;7:141-155.

Evaluation and Treatment of Gender Dysphoria to Prepare for Gender Confirmation Surgery

BACKGROUND

Gender dysphoria is the experience of marked distress due to incongruence between genetically determined gender and experienced gender. Treatment of gender dysphoria should be individualized and multidisciplinary, involving a combination of psychotherapy, social gender transition, cross-sex hormone therapy, gender-affirming surgery, and/or ancillary procedures and services. The goal of all treatment modalities is to alleviate distress and affirm the patient's experienced gender identity. This article is the first in a 3-part series focused on the diagnostic assessment and non-operative treatment of gender dysphoria. Parts 2 and 3 focus on operative aspects of gender dysphoria treatment.

AIM

To summarize the recommendations of the World Professional Association for Transgender Health (WPATH) and the Endocrine Society (ES), as well as review published literature regarding the non-operative treatment of gender dysphoria.

METHODS

A review of relevant literature through January 2017 was performed via PubMed.

OUTCOMES

WPATH guidelines regarding diagnosis and non-surgical treatment of gender dysphoria, specifically regimens and risks of cross-sex hormone therapy were reviewed.

RESULTS

Few physicians have experience with the diagnosis or treatment of gender dysphoria, although the number of patients seeking treatment has risen substantially in recent years. As a result, clinicians have turned to published recommendations from WPATH and ES, both of which promote high-quality, evidence-based care for patients with gender dysphoria. Successful treatment requires an individualized multidisciplinary approach. Non-operative treatment is both safe and effective for the majority of patients with gender dysphoria.

CONCLUSIONS

Guidelines from WPATH and ES, along with published literature pertaining to the diagnosis and non-operative treatment of gender dysphoria, were reviewed and summarized. Hadj-Moussa M, Ohl DA, Kuzon WM. Evaluation and Treatment of Gender Dysphoria to Prepare for Gender Confirmation Surgery. Sex Med Rev 2018;6:607-617.

Outcomes of Ureteroscopic Stone Treatment in Patients With Spinal Cord Injury

OBJECTIVE

To evaluate the association of clinical factors on outcomes in patients with spinal cord injury (SCI) undergoing ureteroscopy. Immobility, recurrent urinary tract infection, and lower urinary tract dysfunction contribute to renal stone formation in patients with SCI. Ureteroscopy is a commonly utilized treatment modality; however, surgical complication rates and outcomes have been poorly defined. Evidence guiding safe and effective treatment of stones in this cohort remains scarce.

METHODS

Records were retrospectively reviewed for patients with SCI who underwent ureteroscopy for kidney stones from 1996 to 2014 at a single institution. Multivariate relationships were evaluated using a general estimating equation model.

RESULTS

Forty-six patients with SCI underwent a total of 95 ureteroscopic procedures. After treatment, stone-free rate was 17% and 20% with <2-mm fragments. The complication rate was 21%. On multivariate analysis, SCI in cervical (C) levels was associated with higher risk of complications (C3: odds ratio [OR] 3.83, 95% confidence interval [CI] 2.17-6.98; C6: OR 3.83, 95% CI 1.08-13.53). American Spinal Injury Association Scale A classification was associated with a lower probability of stone-free status (OR 0.16, 95% CI 0.03-0.82). Patients averaged 2.2 procedures yet more procedures were associated with lower stone-free status (OR 0.83, 95% CI 0.03-0.32). Chronic obstructive pulmonary disease and bladder management modality were not associated with stone-free status or complications.

CONCLUSION

In patients with SCI, higher injury level and complete SCI were associated with worse stone clearance and more complications. Stone-free rate was 17%. Overall, flexible ureteroscopy is a relatively safe procedure in this population. Alternative strategies should be considered after failed ureteroscopy.

Diversity of patient profile, urethral stricture, and other disease manifestations in a cohort of adult men with lichen sclerosus

Purpose

Lichen sclerosus (LS) in men is poorly understood. Though uncommon, it is often severe and leads to repeated surgical interventions and deterioration in quality of life. We highlight variability in disease presentation, diagnosis, and patient factors in male LS patients evaluated at a tertiary care center.

Materials and Methods

We retrospectively reviewed charts of male patients presenting to our reconstructive urology clinic with clinical or pathologic diagnosis of LS between 2004 and 2014. Relevant clinical and demographic information was abstracted and descriptive statistics calculated. Subgroup comparisons were made based on body mass index (BMI), urethral stricture, and pathologic confirmation of disease.

Results

We identified 94 patients with clinical diagnosis of LS. Seventy percent (70%) of patients in this cohort had BMI >30 kg/m², and average age was 51.5 years. Lower BMI patients were more likely to suffer from urethral stricture disease compared to overweight counterparts (p=0.037). Patients presenting with stricture disease were more likely to be younger (p=0.003). Thirty percent (30%) of this cohort had a pathologic diagnosis of LS.

Conclusions

Urethral stricture is the most common presentation for men with LS. Many patients endure skin scarring and have numerous comorbidities. Patient profile is diverse, raising the concern that not all patients with clinical diagnosis of LS are suffering from identical disease processes. The rate of pathologic confirmation at a tertiary care institution is alarmingly low. Our findings support a role for increased focus on pathologic confirmation and further delineation of the subtype of disease based on location and clinical manifestations.

Comparison of a single center, academic surgeon real-world experience with three percutaneous nephrolithotomy lithotripters

INTRODUCTION

We compared a single surgeon, single-institution experience with the Wolf Ultrasonic Model #2167.05 (Richard Wolf Medical Instruments Co., Vernon Hills, IL, USA), Lithoclast Ultra (Boston Scientific, Natick, MA, USA), and CyberWand (Gyrus/ACMI, Southborough, MA, USA) lithotripters for percutaneous nephrolithotomy (PCNL). We assessed each lithotripter's performance and durability.

MATERIALS AND METHODS

We conducted a retrospective chart review on 70 sequential PCNLs. Treatments were split into three cohorts based on the type of lithotripter used, Wolf (August 2003 to February 2004), Lithoclast (March 2004 to November 2008), or CyberWand (December 2008 to October 2009). Operative time, repeat PCNL procedures, lithotripter efficacy, patient body mass index (BMI), and stone-free rates (defined as < 4 mm fragment on postoperative day one noncontrast CT scan) were compared.

RESULTS

Sixty-one patients underwent 70 PCNLs using the Wolf (12), Lithoclast (39) or CyberWand (19). The CyberWand cohort had higher rates of obesity (74% versus 53% for Lithoclast and 45% for Wolf) and staghorn calculi (68% versus 39% for Lithoclast and 36% for Wolf). Operative time were 151 minutes (75-384, Wolf), 190 (55-360, Lithoclast) and 200 (81-387, CyberWand) cohorts. Stone-free rates were 50% (Wolf), 49% (Lithoclast) and 37% (CyberWand). PCNL was repeated within 45 days following 6 (50%) Wolf, 7 (18%) Lithoclast and 1 (5%) CyberWand procedures. Lithotripter malfunction complicated 1 Wolf (8%), 5 (13%) Lithoclast and no CyberWand PCNLs. Intraoperative complications occurred during 1 (8%) Wolf, 9 (23%) Lithoclast, and 2 (11%) CyberWand cases.

CONCLUSIONS

Despite treating larger stones in more obese patients, the CyberWand lithotripter had a lower malfunction and need for repeat PCNL rates. These findings suggest that the CyberWand may be a more durable lithotripter. However, the overall efficacy of each lithotripter in performing PCNL was similar.

Effect of high shock number on acute complication development after extracorporeal shockwave lithotripsy

PURPOSE

We assessed whether high shock number is associated with higher rates of acute complication development after extracorporeal shockwave lithotripsy (SWL).

PATIENTS AND METHODS

A retrospective chart review of 372 patients who underwent 436 SWL procedures at 24 kV using a Medstone STS-T lithotripter (Medstone International Inc., Aliso Viejo, CA) was conducted. Complications occurred within 4 weeks of SWL. Treatments were split into three cohorts based on shock number (<2400, 2401-4000, and >4000). Postoperative sequelae of patients who were stone free and those with residual stone were studied separately. Chi-square tests were used to evaluate the relationship between shock number cohort and postoperative complication development.

RESULTS

SWL treatments recorded for each cohort were 158 (37.4%), 145 (34.4%), and 119 (28.2%), respectively. The short-term complication rate when SWL was successful was 8.3% overall. Complication rate for each cohort was 9.5% (11), 7.8% (5), and 7.2% (7), respectively. When SWL was successful, statistical analysis revealed no significant difference between complication rates and shock number cohort (P=0.63). Complications in patients with a residual stone occurred after 41.4% of treatments and trended upward with shock number cohort, but did not reach statistical significance (P=0.84).

CONCLUSIONS

At high voltage, high shock number was not shown to cause higher rates of short-term postoperative complications, as experienced by patients, when SWL was successful or resulted in a residual stone, yet complication rates associated with residual stone burden were approximately five times as common. Forgoing a higher shock number in the presence of a residual stone may therefore increase the risks of sequelae immediately after SWL.

Use of surgical clips prevents suture slippage when ligating folded vas deferens during vasectomy

OBJECTIVE

We describe a technique of surgical clip placement, which prevents slippage when ligating the folded vas deferens during vasectomy.

METHODS

We utilized this technique in 25 consecutive vasectomy procedures. After isolating the vas, two mosquito clamps are placed approximately 2 cm-3 cm apart and a small 5 mm-10 mm section of full thickness vas is removed. The lumen of each cut end is cauterized. Surgical clips (Ethicon Ligaclip Extra LS-200, Medium) are placed at approximately 2 mm, 3 mm and 15 mm (on the opposite side of the hemostat) from each cut end. By rotating the hemostat, the vas is folded on itself and a 3-0 or 4-0 chromic suture is placed between the two proximal clips and distal to the third clip. The hemostat is carefully removed and the vas gently ligated.

RESULTS

A single surgeon noted no instances of suture slippage in 25 consecutive vasectomies. All patients underwent postoperative semen analysis that showed azoospermia.

CONCLUSION

Placement of the ligating suture between two proximal clips and past a third distal clip prevents suture slippage when ligating the folded end of the vas deferens during vasectomy.

Reversible renal insufficiency secondary to extrinsic splenic compression of the kidney in a patient with chronic lymphocytic leukemia

While increased renal venous and direct renal parenchymal pressure may cause renal insufficiency, there are no prior reports of hypersplenism secondary to chronic lymphocytic leukemia (CLL) doing so. This first report of massive splenomegaly leading to marked compression of the left kidney associated with renal insufficiency that resolved after splenectomy illustrates that profound extrinsic renal compression from splenomegaly may significantly compromise left renal function and splenectomy should be considered in this situation.