Background Intracavernosal injection therapy (ICI) is a well-established therapeutic strategy for men with erectile dysfunction. Complications are often related to patient error when performong ICI. Aim The objective of this study was to examine patient errors in an established patient training program for performing ICI and identify factors that could predict major errors. Methods Patients enrolled in our ICI program are trained on technical aspects, and dose titration is begun. Patients are given explicit instructions during training, both verbally and in written form. Records were reviewed for men using ICI for >= 6 months. Multivariable analysis was used to define predictors of major errors. Outcomes Errors were listed as minor (zero-response injection, penile bruising, expired medication) and major (errors potentially leading to priapism: dose self-titration, double injecting). Results Overall, 1368 patients met the inclusion criteria and were included in the analysis. The mean patient age was 66 +/- 22 (range 29-91) years. Regarding education, 41% of patients had graduate-level education, 48% had college education, and 11% high school education. Mean follow-up was 3.2 +/- 7.6 (range 0.5-12) years. The agents used were trimix (62%), bimix (35%), papaverine (2%), and prostaglandin E1 monotherapy (1%). At least 1 error occurred during self-administration in 42% of patients during their time in the program. Errors included zero response to medication due to technical error (8% of patients), penile bruising (34%), use of an expired bottle (18%), self-titration (5%), and double injecting (4% of patients); 12% of men committed >= 1 error during their time in the program. On multivariable analysis, independent predictors of the occurrence of a major error included: young age, graduate-level education, and <12 months of injection use. Clinical implications To the best of our knowledge, this is the first reported study to investigate ICI errors and risk factors. The identification of factors predictive of major errors allows for more tailored and intensive training in this subset of patients. Strengths and limitations Strengths of this study include a large patient population (1386 men) with a considerable follow-up time. Additionally, the rigorous training, education, and monitoring of the participants, as well as the use of formal definitions, enhances the accuracy and reliability of the results. Despite the strengths of the study, recall bias may be a limitation concern. Conclusion The majority of patients were error free, and the majority of the errors were minor in nature. Major errors occurred in <10% of patients. Younger age, graduate-level education, and less experience with ICI were independent predictors of major errors.

PURPOSE:Testosterone (T) therapy (TTh) in men with T deficiency who have undergone radical prostatectomy (RP) for prostate cancer remains controversial. We aimed to assess the impact of TTh on biochemical recurrence (BCR) rates after RP in men with low-intermediate organ-confined disease. MATERIALS AND METHODS:This study included men who underwent an RP at our institution for organ-confined prostate cancer and had grade groups 1 to 3 on RP pathology. A Cox model was created for time to BCR with T use included as a time-dependent covariate, adjusted for age, preoperative PSA, grade group at RP, and the presence of comorbidities. A landmark analysis was used: Patients were included in the analysis if their last PSA in the 18 weeks postoperatively was undetectable and they had not had BCR or been lost to follow-up by that point, and follow-up for BCR began at 18 weeks. BCR was defined as a PSA ≥ 0.1 ng/mL after RP with a second confirmatory rise ≥ 0.1 ng/mL. RESULTS:The study population included 5199 men after RP, with 198 patients receiving T at any point after RP and 5001 not receiving T. The median age was 59 (interquartile range, 55-65) and 61 (interquartile range, 56-66) years, respectively. Men in the T group tended to present with more vascular comorbidities. For those receiving T, clomiphene citrate was prescribed in 49% of men, 32% received transdermal T, and 19% intramuscular T. We found a nonsignificantly decreased risk of BCR associated with the use of T after RP (hazard ratio, 0.84; 95% CI, 0.48-1.46; P = .5), and overall rates of BCR were low, with probability of BCR at 5 years less than 2% in both groups. CONCLUSIONS:TTh can be given to select men after RP. We found no evidence that administration of TTh after RP causes BCR.

Abstract Introduction The Satisfaction Survey for Inflatable Penile Implants (SSIPI) has been validated in English. No validated Portuguese and Spanish versions currently exist. Objective We aimed to linguistically validate SSIPI in Portuguese and Spanish to evaluate satisfaction outcomes with a validated instrument. Methods Our methodology adhered to best practices established by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and involved: forward translation of the 16-item SSIPI into Portuguese and Spanish by 2 independent IPP surgeons, reconciliation, back translation into English by 2 different independent bilingual IPP surgeons, and comparison to the original SSIPI for conceptual equivalence. The translated SSIPI versions underwent in-parallel cognitive debriefing (CD) at the US, Colombia, Spain, and Brazil centers. All interviews were recorded in person or via secure video conference to determine if misunderstandings or modifications were needed. Results 12 and 17 native Portuguese and Spanish speakers, respectively, with IPPs, participated in the CD process for their native language SSIPI. Interviews lasted approximately 1 hour each. The Portuguese SSIPI validation was conducted at 2 different centers in Brazil, resulting in 83% of the patients reporting that the survey was easy to answer. Of 16 questions, only 3 (Q7, Q11, and Q16) raised concerns for 6 patients. 5 patients had issues with the concept of the word “naturalness” and “spontaneity” from Q7 and Q16. One patient struggled with interpreting the word “conceal” in Q11. Regarding the duration taken to answer, 10/12 patients said it was acceptable. The Spanish SSIPI was tested at 4 US, Colombia, and Spain academic centers. 63% indicated the survey was easy to answer. In most cases, replacing a single word in the item with another was proposed. 53% had difficulties comprehending the answer choice options with Q3; however, all participants perceived the time required to complete the SSIPI as reasonable. Conclusions While the Portuguese SSIPI has been demonstrated to be easier to read and interpret than the Spanish SSIPI, with minor changes to wording/phrasing, both versions have the potential to improve IPP outcomes literature globally. Concerning questions will be modified before conducting the final validation steps. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Roman.

PURPOSE:Multiparametric MRI and the transperineal approach have become standard in the diagnostic pathway for suspected prostate cancer. Targeting of MRI lesions is performed at most centers, but the routine use of systematic cores is controversial. We aim to assess the value of obtaining systematic cores in patients undergoing cognitive fusion targeted double-freehand transperineal prostate biopsy. MATERIALS AND METHODS:Patients who underwent a cognitive fusion, freehand TPB at a single tertiary urology service (Perth, Australia) between November 2020 and November 2021 were retrospectively reviewed. Patients were included if they were biopsy naive and had a clinical suspicion of prostate cancer, based on their mpMRI results. Both targeted and systematic cores were taken at the time of their biopsy. RESULTS:One hundred forty patients suited the selection criteria. Clinically significant cancer was identified in 63% of patients. Of those that had clinically significant cancer, the target lesion identified 91% of the disease, missing 9% of patients whom the target biopsy detected non-clinically significant cancer but was identified in the systematic cores. Higher PI-RADS category patients were also found to be associated with an increasing likelihood of identifying clinically significant cancer within the target. CONCLUSIONS:In patients with PI-RADS 3 and higher, the target biopsy can miss up to 9% of clinically significant cancer. Systematic cores can add value as they can also change management by identifying a high-risk disease where only intermediate cancer was identified in the target. A combination of targeted and systematic cores is still required to detect cancer.

Here we present two cases of post-operative obstructive renal failure following major abdomino-pelvic sarcoma surgery. In both cases, prophylactic ureteric stents were inserted to aid the identification and protection of the ureters during resection of these complex retroperitoneal masses. In case one, obstructive renal failure occurred following ureteric stent removal on day 0 post-operatively. In case two, obstructive renal failure developed on day 1 post-operatively despite having a ureteric stent in situ. Here we propose that a combination of reflex anuria/ureteric edema and papillary sloughing led to the obstructive renal failure in both cases. Re-insertion of bilateral ureteric stents in case one, and replacement of a right ureteric stent in case two saw prompt excretion of urine and sloughy debris with rapid improvement of renal function. This article presents these cases in detail and further reviews the use of prophylactic ureteric stents in major abdomino-pelvic surgery along with the current guidelines for their usage.

ABSTRACT Introduction: Access represents one of the main challenges in performing posterior urethroplasty (1, 2). Several approaches and tactics have been previously described (3). This video demonstrates the Anterior Sagittal Transrectal Approach (ASTRA), which allows better visualization of the deep perineum (4). Materials and Methods: Our patient was a 65-year-old man with post radical prostatectomy vesicourethral anastomotic stenosis. He failed repeated endoscopic interventions, eventually developing urinary retention and requiring a cystostomy. We offered a vesicourethral anastomotic repair through ASTRA. The patient was placed in the jackknife position and methylene blue instilled through the cystostomy. To optimize access to the bladder neck, an incision of the anterior border of the rectum is performed. Anastomosis is carried out with six 4-0 PDS sutures. These are tied using a parachute technique, after insertion of a 16F Foley. Results: The patient was discharged after 72 hours, and the Foley catheter was removed after 4 weeks. There were no access-related complications. Retrograde urethrogram 3 months after surgery confirmed patency of the anastomosis. Upon review 5 months after surgery the patient had urinary incontinence requiring 5 pads/day and was considered for an artificial urinary sphincter. Discussion: In our series of 92 patients who have undergone reconstructive procedure through ASTRA there have been no cases of fecal incontinence. Two patients with prior history of radiotherapy developed rectourethral fistulas. Urinary incontinence was observed in those patients with stenosis after radical prostatectomy. Conclusion: This video presents a step-by-step description of ASTRA, an approach that provides excellent visualization to the posterior urethra, representing an alternative access for repair of complex posterior urethral stenosis.

In contemporary urological practice periurethral abscesses are rare. We report the case of a 61-year-old presenting with a painless penile mass and urinary retention. He underwent imaging with ultrasonography, targeted antibiotics and successful source control through open incision and drainage. He has been symptom, recurrence and complication free at 24 months post intervention. Risk factors for abscesses include obstruction, trauma, urethral diverticula and urethral carcinoma. Inadequate detection and treatment may lead to urethral fistulae, strictures and rarely, necrotizing fasciitis. To our knowledge, this is the first report of a periurethral abscess presenting as a painless penile mass causing urinary retention.

Transurethral enucleation of the prostate leads to greater symptom improvement, increase in flow rate, and reduction in postvoid residual than other transurethral procedures for patients with bladder outlet obstruction caused by prostate enlargement. However, enucleation still shows comparable rates of urethral strictures, and in some series higher rates of early urinary incontinence. We present the concept of Minimally invasive Laser Enucleation of the prostate (MiLEP), in which smaller caliber instruments are used with the aim of reducing urethral complications while maintaining effectiveness and efficiency. Our video shows a Holmium Laser Enucleation of the Prostate (HoLEP) performed using an 18.5Ch (Ultra Slim) endoscope to treat a patient in urinary retention with an estimated prostate size of 80cc. A step-by-step description of our en bloc no touch technique with early sphincter liberation is provided.

ABSTRACT Introduction: Tissue transfer has been used in urethral reconstruction for decades, and several grafts have been described (1, 2). The ideal graft would have optimal tissue characteristics and lead to minimal morbidity at the donor site. Urethroplasty using bladder mucosa was first described by Memmelaar in 1947 (3). The main limitation in using bladder mucosal grafts has been the invasiveness of open harvesting (4). We describe an endoscopic technique using Holmium: YAG laser to harvest bladder mucosal graft for substitution urethroplasty. Methodology: A 33-year-old male with no history of urethral instrumentation, trauma, or infection presented with obstructive lower urinary tract symptoms. On retrograde urethrogram a 6cm bulbar urethral stricture was identified. Several options were discussed, and the patient opted for a one-sided onlay dorsal urethroplasty (5) using a bladder mucosal graft. Equipment used to harvest the graft included an 18.5Fr continuous flow laser endoscope with a Kuntz working element (RZ) and a 60W Holmium Laser (Quanta) with 550μm laser fiber. The procedure was started by making a perineal incision, urethral mobilization and incision of the stricture segment. The laser endoscope was then introduced via the perineum. Settings of 0.5J, 30 Hz, and long pulse were used and a 7 x 2.5cm graft was harvested from the posterior bladder wall. Hemostasis of the harvest site was performed. The bladder mucosal graft was thinned in similar fashion to a buccal mucosal graft and sutured as per previously described techniques. Conclusion: Endoscopic Holmium Laser harvesting of bladder mucosal graft is feasible and may allow this graft to become an alternative to buccal mucosa. Further studies are required to define its role in urethral reconstruction.

The administration of exogenous testosterone (T) to men who have undergone radical prostatectomy (RP) for prostate cancer remains controversial. Besides small case series there are no large population, long-term studies assessing the safety of this treatment in this population. We have adopted a policy of allowing the decision regarding T therapy in men post-RP to be a negotiated one with a comprehensive discussion of the data and the pros and cons of T therapy. This prospective study was undertaken to define the safety of exogenous T therapy in men post-RP. Men were considered candidates for T therapy if (i) they had two early morning total T level <300 ng/dl (ii) had symptoms/signs of TD (iii) had pathologically organ-confined, Gleason 6-7 prostate cancer and (iv) an undetectable PSA level post-RP pre-commencement of T therapy. Once men opted for treatment they had labs tested 4 weeks later. T dose was titrated to achieve a serum level of 500-600ng/dl. Patients had serum T levels and PSA checked every 6 months.

Introduction & Objectives: The diagnostic pathway for prostate cancer in patients with abnormal PSA and/or DRE has moved away from routine systematic prostate biopsy to mpMRI based triage with selective biopsy. Moreover, many centres have ceased transrectal prostate biopsies (TRPB) in favour of a transperineal (TPPB) to reduce infective complications. The cost implications of these shifts in practice have not been widely reported. This analysis describes the costs before and after a practice change in a tertiary referral centre. Methods: All men undergoing prostate biopsy at the Royal Brisbane and Women's Hospital (RBWH) between January 2006 and December 2017 were considered. A departmental shift away from TRPB in preference for mpMRI triage followed by selective TPPB occurred in 2014 following increased infective complications. Costing data were obtained for the elective biopsy admission and subsequent readmissions due to procedural complications. Results: 2,076 men underwent prostate biopsy over 12 years, comprising 1,309 TRPB and 767 TPPB with a trend towards less biopsies observed with time. The mean age was 64.68 years (SD 8.84) and 64.35 years (SD 7.78), with mean elective admission costs of $2,673 and $3,520, respectively. Following biopsy, 95 (7.2%) and 29 (3.8%) readmissions occurred following TRPB and TPPB, respectively. Readmission after TRPB were mostly due to infective complications, and after TPPB due to haematuria and urinary retention. When computing the elective admission and readmission costs, the total mean cost of each TRPB was $2,873 and TPPB $3,636. Considering that by using the mpMRI triage pathway 48% of patients avoid biopsy, the shift in practice reduced the cost per patient from $2,873 to $2,340 (including MRI cost of $450). Conclusions: Use of mpMRI triage with subsequent TPPB resulted in reduced morbidity and expenditure. This approach warrants consideration in other jurisdictions.

ObjectiveTo examine national trends in the medical and surgical treatment of benign prostatic hyperplasia (BPH) using Australian Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) population data from 2000 to 2018.Patients and methodsAnnual data was extracted from the MBS, PBS and Australian Institute of Health and Welfare databases for the years 2000–2018. Population‐adjusted rates of BPH procedures and medical therapies were calculated and compared in relation to age. Cost analysis was performed to estimate financial burden due to BPH.ResultsOverall national hospital admissions due to BPH declined between 2000 and 2018, despite an increased proportion of admissions due to private procedures (42% vs 77%). Longitudinal trends in the medical management of BPH showed an increased prescription rate of dutasteride/tamsulosin combined therapy (111 vs 7649 per 100 000 men) and dutasteride monotherapy (149 vs 336 per 100 000 men) since their introduction to the PBS in 2011. Trends in BPH surgery showed an overall progressive increase in rate of total procedures between 2000 and 2018 (92 vs 133 per 100 000 men). Transurethral resection of the prostate (TURP) remained the most commonly performed surgical procedure, despite reduced utilisation since 2009 (118 vs 89 per 100 000 men), offset by a higher uptake of photoselective vaporisation of prostate, holmium:YAG laser enucleation of prostate, and later likely due to minimally invasive surgical therapies including prostatic urethral lift and ablative technologies (including Rezūm™). Financial burden due to BPH surgery has remained steady since 2009, whilst the burden due to medical therapy has risen sharply.ConclusionDespite reduced national BPH‐related hospitalisations, overall treatment for BPH has increased due to medical therapy and surgical alternatives to TURP. Further exploration into motivators for particular therapies and effect of medical therapy on BPH progression in clinical practice outside of clinical trials is warranted.

68Ga prostate specific membrane antigen PET/CT (68Ga-PSMA PET/CT) may be superior to multiparametric MRI (mpMRI) for localisation of prostate cancer tumour foci, however the concordance and differences between 68Ga-PSMA PET/CT and mpMRI when applied to all biopsied patients and potential benefit in patients with negative mpMRI is unclear. Retrospective analysis of patients undergoing mpMRI, prostate biopsy and 68Ga-PSMA PET/CT over a 3-year period. Diagnostic performance of 68Ga-PSMA PET/CT and mpMRI were assessed using biopsy histopathology for the entire cohort and radical prostatectomy specimen in a subset of patients. Lesion concordance and additional detection of each modality were determined, including in a dedicated cohort of patients with mpMRI PIRADS 2 scans. A total of 144 patients were included in the study. Index lesion/foci detection was similar between 68Ga-PSMA PET/CT and mpMRI (sensitivity 83.1% vs 90.1%; p = 0.267), however lesions missed by mpMRI were larger (1.66 cm3 vs 0.72 cm3; p = 0.034). Lesion detection rates were similar across the biopsy histopathology and radical prostatectomy specimen subset, with a high concordance for index (80.1%) and a moderate concordance for total (67%) lesions between the 2 imaging modalities. The additional detection yield favoured 68Ga-PSMA PET/CT over mpMRI for index (13.5% vs 4.3%) and total (18.2% vs 5.4%) lesions; both modalities missed 2.1% and 12.3% of index and total lesions, respectively. 68Ga-PSMA PET/CT identified 9 of 11 patients with PIRADS 2 mpMRI but subsequently diagnosed with Gleason ≥ 3 + 4 disease. Despite high concordance rates, 68Ga-PSMA PET/CT incrementally improved tumour localisation compared with mpMRI. These results suggest that 68Ga-PSMA PET/CT may have an incremental value to that of mpMRI in the diagnostic process for prostate.

Purpose Testosterone replacement therapy (TRT) is commonly used for various causes of androgen deficiency and subsidized by the Pharmaceutical Benefits Scheme (PBS) in Australia when appropriate. In response to a sharp increase in the prescribing of subsidized TRT, the Australian government instituted new, stricter prescription criteria in April 2015. We aim to demonstrate longitudinal changes in the prescription patterns of subsidized TRT over time. Materials and Methods The publicly available PBS database was accessed for TRT prescription data between 1992–2018. Population estimate data was collected from the Australian Bureau of Statistics for population-adjustment. Data analysis was performed according to class and specific formulation of TRT. Total and population-adjusted trends were considered, as was indexation to 2015 when restrictions were implemented. Results Longitudinal trends in subsidized TRT prescription demonstrated a progressive overall increase since 2000, according to total prescriptions and population-adjusted estimates, with greater use of topical formulations (gel, patch, cream/spray) and injections. Since 2015, a 37% decline in total population-adjusted prescriptions was observed (1,399–883 per 100,000 persons). Since 2015, relatively increased use of injections (50%) and 1% gel (30%) comprise the majority of contemporary TRT. Annual financial burden due to TRT was $AU16,768 per 100,000 persons prior to 2000 (mean cost 1992–2000), increasing to $AU112,539 in 2018 (due to use of injections). The rate of change in costs slowed after the restrictions were introduced in 2015. Conclusions The restrictions in subsidized TRT eligibility enforced by the PBS have reduced overall TRT prescriptions and slowed the cumulative financial burden.