Sexual Medicine 9:00 - 10:00Am Monday, 26Th October, 2020
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Sexual Medicine 9:00 - 10:00am Monday, 26th October, 2020 33 Predictors of Rapid Disease Progression from Initial Diagnosis of Erectile Dysfunction to Surgical Intervention Ramzi Jabaji M.D.1, Yu-Hsiang Shu PhD2, Mark Feng M.D.3, Polina Reyblat M.D.1, Hossein Mirheydar M.D.3 1Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA. 2Kaiser Permanente Department of Research and Evaluation, Pasadena, CA, USA. 3Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, CA, USA Abstract Objectives: The prevalence of erectile dysfunction (ED) increases with age. Its association with metabolic syndrome, which poses a growing threat in the United States, has been well described. Urologists commonly follow a treatment algorithm involving phosphodiesterase type 5 inhibitors as first-line therapy, with escalation to other therapies and ultimately to penile prosthesis placement. While many are aware of risk factors for the development of ED, less is known about the comorbidities which may contribute to earlier surgical intervention. We aimed to look at trends in the treatment of men with ED from diagnosis to surgery, and clinical data associated with this progression. Materials and Methods: We used medical coding to query our database and identify men who underwent penile prosthesis implantation for ED from 2002 to 2017 within Kaiser Permanente Southern California (KPSC), excluding men with post-prostatectomy ED. We determined the date of initial ED diagnosis, and analyzed patient clinical data and associations with shorter time interval from diagnosis to surgical intervention using accelerated failure time models. Results: We identified 1280 men who underwent penile prosthesis surgery at KPSC over this 15-year period. Using strict exclusionary criteria, we ultimately analyzed data on 760 men. Mean and median time interval from diagnosis of ED to initial surgery was 4.4 and 6 years, respectively. About 55% of our population underwent surgery within 5 years of ED diagnosis, and 80% within 9 years of diagnosis. High rates of obesity (50.1%), diabetes mellitus type 2 (DM2, 48.8%), estimated glomerular filtration rate (eGFR) <30 (24.7%), depression (23.7%), peak hemoglobin A1c at presentation ≥9% (16.6%), and hypertension (12.6%) were noted in our study population. Presence of hypertension was significantly associated with a 5.6x quicker time interval from diagnosis to surgery (p<0.001), as was age ≥70 years old (1.9x, p=0.022), DM2 (1.4x, p=0.001), and eGFR <30 (1.3x, p=0.026). Conclusions: Clinical data associated with shorter time from diagnosis of ED to surgical intervention include hypertension, increased patient age, DM2, and eGFR<30. These results may be used to predict failure of less aggressive treatment modalities for men with erectile dysfunction. Source of Funding: None If funding provided, type in source company / entity name(s): None 211 Access to Medically Necessary Erectile Dysfunction (ED) Treatment: Not All Health Benefits are Equal Garrick M. Greear MD1, Arman Walia MD1, Natalie C. Edwards MSc2, Krista D. Nitschelm BC, COC, PAHM3, Tonya M. Barrett BS, RHIT3, Tung-Chin Hsieh MD1 1University of California – San Diego, La Jolla, CA, USA. 2Health Services Consulting Corporation, Boxborough, MA, USA. 3Boston Scientific Corporation, Marlborough, MA, USA Abstract Introduction: Approximately 61% of adults aged 18 – 64 years in the United States receive health benefits via employer-sponsored health plans (ESHP), according to a recent estimate by the Kaiser Family Foundation. This study evaluated barriers to access to ED treatment among men insured under an ESHP. Despite published medical policies from plan administrators (insurance carriers), claims must be processed in accordance with the ESHP benefit designs, which may include benefit exclusions and result in unequal access to treatment. Patients and Methods: From October 1, 2018 to October 31, 2019, De-identified data from an industry insurance benefit verification database were analyzed to evaluate ESHPs-related barriers to access for ED treatment. Results: Of 2,150 cases with a commercial payer, 798 included ESHP data. Of these men, 31% were denied access to ED treatment due to an ESHP benefit exclusion. Geographically, ESHPs in Texas (19%) and Georgia (10%) had the highest exclusion rates versus Maryland (3%) and South Carolina (1%). Employees of religious organizations (50%) had the highest exclusion rate; followed by retail and wholesale trade, education, or healthcare (41%); construction, mining, or agriculture (38%); manufacturing (36%); professional and business services (34%); and finance or insurance (33%); utilities (28%); transportation (25%); labor union organizations (24%); leisure and hospitality (21%); and public, state, or government administration (21%). Conclusion: Despite insurance carrier medical policies, many men with an ESHP have no access to ED treatment due to health benefit exclusions designs by employers. Policy interventions addressing benefit exclusions could improve patient-centered care and improve inequalities in access to ED treatment. 107 Characterizing Transgender Individuals Undergoing Bilateral Simple Orchiectomy Without Concomitant Vaginoplasty or Vulvoplasty Robert Craig Sineath MD, MPH, Kyle A Gillis MD, Jonathan L Witten MD, Daniel Dugi MD, Jyoti D. Chouhan DO, PharmD Oregon Health and Science University, Portland, OR, USA Abstract Introduction & Objective: Little is known about the characteristics of transgender individuals who have undergone bilateral simple orchiectomy (BSO) without concomitant vaginoplasty or vulvoplasty. We also report on the presence or absence of spermatogenesis on final pathology of the testes. Methods: A retrospective review was performed at a single academic medical center between May 2016 and May 2019. We reviewed all transgender individuals who underwent BSO without concomitant vaginoplasty or vulvoplasty. Statistical analysis was performed using Chi square tests (SPSS®, Armonk, New York). Results: There were a total of 108 patients who underwent BSO as a stand-alone procedure. Please see Table 1 for analysis of the entire population and Table 2 for analysis by age group. Reporting on the presence or absence of spermatogenesis was inconsistent on pathology reports (n=26/108, 23.9%). Of the 26 that reported on spermatogenesis, please see Table 3 for the level of spermatogenesis as compared to the duration of hormone use. Conclusion: Transgender individuals undergoing BSO without concomitant vaginoplasty or vulvoplasty are a diverse population. Urologists performing these procedures should understand that not all patients undergoing BSO alone desire further gender affirming genital surgery. In addition, age was not found to influence the desire for additional genital gender affirming surgery. Lastly, the presence or absence of spermatogenesis does not seem to be related to duration of hormone use. If funding provided, type in source company / entity name(s): N/A 73 Surgical Technique for Removal of the Penuma® Penile Implant Lauren H Poniatowski MD, MS, Akash Kapadia MD, Thomas J Walsh MD, MS University of Washington, Seattle, WA, USA Abstract Objectives: The Penuma® penile implant is a silicone sleeve placed for changing aesthetic appearance of the penis. Reported indications for placement include increasing penile length or girth and addressing penile irregularities including retractile penis or penile indentation.1 Complications following implant placement include pain and infection, and after subsequent removal there have been reports of scarring, penile shortening and erectile dysfunction.2 Our objective is to present surgical technique for removal of the Penuma® implant including dissection around the neurovascular bundle. Materials and Methods: Implant removal was performed in a patient with previous penile implant placement complicated by penile neuropraxia with complete loss of sensation to the distal penis. Steps for performing the procedure include 1) distal circumcising incision and penile exploration 2) removal of the silicone portion of the implant 3) dissection of remaining mesh from the neurovascular bundle and dartos tissue and finally 3) wound closure and drain placement. Results: Using the techniques described, the silicone implant and associated mesh were explanted and removed. The mesh was significantly incorporated into the neurovascular bundle and dartos tissue requiring extensive dissection (Figure 1). Intraoperative decision making was complicated by goal of removing mesh in its entirety while weighing this against potential for further damage to the dorsal nerves/vessels. Pathology demonstrated fibroconnective tissue with embedded mesh and no evidence of nerve tissue. Documentation of penile neuropraxia was completed pre- and post-op by neurology and demonstrating loss of sensation in the dorsal nerve distribution. There was no significant change in sensation following removal of the implant on post-op day zero. Conclusions: Using the described surgical techniques, it is possible to safely remove the Penuma® penile implant. Intraoperative decisions must be made to prevent further harm to the neurovascular bundle. Source of Funding: None 1. Elist JJ, Levine L, Wang R, Wilson SK. Patient selection protocol for the Penuma® Implant: Suggested preoperative evaluation for aesthetic surgery of the penis. Int J Impot Res 2020;32(2):149-152. 2. Furr J, Hebert K, Wisenbaugh E, Gleman J. Complications of genital enlargement surgery. J Sex Med 2018;15(12):1811-1817. If funding