Publications by authors named "Ruben Blachman-Braun"

77 Publications

Comparison of Intratesticular Testosterone between Men Receiving Nasal, Intramuscular, and Subcutaneous Pellet Testosterone Therapy: Evaluation of Data from Two Single-Center Randomized Clinical Trials.

World J Mens Health 2022 Apr 22. Epub 2022 Apr 22.

Department of Urology, Miller School of Medicine, University of Miami, Miami, FL, USA.

Purpose: Testosterone replacement therapy (TRT) can potentially cause decreased spermatogenesis and subsequent infertility. Recent studies have suggested that 17-hydroxyprogesterone (17-OHP) is a reliable surrogate for intratesticular testosterone (ITT) that is essential for spermatogenesis. We evaluated data from two ongoing open-label, randomized, two-arm clinical trials amongst different treatment preparations (Trial I) subcutaneous testosterone pellets (TP) and (Trial II) intranasal testosterone (NT) or intramuscular testosterone cypionate (TC).

Materials And Methods: Seventy-five symptomatic hypogonadal men (2 serum testosterone <300 ng/dL) were randomized into open label randomized clinical trials. Eligible subjects received 800 mg TP, 11 mg TID NT or 200 mg ×2 weeks TC. 17-OHP and Serum testosterone were evaluated at baseline and follow-up. The primary outcome was changes in 17-OHP. Secondary outcome was changes in serum testosterone. Data was analyzed by two-sample and single-sample t-tests, and determination of equal or unequal variances was computed using F-tests.

Results: Median participant age was 45 years old, with overall baseline 17-OHP of 46 and serum testosterone of 223.5 ng/dL. 17-OHP significantly decreased in subjects prescribed long-acting TP or TC. The 4-month change in 17-OHP in the NT group (-33.3% from baseline) was less than the change seen in TC (-65.3% from baseline) or TP (-44% from baseline) (p=0.005). All testosterone formulations increased serum testosterone levels at follow-up, with the largest increase seen in TC (+157.6%), followed by NT (+114.3%) and TP (+79.6%) (p=0.005).

Conclusions: Short-acting nasal testosterone appear to have no impact on serum 17-OHP especially in comparison to long-acting testosterone formulations. All modalities saw significant increases in serum testosterone levels at follow-up. NT and other short acting testosterone formulations may better preserve ITT and be beneficial for hypogonadal men seeking to maintain fertility potential while on TRT.
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http://dx.doi.org/10.5534/wjmh.210261DOI Listing
April 2022

Socioeconomic differences associated with consumption of a plant-based diet: Results from the national health and nutrition examination survey.

Nutr Health 2022 Jun 22:2601060221109669. Epub 2022 Jun 22.

Department of Urology, 12235University of Miami Miller School of Medicine, Miami, FL, USA.

Background: A plant-based diet (PBD) has been associated with potential health benefits, but factors that may affect access to and consumption of a PBD are not well defined.

Aim: To determine the association between socioeconomic status and plant-based dietary consumption among participants enrolled in the National Health and Nutrition Examination Survey (NHANES).

Methods: This was a cross-sectional study using data obtained from the NHANES database. The following covariates were assessed: age, sex, race/ethnicity, educational level, marital status, smoking status, physical activity, alcohol use, history of diabetes, and hypertension. Socioeconomic status was categorized according to poverty-income ratio (PIR). Food frequency questionnaires were used to calculate previously validated plant-based diet index (PDI) and healthful plant-based diet index (hPDI). Multivariable-adjusted logistic regression was performed to determine the association between PIR, clinical, demographic, and plant-based diet indices.

Results: A total of 5037 participants were in the final analytic sample. Median age of participants was 51 ± 18.5 years. Overall PDI and hPDI were 50 [46-54] and 52 [47-57], respectively. Median PDI index was significantly different among PIR groups (PDI, p = 0.018; hPDI, p < 0.001). On multivariable analysis, participants in the poorest socioeconomic group (PIR ≤ 130%) were more likely to have lower consumption of a healthful PBD (hPDI).

Conclusion: Lower socioeconomic status (PIR ≤ 130%) was associated with decreased consumption of a healthful plant-based diet. These data suggest that socioeconomic disparities may limit consumption of healthier food and contribute to the high prevalence of adverse health conditions that exist in certain population groups.
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http://dx.doi.org/10.1177/02601060221109669DOI Listing
June 2022

Morphometric Analysis of Prostate Zonal Anatomy After Transurethral Resection of Prostate and Holmium Laser Enucleation of Prostate Using Magnetic Resonance Imaging: A Pilot Study.

Turk J Urol 2022 May;48(3):201-208

Department of Radiology, University of Miami Miller Faculty of Medicine, Miami, FL.

Objective: The primary purpose was to compare the completeness of adenomectomy and zonal anatomy of prostate on magnetic resonance imaging prostate after transurethral resection of prostate and Holmium enucleation of prostate. The secondary purpose was to investigate the relationship between preoperative total prostate volume and postoperative transition zone and peripheral zone volume after both procedures.

Material And Methods: A retrospective review of all patients who underwent transurethral resection of pros- tate or Holmium enucleation of prostate over 3 years (2017-2020) and had at least 1 postoperative magnetic resonance imaging prostate was performed. Volume estimations of the prostate and individual zones were per- formed, and statistical comparisons were made to evaluate morphometric changes between the 2 procedures.

Results: A total of 9 patients (mean age, 71.8 years) underwent transurethral resection of prostate and 12 patients (mean age, 66.9 years) underwent Holmium enucleation of prostate. The median pre-operative prostate volume in the Holmium enucleation of prostate group was higher than the transurethral resection of prostate group (101.5 g vs. 62 g; P =.102). However, there was a significant difference in the resected tissue weight favoring Holmium enucleation of prostate over transurethral resection of prostate (P value=.004). The postoperative transition zone and peripheral zone volume as calculated by magnetic resonance imaging remained relatively constant in both procedures. The peripheral zone volume on postoperative magnetic res- onance imaging was found to be independent of transition zone volume even for very large-sized prostates.

Conclusion: A well-performed transurethral resection of prostate or Holmium enucleation of prostate cannearly completely eliminate the transition zone volume, irrespective of the size of the prostate as confirmed by magnetic resonance imaging prostate. Additionally, the peripheral zone volume is consistent across the entire spectrum of the prostate size.
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http://dx.doi.org/10.5152/tud.2022.21326DOI Listing
May 2022

Is tadalafil associated with decreased risk of major adverse cardiac events or venous thromboembolism in men with lower urinary tract symptoms?

World J Urol 2022 Jul 25;40(7):1799-1803. Epub 2022 Apr 25.

Department of Urology, University of Miami Miller School of Medicine, Clinical Research Building (CRB), 1120 NW 14th Street, Miami, FL, 33136, USA.

Purpose: To evaluate the association of tadalafil, a phosphodiesterase-5 inhibitor (PDE5I), with major adverse cardiac events (MACE) or venous thromboembolism (VTE) in men with lower urinary tract symptoms (LUTS).

Methods: Data was obtained from the TriNetX Research Network, ICD-10 codes were used to identify men with LUTS, MACE, and VTE. In addition, demographic characteristics and use of tadalafil or alpha-blocker was evaluated. Then, unbalanced and balanced association analyses was performed to assess the relation between tadalafil and/or alpha-blocker use with MACE/VTE.

Results: After participant selection, analysis included 821,592 men that did not use an alpha blocker or tadalafil, 5,004 men that used tadalafil but no alpha blocker, 327,482 men that used an alpha blocker but no tadalafil, and 6,603 men that used both an alpha blocker and tadalafil. On balanced analysis, tadalafil was independently associated with a decreased risk of MACE/VTE within a 3-year time period (OR = 0.59, 95%CI 0.49-0.70, p < 0.0001). Among men with a history of alpha blocker use, tadalafil use was also independently associated with a decreased risk of MACE or VTE, both before and after controlling for potentially confounding variables (OR = 0.57, 95%CI: 0.50-0.66; p < 0.0001).

Conclusions: In our study, tadalafil was associated with a decreased risk of MACE/VTE in men with LUTS with and without a history of alpha blocker use. It is time to perform further long-term prospective randomized studies to further analyze the cardiovascular effects of PDE5Is as combination treatment with alpha blockers in the management of LUTS.
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http://dx.doi.org/10.1007/s00345-022-04005-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9037966PMC
July 2022

Ureteroscopy under conscious sedation: A proof-of-concept study.

Can Urol Assoc J 2022 Apr 11. Epub 2022 Apr 11.

Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada.

Introduction: Ureteroscopies (URSs) are commonly performed under general anesthesia (GA) to maximize patient tolerability and minimize surgical complications. However, given the improvements in endoscopic technology and risks associated with GA, alternate forms of anesthesia have been postulated. We aimed to evaluate the outcomes of URS under conscious sedation.

Methods: We completed a retrospective cohort study from November 2019 to June 2020 at a tertiary-level hospital. All URSs that were performed under urologist-directed conscious sedation were included. Our primary outcome was the ability to complete URSs, defined as success rate. Secondary outcomes included: stone-free rate, intraoperative complication rate, hospital admission rate, and sedation requirement. Univariate- and multivariate-adjusted logistic regression analyses were employed.

Results: Ninety-nine URSs were included. Most (73/99, 73.7%) were performed for urolithiasis. The overall success rate was 83.8% (83/99), with 81.0% (34/42) intra-renal and 70.0% (16/23) proximal ureter success rates. The stone-free rate was 80.8% (59/73). No intraoperative complications nor hospital admissions were reported. The mean amount of sedation required was three (interquartile range [IQR] 2-4] mg of midazolam and 100 (100-150) μg of fentanyl. On multivariate analysis, midazolam was significantly associated with increased success (odds ratio 2.496, 95% confidence interval 1.057-5.892, p=0.037).

Conclusions: We have shown that proximal and intra-renal URS under conscious sedation is safe and effective. We were limited by our lack of followup, small sample size, selection bias to chose healthy patients, and lack of patient tolerability data. Patients and healthcare systems may benefit from implementing this innovation more broadly.
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http://dx.doi.org/10.5489/cuaj.7750DOI Listing
April 2022

PSA Testing in Men Receiving Testosterone Therapy With History of Prostate Cancer: A Matched Analysis of a Large Multi-Institutional Research Network.

Urology 2022 Jul 25;165:237-241. Epub 2022 Feb 25.

Department of Urology, University of Miami Miller School of Medicine, Miami, FL. Electronic address:

Objective: To investigate the frequency of prostate-specific antigen (PSA) testing in men receiving testosterone replacement therapy (TT) and with a history of prostate cancer (PCa).

Methods: We queried the TriNetX network database, a global health research network consisting of 65 million men in 44 large healthcare organizations, to investigate rates of PSA testing in 4 cohorts of men aged 55-69 with a history of PCa diagnosis and/or a prescription for any route or formulation of testosterone. We further stratified each cohort to evaluate PSA testing in men with previously treated (CPT 55,840, 55,866, 77,778, 77,385) or untreated PCa. All cohorts' PSA testing rates were compared against the "no PCa or TT" cohort by Chi-square test.

Results: A total of 4,525,259 men, aged 55-69, were included in our study. Following stratification into cohorts based on PCa or TT history, we found that 14.2% (P < .0001) of men without PCa or TT underwent PSA testing following an initial ambulatory visit. Among men without PCa who received TT, 33.6% (P < .0001) underwent testing. Unfortunately, only 53.2% (P < .0001) and 61.0% (P < .0001) of men receiving TT with previously untreated and treated PCa, respectively, had PSA testing.

Conclusion: In contrast to current guidelines, a large proportion of men receiving TT and with a history of PCa did not undergo PSA testing. Further studies are necessary to better characterize reasons why PSA testing rates are low even in this high-risk cohort.
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http://dx.doi.org/10.1016/j.urology.2022.02.010DOI Listing
July 2022

Consumption of a Healthy Plant-based Diet is Associated With a Decreased Risk of Erectile Dysfunction: A Cross-sectional Study of the National Health and Nutrition Examination Survey.

Urology 2022 Mar 1;161:76-82. Epub 2022 Jan 1.

Department of Urology, Miller School of Medicine, University of Miami, Miami, FL. Electronic address:

Objective: To investigate the association between the plant-based content of diet and erectile dysfunction in men from the National Health and Nutrition Examination Survey (NHANES).

Methods: We collected de-identified information from the NHANES database on demographics, comorbidities, diet, and erectile dysfunction (ED). Exclusion criteria were age <20 or >70 years, incomplete plant-based diet index information, history of prostate cancer, or other missing information. Using the food frequency questionnaire, an overall plant-based diet index (PDI) and healthful plant-based diet index (hPDI) were developed. A higher score on the PDI and hPDI is indicative of greater consumption of plant-based foods.

Results: A total of 2549 men were analyzed, of those 1085 (42.6%) have good erectile function and 1464 (57.4%) have some degree of ED [usually have erections 521 (20.4%), sometimes have erection 690 (27.1%), or never have erections 253 (9.9%)]. The median age and BMI were 54 [41-64] years and 28.8 [25.5-32.6] kg/m, respectively. The median PDI and hPDI were 50 [46-54] and 50 [45-56], respectively. In multivariable adjusted logistic regression analysis, hPDI was negatively associated with ED (OR = 0.98, 95% CI: 0.96-0.99; P = .001). There was no association between PDI and ED.

Conclusion: In a well characterized national database, we showed that a healthful plant-based diet is associated with less chance of having erectile dysfunction. Whether interventions with a plant-based diet will improve erectile function remains to be studied.
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http://dx.doi.org/10.1016/j.urology.2021.12.021DOI Listing
March 2022

Neonatal Circumcision: What Are the Factors Affecting Parental Decision?

Cureus 2021 Nov 9;13(11):e19415. Epub 2021 Nov 9.

Pediatric Urology, Nicklaus Children's Hospital, Miami, USA.

Introduction: The American Academy of Pediatrics (AAP) guidelines state that the health benefits of circumcision outweigh the risks, but these benefits are not enough to recommend universal newborn circumcision. Therefore, it is the guardians' decision to circumcise their son. In this study, we assess the factors that influence the decision-making process for newborn circumcision.

Methods: A prospective study was done from January to April 2020 for newborn circumcision. AAP guidelines were used as an educational tool and given to the parents on the day of patient circumcision assessment. On procedure day, a self-reported survey regarding the reasons for circumcision and the usefulness of the guideline as an educational resource was given to guardians.

Results:  A total of 265 parents completed the survey. Of the study variables, the future health of the child and the circumcision status of the father were considered extremely important factors influencing the decision-making process for 168 (63.4%) and 90 (34%) guardians, respectively. The study showed that 226 (85.3%) of the parents found the AAP guidelines helpful whereas 39 (14.7%) did not.

Conclusion:  Overall results suggest that the health of the child and the father of the child being circumcised are the primary factors that influence the guardians' decision to circumcise their child. In addition, providing parents with an educational resource such as the AAP guidelines policy statement prior to circumcision may serve as a way to supplement the discussion between parents and providers.
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http://dx.doi.org/10.7759/cureus.19415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8654051PMC
November 2021

Association between low testosterone and anaemia: Analysis of the National Health and Nutrition Examination Survey.

Andrologia 2021 Dec 9;53(11):e14210. Epub 2021 Aug 9.

Department of Urology, University of Miami Miller School of Medicine, Miami, Florida, USA.

There is an androgen effect on haematopoiesis; however, the effect of low testosterone in anaemia has not been fully studied. In this study, we aim to explore the association of total serum testosterone, low testosterone (≤300 ng/dl), haemoglobin concentration and prevalence of anaemia in a nationally representative sample of men. We analysed data from the NHANES III database, and men between the age of 18-80 years of age were selected. We defined anaemia as haemoglobin ≤13.5 ng/dl and low serum testosterone as ≤300 ng/dl. After analysing 5,888 men, it was shown that those with anaemia had a higher prevalence of low serum testosterone (32.3%) compared to those without anaemia (24.1%) (p < .001), and in multivariable-adjusted analysis, it was shown that low testosterone was significantly associated with anaemia (OR = 1.44; 95% CI: 1.17-1.78; p = .001). Our findings suggest that men with low serum testosterone have a higher risk of anaemia, and there is a positive association between serum testosterone and serum Hb. Further prospective studies need to be performed to confirm our findings.
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http://dx.doi.org/10.1111/and.14210DOI Listing
December 2021

Impact of Plant-Based Diet on PSA Level: Data From the National Health and Nutrition Examination Survey.

Urology 2021 10 22;156:205-210. Epub 2021 Jul 22.

Department of Urology, Miller School of Medicine, University of Miami, Miami, FL.

Objective: To determine the potential association between plant-based dietary content and PSA levels among men enrolled in the National Health and Nutrition Examination Survey (NHANES).

Methods: Data on demographics, diet, and PSA levels was acquired from the NHANES database. Plant-based diet index (PDI) and healthful plant-based diet index (hPDI) were calculated using food frequency questionnaires. A higher score on PDI and hPDI indicates higher consumption of plant foods or healthy plant foods, respectively. Multivariable-adjusted logistic regression analysis was performed to determine the association between elevated PSA, clinical variables, demographics, and plant-based diet indices.

Results: A total of 1399 men were included in the final cohort. Median age of participants was 54 [46-63] years. Median PSA level was 0.9 [0.6-1.5] ng/dL, and 69 (4.9%) men had a PSA level ≥4 ng/dL. Although there was no association between elevated PSA and PDI, on multivariable analysis patients with higher consumption of healthy plant-based diet (high hPDI scores) had a decreased probability of having an elevated PSA (OR = 0.47, 95% CI: 0.24-0.95; P = .034).

Conclusion: There is a significant association between increased consumption of a healthy plant-based diet and lower PSA levels. This finding may be incorporated into the shared-decision making process with patients to promote healthier lifestyle choices to reduce the likelihood of prostate biopsy and potential treatment-related morbidity.
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http://dx.doi.org/10.1016/j.urology.2021.05.086DOI Listing
October 2021

Are all procedures for benign prostatic hyperplasia created equal? A systematic review on post-procedural PSA dynamics and its correlation with relief of bladder outlet obstruction.

World J Urol 2022 Apr 2;40(4):889-905. Epub 2021 Jul 2.

Department of Urology, University of Miami, Miller School of Medicine, Miami, USA.

Purpose: To evaluate and provide a comprehensive literature review of Prostate specific antigen (PSA) dynamics after various surgical procedures for benign prostatic hyperplasia (BPH).

Methods: A thorough PubMed database search was performed over last 30 years including terms "PSA" and various surgical procedures for BPH. PSA nadir after various procedure was evaluated. The post-operative improvement in International Prostate Symptom Score, maximum void rates and post-void residue after surgeries were recorded. An indirect correlation was made between PSA nadir and outcome of various BPH surgical procedures.

Results: Enucleation procedures like simple prostatectomy and endoscopic enucleation of prostate (EEP) produced maximum drop in PSA level after surgery and were associated with the highest improvement in post-operative parameters. The PSA nadir following resection techniques like transurethral resection of prostate and Holmium laser resection of prostate and vaporization technique was variable and less robust when compared to EEP. Newer techniques like Aquablation, Rezum, Urolift, Prostate artery embolization and Temporary implantable nitinol devices (iTIND) produce relatively less reduction in PSA and lesser percentile improvement in post-operative parameters.

Conclusions: Various surgical procedures for BPH result in varying PSA nadirs level. Enucleation procedures and simple prostatectomy produce the most drastic and sustained decrease in PSA. There is a possible indirect evidence suggesting that the level of PSA nadir corresponds closely with the degree of post-operative improvement and durability of the procedure. Establishing the new PSA nadir at 3-6 months after the procedure is recommended as a part of routine surveillance for prostate cancer in eligible patients.
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http://dx.doi.org/10.1007/s00345-021-03771-wDOI Listing
April 2022

Safety and efficacy of holmium laser enucleation of prostate as salvage procedure for persistent or recurrent lower urinary tract symptoms secondary to bladder outlet obstruction after prior prostate artery embolization: a match analysis.

World J Urol 2021 Nov 3;39(11):4199-4206. Epub 2021 Jun 3.

Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA.

Purpose: To evaluate safety and efficacy of Holmium laser enucleation of Prostate (HoLEP) for management of persistent or recurrent lower urinary tract symptoms after prior prostate artery embolization (PAE). We also evaluated histopathological changes in prostate after PAE.

Methods: Ten patients who underwent HoLEP after prior PAE were matched according to age, weight of resected prostate tissue, and anticoagulation status in 1:2 ratio with patients who underwent HoLEP without prior PAE by a researcher who was blinded to patient's outcome at the time of matching. Histopathological examination of prostate tissue was performed to look for changes related to prior PAE. Patient's demographics, perioperative parameters, and follow-up data were retrospectively compared.

Results: The median interval between PAE and HoLEP was 25 months [IQR 14.5-37.5]. Patients demographic were comparable in both groups. Intra-operatively plane of enucleation were well-maintained in spite of prior PAE. The differences in duration of surgery, enucleation efficiency, hemoglobin drop, duration of catheterization and hospital stay, and complications were statistically insignificant. Incidental prostate cancer was identified in 10% specimens from both groups. Post-PAE prostate specimens demonstrated evidence of remote-healed infarction represented by dense hyalinized paucicellur connective tissue with surrounding squamous metaplasia. There were no statistically significant differences in AUA symptom scores, maximum urine flow rate, post-void residual urine volume, and PSA at 3- and 6-month follow-up between both groups.

Conclusions: Plane of enucleation is well-maintained after prior PAE. Salvage HoLEP is safe and effective after previous PAE and provide outcome comparable with HoLEP as a primary procedure.
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http://dx.doi.org/10.1007/s00345-021-03747-wDOI Listing
November 2021

Is Sexual Function Impacted After Minimally Invasive Surgery for Benign Prostatic Obstruction?

Eur Urol 2021 08 19;80(2):188-189. Epub 2021 May 19.

Department of Urology, Miller School of Medicine, University of Miami, Miami, FL, USA. Electronic address:

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http://dx.doi.org/10.1016/j.eururo.2021.05.003DOI Listing
August 2021

Predictors of mortality for patients admitted to the intensive care unit with obstructing septic stones.

Can Urol Assoc J 2021 Nov;15(11):E593-E597

Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada.

Introduction: Patients diagnosed with septic stone are at significant risk of morbidity and mortality should source control through drainage be delayed, and they are often admitted to intensive care units (ICU) for hemodynamic support. The purpose of this study was to determine patient factors that may predict mortality in patients admitted to ICU with septic stone, particularly whether rural patients at a greater distance from a tertiary care center were at greater risk of mortality given the inherent delay in intervention.

Methods: The Manitoba Intensive Care Unit prospective registry began in 1999 and includes all patients admitted to ICU across Manitoba. Baseline characteristics, such as age, gender, vital signs, creatinine, Charlson comorbidity index (CCI), mortality outcomes, and location of residency were obtained for those admitted to ICU for septic stone. Association between death and clinical/demographic variables was performed with adjusted multivariable logistical regression analysis.

Results: A total of 342 patients admitted to the ICU were analyzed, with a mean age of 63.5±15.5 years. Baseline characteristics were similar between groups (p>0.05). On multivariable adjusted logistical regression, the presence of acute kidney injury (AKI) (p<0.001) and intubation (p<0.001) were associated with mortality. There was no difference in mortality attributable to location of residency, vital signs, or CCI.

Conclusions: Among patients admitted to the ICU for septic stones in Manitoba, we demonstrate an association between AKI and intubation with mortality. Other factors, such as whether patients were from a rural region and baseline patient characteristics, were not predictive of mortality.
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http://dx.doi.org/10.5489/cuaj.7118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8641904PMC
November 2021

Predictive factors for early discharge (≤24 hours) and re-admission following robotic-assisted laparoscopic pyeloplasty in children.

Can Urol Assoc J 2021 Nov;15(11):E603-E607

Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, FL, United States.

Introduction: Minimally invasive pyeloplasty (MIP) for correction of ureteropelvic junction obstruction in children has significantly improved the postoperative management of these patients. In this study, we sought to examine the factors associated with early discharge (≤24 hours) in children who underwent robotic-assisted laparoscopic pyeloplasty (RALP).

Methods: We performed a retrospective chart review of all children who underwent RALP from 2012-2018 in our center. Descriptive statistics and a non-adjusted risk analysis were performed to evaluate the factors associated with early discharge (≤24h), re-admission, and complications within the first 30 days after the procedure.

Results: Eighty-nine patients out of 124 total pyeloplasties (72%) stayed ≤24 hours post-surgery. Of the variables analyzed, later cases were statistically associated with length of stay (LOS); the first 55 patients had a lower probability of being hospitalized for ≤24 hours (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.09-0.64, p=0.004).

Conclusions: RALP for children is associated with a high rate of early recovery, short hospital stay, and low re-admission and complication rates. Although not statistically significant, patients with shorter operative room time also had a shorter LOS. An increased LOS was observed in the initial patients of our series, and this is most likely explained by the initial learning curve of the team for the procedure itself and the more conservative postoperative management.
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http://dx.doi.org/10.5489/cuaj.7062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8641902PMC
November 2021

Advanced Paternal Age and Sperm DNA Fragmentation: A Systematic Review.

World J Mens Health 2022 Jan 16;40(1):104-115. Epub 2021 Apr 16.

Department of Urology, Miller School of Medicine, University of Miami, Miami, FL, USA.

Purpose: Male ageing is often associated with defective sperm DNA remodeling mechanisms that result in poorly packaged chromatin and a decreased ability to repair DNA strand breaks. However, the impact of advanced paternal age on DNA fragmentation remains inconclusive. The aim of the present systematic review was to investigate the impact of advancing paternal age (APA) on DNA fragmentation.

Materials And Methods: We conducted a thorough search of listed publications in Scopus, PubMed, and EMBASE, in accordance with the PRISMA guidelines.

Results: We identified 3,120 articles, of which nineteen were selected for qualitative analysis, resulting in a sample of 40,668 men. Of the 19 articles evaluating the impact of APA on DFI% (DNA fragmentation Index) included, 4 were on Normozoospermic and subfertile men, 3 on normozoospermic, Oligoasthenoteratozoospermic and Teratozoospermic, 6 on fertile and infertile men, 4 on just infertile men, and 2 evaluated a general population. Seventeen of the ninrnteen studies demonstrated APA's effect and impact on DFI%.

Conclusions: Although there was no universal definition for APA, the present review suggests that older age is associated with increased DFI. In elderly men with normal semen parameters, further studies should be performed to assess the clinical implications of DFI, as a conventional semen analysis can often fail to detect an etiology for infertility.
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http://dx.doi.org/10.5534/wjmh.200195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8761235PMC
January 2022

Elevated sperm DNA fragmentation does not predict recurrent implantation failure.

Andrologia 2021 Aug 7;53(7):e14094. Epub 2021 May 7.

Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA.

In this study, we sought to determine whether sperm DNA fragmentation (DFI%) and high DNA stainability (HDS%) evaluated by sperm chromatin structure assay (SCSA) predict recurrent implantation failure (RIF) or pregnancy rate. A retrospective study was performed of consecutive cycles of ICSI treatment from 2009 to 2018. A total of 386 couples that underwent 1,216 frozen embryo transfer (FET) cycles were analysed. Mean female and male age was 34 ± 3.6 years and 37.3 ± 6.6 years, respectively, and a median total motile sperm count (TMSC) was 43.5 [9.9-105.5] million. Overall median DFI% and HDS% was 12 [7.1-18.9] and 9.6 [6.5-14.4] respectively. On multivariable analysis, DFI% and HDS% were not associated with RIF (DFI%: OR = 1.01, 95% CI: 0.98-1.04, p = .414; HDS%: OR = 0.97, 95% CI: 0.94-1.01, p = .107) or IVF success, defined as clinical pregnancy (DFI%: OR = 1.00, 95% CI: 0.99-1.01, p = .641; HDS%: OR = 1.01, 95% CI: 0.99-1.02, p = .565). We found that neither DFI% or HDS%, as assessed by SCSA, were predictive of RIF or pregnancy rate. This finding suggests that sperm DNA fragmentation does not predict RIF or pregnancy rate.
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http://dx.doi.org/10.1111/and.14094DOI Listing
August 2021

Using molecular genetics in complete androgen insensitivity syndrome: toward a more personalized medicine approach.

Fertil Steril 2021 05 19;115(5):1172. Epub 2021 Mar 19.

Department of Urology, University of Miami Miller School of Medicine, Miami, Florida.

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http://dx.doi.org/10.1016/j.fertnstert.2021.02.035DOI Listing
May 2021

A prospective evaluation of high- and low-power holmium laser settings for transurethral lithotripsy in the management of adults with large bladder calculi.

World J Urol 2021 Sep 24;39(9):3481-3488. Epub 2021 Feb 24.

Department of Urology, Miller School of Medicine, University of Miami, Miami, USA.

Purpose: To prospectively investigate the efficacy and safety of high-power (100 W) vs low-power (20 W) laser settings for transurethral laser lithotripsy in the management large vesical calculi (> 4 cm).

Methods: All patients with vesical calculi > 4 cm in the maximum dimension and scheduled for transurethral holmium laser lithotripsy were invited to participate in the study. Every alternate patient was treated with either the low- or high-power laser settings. We used a continuous irrigation resectoscope with laser bridge or a laser working element (Karl Storz) for laser lithotripsy of bladder stones. We compared the operative time, intra-operative/post-operative complications (up to 1 year), and stone-free rates between the treatment groups using IBM SPSS Statistics 24 software. Comparisons between treatment groups for continuous variables were assessed using the Welch test, while categorical variables were compared with either the Chi-square or Fisher's exact test. A p value < 0.05 was considered statistically significant.

Results: Twenty patients with ten in each cohort were recruited. Preoperative data and mean bladder stone size were comparable in both groups. The duration of surgery was significantly reduced from 70.80 ± 25.28 min in low-power cohort to 40.90 ± 15.01 min in the high-power group (p = 0.005). There were no significant intra-operative complications in either group. All patients were stone-free following the procedure.

Conclusion: High-power laser setting of up to 100 W results in a significant reduction in duration of surgery without any increase in the complication rate for treatment of large bladder stones.
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http://dx.doi.org/10.1007/s00345-021-03617-5DOI Listing
September 2021

Patient Satisfaction With Telemedicine Appointments in an Academic Andrology-focused Urology Practice During the COVID-19 Pandemic.

Urology 2021 07 13;153:35-41. Epub 2021 Jan 13.

Section of Urology, University of Manitoba, Winnipeg, Manitoba, Canada. Electronic address:

Objective: To evaluate patient satisfaction with telemedicine appointments as an alternative to in-person appointments at an Andrology-focused academic urology practice during the coronavirus disease 2019 pandemic.

Methods: Between March and June 2020, all appointments at the practice of a single Andrology-focused academic urologist were conducted by telephone. Consecutive patients were contacted by telephone following their appointment to complete a telephone questionnaire. Baseline demographic information was obtained, and perceptions regarding telephone appointments were assessed using a Likert scale.

Results: Ninety-six patients completed the telephone questionnaire. Median age was 48.5 years (interquartile range 37.3-62.8 years) with 55 of 96 (57.3%) of the appointments Andrology-focused. Mean distance of residence from the hospital was 8.4 km (interquartile range 4.7-25.2 km). Only 9 of 96 (9.3%) of the patients felt that the telephone format did not adequately address their needs. However, 26 of 96 (27.1%) of patients said they would prefer an in-person appointment. On multivariable analysis adjusting for age, gender, presenting complaint, type of appointment, education level, and employment status, no factors were associated with feeling that the telephone appointment adequately addressed needs or preference for an in-person appointment in the future.

Conclusion: Patients were generally satisfied with telephone appointments as an alternative to in-person appointments during the coronavirus disease 2019 pandemic. Nonetheless, a substantial portion of patients said they would prefer in-person appointments in the future.
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http://dx.doi.org/10.1016/j.urology.2020.11.065DOI Listing
July 2021

Evaluation of a serum 17-hydroxyprogesterone as a predictor of semen parameter improvement in men undergoing medical treatment for infertility.

Can Urol Assoc J 2021 Jul;15(7):E340-E345

Department of Urology, University of Miami Miller School of Medicine, Miami, FL, United States.

Introduction: The goal of medical therapy for infertile men with testosterone deficiency (TD) is to improve intratesticular testosterone (ITT). There is a gap in knowledge to identify those who will respond with semen parameter(s) improvement. We hypothesized that serum 17-hydroxyprogesterone (17-OHP) - a marker of ITT - can be used to predict improvement of semen parameter(s).

Methods: Between July 2018 and January 2020, we conducted a prospective study of 31 men with primary infertility, TD, and secondary hypogonadism receiving clomiphene citrate (CC) and/or human chorionic gonadotropin (hCG) for three months. We assessed baseline and followup hormones, including testosterone, 17-OHP, semen parameter(s), and demographics. Semen quality upgrading was based on assisted reproduction eligibility: in-vitro fertilization (<5 million), intrauterine insemination (IUI) (5-9 million), and natural pregnancy (>9 million). Variables were compared using the Mann-Whitney U or Wilcoxon rank test.

Results: Twenty-one men received CC and 10 received CC/hCG. Median followup was 3.7 (3.3-5.1) months. Sixteen men upgraded semen quality. Six of 10 men with baseline total motile sperm count (TMSC) of 0 had motile sperm after treatment, and 11/20 men with TMSC <5 upgraded semen quality into TMSC >5 range. Low 17-OHP was the only factor that predicted semen quality upgrading. Men with 17-OHP ≤55 ng/dL upgraded semen quality and improved hormones, whereas men with 17-OHP >55 ng/dL did not upgrade semen quality.

Conclusions: Medical therapy for infertile men with TD resulted in the improvement of sperm concentration, TMSC, testosterone, and 17-OHP. Semen quality upgrading appears to be more significant in patients with low 17-OHP, suggesting that ITT can be used as a biomarker to predict semen parameter(s) improvement.
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http://dx.doi.org/10.5489/cuaj.6846DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8279241PMC
July 2021

Association between congenital heart disease and gene polymorphisms: systematic review and meta-analysis.

Biomark Med 2020 12;14(18):1747-1757

Department of Molecular Biology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.

To analyze the association of gene with congenital heart disease (CHD), and to determine if the variants rs703752, rs3729753 and rs2277923 increase the risk for developing CHD. PubMed, EBSCO and Web of Science databases were screened to identify eligible studies. Through a comprehensive meta-analysis software, the association between gene variants and susceptibility of CHD was calculated by pooled odd ratio (ORs) and 95% CI. We observed that the allelic model of rs703752 and rs2277923 increased the risk in the overall population: OR = 1.24; 95% CI: 1.00-1.55; Z p-value = 0.049; OR = 1.18; 95% CI: 0.01-1.37; Z p-value = 0.036; respectively. Our results suggested that the rs703752 and rs2277923 polymorphisms of the gene are associated with CHD.
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http://dx.doi.org/10.2217/bmm-2020-0190DOI Listing
December 2020

Sperm DNA fragmentation index and high DNA stainability do not influence pregnancy success after intracytoplasmic sperm injection.

F S Rep 2020 Dec 15;1(3):233-238. Epub 2020 Aug 15.

Department of Urology, University of Miami, Miller School of Medicine, Miami, FL, USA.

Objective: To evaluate the ability of sperm DNA fragmentation index (DFI%) and high DNA stainability (HDS%) to influence the chance of achieving pregnancy in couples undergoing intracytoplasmic sperm injection (ICSI) cycles.

Design: A retrospective study evaluating couples that underwent an ICSI cycle between 2009 - 2018.

Setting: High-volume reproductive center.

Patients: Consecutive couples who underwent an ICSI cycle and had a semen analysis with subsequent DFI% and HDS% testing, evaluated by Sperm Chromatin Structure Assay (SCSA).

Interventions: Measurement of DFI% and HDS% prior to ICSI cycle.

Main Outcome Measures: To determine whether DFI% or HDS% of sperm was predictive of the number of ICSI cycles until the first clinical intrauterine pregnancy.

Results: A total of 550 couples who underwent 1050 ICSI cycles were analyzed. Of those, a total of 330 couples achieved pregnancy. As expected, in couples that achieved pregnancy, females were younger (33.7 ± 3.6 years vs 35.3 ± 3.4 years; p < 0.001) and underwent fewer cycles (2 [1-2] vs 2 [1-3]; p =0.001). Importantly, the DFI% and HDS% were similar between couples who achieved pregnancy (DFI% = 12.9 [8-20]; HDS% = 9.3 [6.1-14.6]) and couples who did not (DFI% =12.2 [7.1-20.2]; HDS% = 9.1 [6.7-14]). A multivariable-adjusted analysis evaluating female age at the first cycle was negatively associated with pregnancy (OR = 0.827, 95% CI: 0.778 - 0.879; p < 0.001).

Conclusions: Neither DFI nor HDS at baseline influence the chances of a couple to achieve pregnancy after ICSI. Increased female age and couples who underwent more ICSI cycles were associated with lower chances of achieving pregnancy.
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http://dx.doi.org/10.1016/j.xfre.2020.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7748016PMC
December 2020

Location of residence and mortality for patients diagnosed with Fournier's gangrene.

Can Urol Assoc J 2021 May;15(5):E267-E271

University of Manitoba, Winnipeg, MB, Canada.

Introduction: Fournier's gangrene (FG) is a necrotizing infection of the genitalia. Time from to surgical intervention is a critical determinant of prognosis. We sought to investigate whether patients from rural locations have worse clinical outcomes given distance from a tertiary center.

Methods: The Manitoba Intensive Care Unit (ICU) registry includes patients who have been admitted into ICUs across Manitoba. We identified patients admitted with FG from February 1999 to October 2019. Age, gender, Charlson comorbidity index (CCI), presence of colostomy and scrotal debridement, length of stay (LOS), and mortality outcomes were obtained. Patients were categorized as being rural or urban.

Results: From 1999-2019, a total of 79 patients were admitted with FG. The median age was 60 years [interquartile range [IQR] 48-67). The mortality rate during hospitalization was 16.5%. There was no statistically significant difference in the number of deaths for patients from urban vs. rural dwellings (9/47 [19.1%] vs. 4/32 [12.5%], p=0.434]. A comparison of the 66 (83.5%) patients that survived and the 13 (16.5%) that died during ICU hospitalization demonstrated no difference in age, gender, CCI, presence of colostomy, and rates of scrotal re-debridement (p>0.05). Multivariable analysis demonstrated that living in a rural area was not associated with increased mortality (odds ratio 0.64, 95% confidence interval 00.16-2.57, p=0.527).

Conclusions: Location of residence was not predictive of death from FG. In addition, baseline characteristics such as age, gender, CCI, surgical interventions, or LOS were not found to be associated with mortality.
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http://dx.doi.org/10.5489/cuaj.6749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8095282PMC
May 2021

A Systematic Review of Reported Ejaculatory Dysfunction in Clinical Trials Evaluating Minimally Invasive Treatment Modalities for BPH.

Curr Urol Rep 2020 Oct 26;21(12):54. Epub 2020 Oct 26.

Department of Urology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, 15th Floor, Miami, FL, 33136, USA.

Purpose Of Review: To explore the sexual outcomes following the novel minimally invasive surgical procedures for benign prostatic hyperplasia- (BPH-) related lower urinary tract symptoms (LUTS), with an emphasis on ejaculatory dysfunction (EjD).

Recent Findings: A database search with a 10-year time restriction was carried out until February 20, 2020 using MEDLINE through the PubMed Platform evaluating minimally invasive treatment modalities for BPH and their effect on EjD. After the article selection, we retrieved data for men randomized in 19 different studies with results in 40 separate published articles investigating minimally invasive BPH surgery and reporting EjD rates. To date, water vapor thermal therapy or Rezūm, prostatic urethral lift (PUL) or UroLift®, prostate artery embolization (PAE), and Aquablation showed acceptable rates (< 2%) of retrograde ejaculation by 1 year and had very low adverse events related to the procedure. Both PUL and Rezūm demonstrated lower rates when compared with PAE and Aquablation. With comparable sexual side effect profiles postoperatively, clinicians may determine which therapeutic modality is optimal for patients based on efficacy and cost-benefit. Further randomized clinical trials are required to directly compare the effect of novel minimally invasive surgical procedures for BPH-related LUTS on ejaculation and sexual function.
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http://dx.doi.org/10.1007/s11934-020-01012-yDOI Listing
October 2020

Association of aging and obesity with decreased 17-hydroxyprogesterone, a serum biomarker of intratesticular testosterone.

Int J Impot Res 2022 Jan 2;34(1):44-49. Epub 2020 Oct 2.

Department of Urology, University of Miami Miller School of Medicine, Miami, FL, United States.

Obesity's negative association with serum testosterone can be explained by either decreasing luteinizing hormone (LH) production from the pituitary gland and/or directly impacting intratesticular testosterone production. We hypothesize that obesity will negatively impact intratesticular testosterone levels when compared to those of non-obese men. We performed a cross-sectional analysis of men with symptoms of testosterone deficiency and male infertility between July 2018 and April 2020 to evaluate the association between body mass index (BMI) and age with intratesticular testosterone (using serum 17-hydroxyprogesterone (17-OHP) as a biomarker), and between BMI with LH. Univariable and multiple linear regression analysis were performed using confounding variables to predict 17-OHP and testosterone. A total of 340 men were selected. Median age was 38 [33-44] years, BMI 27.8 [25.4-31.1] kg/m, serum testosterone 363 [256.3-469.6] ng/dl, 17-OHP 60.5 [39.3-85.8] ng/dl, and LH 4.2 [2.8-5.7] mIU/ml. Older and obese men had lower testosterone compared to younger and non-obese men. Interestingly, increasing age and higher BMI were associated with lower 17-OHP (p < 0.001). Contrarily, age and BMI were not associated with LH levels (p = 0.478). In conclusion, obesity and aging negatively affected 17-OHP independent of LH, suggesting a possible direct effect on testicular function, rather than a secondary effect from a decline in pituitary signaling.
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http://dx.doi.org/10.1038/s41443-020-00358-8DOI Listing
January 2022

The Effect of Longer-Acting vs Shorter-Acting Testosterone Therapy on Follicle Stimulating Hormone and Luteinizing Hormone.

Sex Med Rev 2021 01 8;9(1):143-148. Epub 2020 Sep 8.

Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA. Electronic address:

Introduction: Testosterone (T) replacement therapy causes suppression of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) that can lead to decrease in semen parameters and possible infertility. Different T formulations may have varying suppression on FSH and LH.

Objective: To study whether shorter-acting T (multiple daily dosing) has less suppression on FSH and LH serum levels compared with longer-acting T (transdermal gel, injectable).

Methods: A systematic literature search was conducted by following the protocol based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocols. We comprehensively reviewed the literature by systematically searching manuscripts indexed in PubMed from 1995 to March 13, 2019 to identify studies reporting changes in FSH and LH in hypogonadal men treated with exogenous T which evaluated the effect of exogenous T on FSH and LH.

Results: A total of 8 studies reported the effect of T on FSH and LH in 793 hypogonadal men: 2 used long-acting injectables (enanthate or undecanoate) in a total of 16 men, 5 used intermediate-acting daily topical gels or patches in a total of 471 men, and 1 used short-acting intranasal T (125 μL/nostril, twice a day or three times a day) in 306 men. Long-acting injectables decreased FSH by 86.3%, intermediate-acting daily gels/patches decreased FSH by 60.2%, and short-acting intranasal gel decreased FSH by 37.8%. Long-acting injectables decreased LH by 71.8%, intermediate-acting daily gels/patches decreased LH by 59.2%, and short-acting intranasal gel decreased LH by 47.3%.

Conclusions: Our findings suggest that short-acting T preparations do not decrease serum FSH or LH to the same extent as longer-acting transdermal gels and injectables. However, further clinical trial data are necessary to determine whether the effect of short-acting TRT on gonadotropins translates into similar changes in semen parameters and fertility. Masterson TA, Turner D, Vo D, et al. The Effect of Longer-Acting vs Shorter-Acting Testosterone Therapy on Follicle Stimulating Hormone and Luteinizing Hormone. Sex Med Rev 2021;9:143-148.
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http://dx.doi.org/10.1016/j.sxmr.2020.07.006DOI Listing
January 2021

A prospective study analyzing both inflation and deflation preference for commonly available inflatable penile prostheses.

Int J Impot Res 2021 Sep 10;33(6):652-659. Epub 2020 Aug 10.

Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA.

Despite popularity, satisfaction rates of inflatable penile prosthesis (IPP) use can be improved by evaluating the ability to operate devices in the preoperative setting. The purpose of this study was to prospectively analyze the preference of three commonly available IPPs. In total, 125 IPP-naïve men 60 years of age or older were prospectively recruited from an outpatient Urology clinic from June 2019 to January 2020. A questionnaire standardized to all encounters was utilized to collect demographics, selected medical information, and key pinch strength. Participants were then asked to rank three models in terms of preference (from 1 to 3, 1 representing most preferred) for each inflation and deflation in a double-blinded manner. Statistical analysis was performed using ANOVA, a Chi-square test and multivariable logistical regression analysis. The results demonstrated preference for Coloplast Titan (44%) for inflation, and preference for AMS 700 (40%) for deflation. Men who preferred the Coloplast Titan inflation had a lower chance of preferring the AMS 700 MS deflation (OR = 0.29; p = 0.010) and Coloplast Titan Touch deflation (OR = 0.27; p = 0.012). Preference for Coloplast Titan was weakly associated with participant history of coronary artery disease (OR = 5.96, p = 0.006) and osteoarthritis (OR = 3.04, p = 0.044). Neither key pinch strength nor age was associated with preference for a particular model. IPP-naïve men over 60 years favor Coloplast Titan for inflation and AMS 700 for deflation, and men who preferred the Coloplast Titan for inflation were less likely to choose the AMS 700 MS or Coloplast Titan Touch for deflation. Further studies should aim to confirm these findings.
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http://dx.doi.org/10.1038/s41443-020-0339-0DOI Listing
September 2021
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