Kevin Hebert’s research while affiliated with University of Utah and other places

Introduction Prostate cancer (PCa), erectile dysfunction (ED), and urinary incontinence (UI) can all independently increase a person’s risk of mental health (MH) disorders. However, the relationship between ED and UI on the MH of PCa patients is poorly understood. Objective Our objective is to assess the impact of ED and UI on MH in PCa patients at different stages of diagnosis and treatment. Methods We performed a retrospective cohort study using the insurance claims database, IBM MarketScan, between 2011-2020. Using ICD9/10 and CPT codes, we identified all patients with a diagnosis of PCa and matched each to a control without PCa by age and CCI, which was modified to exclude cancer diagnoses. PCa status was categorized into four groups based on where patients were in their prostate cancer timeline: pre-cancer (PCa patients prior to diagnosis), watching (patients with a diagnosis of PCa without treatment), radiation and prostatectomy. We also noted the first diagnosis of UI and ED for each patient. Patients were followed throughout their enrollment period and any MH diagnoses were recorded, including depressive disorders, anxiety disorders, psychotic disorders, substance abuse disorders and self-harm/suicide attempts. Multivariable cox proportional hazard models were used to assess the relationship between PCa, ED or UI, and MH diagnoses. Models additionally controlled for age, rurality and comorbidities. Patients were censored when their enrollment ended. Interaction terms between PCa status and ED or UI were included to test for differential responses to urologic comorbidities between cancer patients and cancer-free controls. Results A total of 1,253,618 patients were included in the analysis. All patients in the pre-cancer, watching, prostatectomy, and radiation groups without ED or UI showed a decreased risk of being diagnosed with a MH condition compared to controls [HR: 0.86 (0.84-0.88), 0.93 (0.92-0.94), 0.77 (0.74-0.81), and 0.89 (0.86-0.93), respectively; p<0.001]. MH diagnosis was significantly increased in controls with ED [HR: 1.13 (1.10-1.15); p<0.001]. Though the effect of ED was increased in the pre-cancer group [HR: 1.05 (1.00-1.11); p<0.05] compared to controls, the effect was significantly ameliorated in the watching, prostatectomy and radiation groups [HR: 0.88 (0.85-0.90), 0.91 (0.85-0.98) and 0.88 (0.82-0.95), respectively; p<0.01]. UI also significantly increased the likelihood of a MH diagnosis in controls [HR: 2.07 (2.00-2.15); p<0.001], but the effect was significantly dampened for men in the pre-cancer, watching, prostatectomy and radiation groups [HR: 0.83 (0.76-0.91), 0.67 (0.64-0.71), 0.54 (0.50-0.58), and 0.69 (0.62-0.77), respectively; p<0.001). Conclusions Compared to age and CCI-matched controls, PCa patients with ED in watching, prostatectomy and radiation groups and PCa patients with UI have a decreased risk of being diagnosed with a MH condition compared to controls with the same urologic comorbidities. This relationship between PCa groups and MH disorders has been observed in other cancer patient populations and is sometimes referred to the “cancer paradox” or “post-traumatic growth” since these patients with cancer experience a lower incidence of MH compared to those without cancer. Possible reasons for this phenomenon include enhanced resilience, a reevaluation of life priorities and/or a greater appreciation for life due to a shift in perspective of cancer patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Inherent bio, Paterna bio, Firmtech, Turtle health, Maximus, Carrot.

As volume and understanding of genital gender affirming surgery (gGAS) has grown, so has the spectrum of surgical techniques to better serve a wider range of transgender and non-binary individuals. Given the diverse spectrum of individuals seeking phalloplasty, we emphasize the importance of patient driven decision-making, beginning with the initial consultation. Phalloplasty surgery is not a one-size-fits-all surgery, but instead should be viewed from an individually-customized approach. This article discusses the technical details for vaginal preservation without scrotoplasty or clitoral tissue burial in a shaft-only phalloplasty (SOP). The technique involves degloving the clitoral shaft, with inset at the ventral base of the phallus, addressing the redundant clitoral hood, and accompanying reduction labiaplasty with a Y-to-V adjacent tissue transfer. The phallus may be neurotized with clitoral nerves from one side of the clitoris, and/or the ilioinguinal nerve. This technique obliterates the degloved clitoral hood and re-suspends the labia minora anteriorly, improving final aesthetics and striving to meet patient genital goals.

Introduction Transfeminine genital reconstructive surgery is an important part of gender affirmation for many transgender women. Currently, various vaginoplasty techniques are performed by different surgeons across the United States. Surgical outcomes of individual surgeons and groups have been published in the literature, however complications using an insurance claims database have yet to be reported. Objective Our objective is to present post-vaginoplasty complication rates among surgeons in the United States using a large claims database. Methods A retrospective review was conducted of all transgender women who underwent vaginoplasty using IBM MarketScan insurance claims database between 2011-2020. Baseline patient characteristics, including age, obesity, smoking status, Charlson Comorbidity Index (CCI) and the region the surgery was performed were obtained. Patients were followed after surgery to identify complications. Common surgical complications, such as bleeding/hematoma, wound dehiscence, postsurgical infection, DVT, PE, and MI, and complications specific to gender affirming surgery, such as pelvic pain, dyspareunia, rectal injury, urinary issues, urethral stricture, loss of neovaginal depth, and prolapse, were investigated using ICD-9/ICD-10 and CPT codes. Hazard ratios (HRs) were calculated to determine how baseline factors influenced complications. Results A total of 1588 privately insured patients who underwent vaginoplasty for gender affirmation with 414 different surgeons were identified. The mean age was 34 years (22-53 years), 16% were obese and 8% were smokers. The majority (70%) of patients had a CCI of 0. Overall, at a mean follow-up of 14 months (5-28 months), 66% of patients had a complication. A common surgical complication occurred in 19% of patients and a gender affirming surgery complication occurred in 61% of patients. Among those with a gender affirming surgery complication, 17% had pelvic pain, 3% had dyspareunia, <1% had a rectal injury, 21% had urinary issues, 19% had a urethral stricture, 16% had loss of neovaginal depth and 15% had prolapse. A CCI of 2 had a HR of 1.82 (p=0.004) for a common complication and age had a HR of 1.01 (p<0.001) for a gender affirming complication. Smoking was associated with a statistically significant HR for both common complications and gender affirming complications (1.48 and 1.26, respectively; P<0.05). Conclusions Post-vaginoplasty, the majority of patients have at least one complication based on insurance claims data. All patients should be counseled on smoking cessation prior to surgery to potentially decrease the risk of complications. Disclosure No

Introduction The SARS-CoV-2 virus and associated COVID-19 infection is known to cause endothelial cell dysfunction. This has led some to hypothesize that COVID-19 infection may increase the risk of erectile dysfunction. Initial studies evaluating this association have been limited to small, single institution studies or have utilized electronic medical record databases that lack universal follow-up given they only capture follow-up care at a small proportion of health care facilities. Objective To assess if COVID-19 infection recovery is associated with increased rates of newly diagnosed erectile dysfunction (ED) using an insurance claims database. Methods Using IBM MarketScan, a commercial claims database, men with prior COVID-19 infection between January 2020 and January 2021 were identified using ICD-10 diagnosis codes. Using this cohort along with an age-matched cohort of men without prior COVID-19 infection, we assessed the incidence of newly diagnosed erectile dysfunction (ED). Men with ED secondary to prostatectomy or radiation were excluded. Covariates were assessed using a multivariable model to determine association of prior COIVD-19 infection with newly diagnosed ED. Results 42,406 men experienced a COVID-19 infection between January 2020 and January 2021 of which 610 (1.44%) developed new onset ED within 6.5 months follow up. On multivariable analysis while controlling for diabetes, cardiovascular disease, smoking, obesity, hypogonadism, thromboembolism, and GU malignancy, prior COVID-19 infection was associated with increased risk of new onset ED (HR 1.27; 95% CI 1.1-1.5; P=0.001). COVID-19 infection carried a similar association with new onset ED as did diabetes and BMI 25-30, HR 1.3 and 1.29, respectively. Conclusions Prior to the widespread implementation of the COVID-19 vaccine, the incidence of newly diagnosed ED is higher in men with prior COVID-19 infection compared to age-matched controls. Prior COVID-19 infection was associated with a 27% increased likelihood of developing new-onset ED when compared to those without prior infection. Additional longitudinal studies are needed to evaluate the risk of erectile dysfunction after following asymptomatic infection and in the setting prior vaccination. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Cooper Medical, Boston Scientific, Acerus, Coloplast, Endo, Turtle Health, Maximus, FirmTech, StreamDx, Inherent Bioscience.