Steiner AZ, Hansen KR, Barnhart KT, et al. The effect of antioxidants on male factor infertility: the Males, Antioxidants, and Infertility (MOXI) randomized clinical trial. Fertil Steril. 2020;113(3):552-560.

Special thanks to Dr Richard Schoor at NYU Long Island.

Since the discovery that sperm exposed to reactive oxidative species incur damage, physicians have been recommending antioxidant therapy to males in an infertile relationship. The supplement industry began selling antioxidant preparations as fertility aids and despite a paucity of data that these pills did anything for anyone, doctors, even urologists, recommended them; even sold them. The above referenced randomized, placebo-controlled study investigated whether or not commercially available antioxidant preparations improved a man’s fertility. Though not a perfect study, it is a good study. From an initial screen of 822 patients, 264 men met inclusion criteria and were randomly assigned to take either a placebo or an antioxidant preparation. Over a period of 3 months, outcomes such as pregnancies, live births, semen analysis, and DNA fragmentation between the 2 groups were analyzed. The investigators found no difference in any outcome between the placebo and investigative arm. In other words, antioxidants, at least in pill form, don’t seem to do much good for men who are sub-fertile. Do these results end the debate on whether or not we as urologist ought to recommend antioxidant pills to our patients? Probably not. The sample size was too small and the follow-up, 3 months, was too short. Since spermatogenesis takes 3 months to complete, one might think that any therapy directed at a man needs at least 3 to 6 months to show effect. So, what is the take home message? Patients can save their money for treatments that work better.

Brant A, Lewicki P, Wu X, et al. Impact of left-digit age bias in the treatment of localized prostate cancer. J Urol. 2022;208(5):997-1006.

Special thanks to Drs Rabun Jones and Omer Acar at the University of Illinois at Chicago.

There are many reasons for which a urologist may recommend surgery vs radiation treatment for localized prostate cancer, and many factors must be considered in the decision-making process. Age is often the first factor to be taken into account when evaluating treatment options for localized prostate cancer.

The authors of this study evaluated whether there is a bias based on the leftmost digit of a patient’s age, especially in the context of treatment recommendations for a 69-year-old with localized prostate cancer vs a 70-year-old with the same diagnosis. They reviewed 2 national databases to assess whether an increase in patient age from 69 to 70 years was associated with a disproportionate change in treatment recommendations and found that there was a significant discontinuity in treatment recommendations between 69 and 70 years of age, regardless of Gleason score. This finding persisted when the bias was examined between White and non-White patients and was largest when evaluating treatment recommendation trends for Gleason 7 disease.

This well-known “left-digit” bias has been studied in every setting from used-car odometers to the cost of a jar of jam, but this is the first time it has been examined in the context of prostate cancer. These findings offer an important reminder that cognitive biases exist and can sneak their way into the interactions with our patients.

Elliott CS, Dallas K, Shem K, Crew J. Adoption of single-use clean intermittent catheterization policies does not appear to affect genitourinary outcomes in a large spinal cord injury cohort. J Urol. 2022;208(5):1055-1074.

Special thanks to Drs Rabun Jones and Omer Acar at the University of Illinois at Chicago.

In an ever-present effort to combat urinary tract infections, Medicare expanded coverage from 4 reused urinary catheters per month to 200 single-use catheters per month in 2008. This policy change expanded access to catheters for patients who perform clean intermittent catheterization, but did it accomplish the intended effect of decreasing urinary tract infections? To answer this question, the authors of this study used The National Spinal Cord Injury Database to evaluate rates of hospitalizations for genitourinary causes in spinal cord injury (SCI) patients who performed clean intermittent catheterization before and after the policy change.

The authors examined hospitalization rates due to all genitourinary causes, including but not limited to urinary tract infections. Interestingly, they found that hospitalization rates increased significantly after 2008 even when controlling for age, biological sex, and hospitalization due to other reasons.

This study suggests that access to single-use catheters does not change hospitalization rates due to genitourinary causes in the SCI patient population. However, the impact of the Medicare coverage change to promote single-use rather than reusable catheters may have had effects that are difficult to quantify in a retrospective population-based study like this. The complicated relationships between insurance coverage, patient-related factors, and provider beliefs, practices, and preferences limit the generalizability of the findings, but the assumed clinical benefit of single-use catheters likely does not outweigh the financial cost and environmental impact associated with them. Could these findings change the hearts and minds of SCI patients and their urologists?