Background: Direct-to-consumer (DTC) Internet-based prescription and pharmacy platforms offer electronic consultation for evaluation and pharmacologic treatment of erectile dysfunction (ED) without a physical exam or in-person visit, presenting a potentially dramatic shift in care for this condition. Aim: To characterize the extent to which DTC prescribing sites for ED generate traffic and attract individual users. Methods: Using SEMRush, a marketing software platform that provides analytics regarding website traffic, we examined online site visits to 6 major DTC prescribing websites offering ED evaluation and treatment from October 2017 through December 2019. Outcomes: We recorded trends in the number of unique visitors over time, visitor referral patterns, and the proportion of overall visitors to individual sites. Results: During the study period, the total number of unique, quarterly visitors increased by 1,688% from 655,733 in the 4th quarter (Q4) 2017 to over 11 million in Q4 2019. In 2019, there were on average 4,971,674 visits to all sites combined each month. For the 2 largest sites (Hims and Roman), visitors predominantly reached the site via direct web address (27.3%) or search engine referral (27.3%). Clinical implications: An increasingly large number of potential patients are utilizing DTC prescribing platforms for the diagnosis and treatment of ED, which do not require physical exams or treatment of other comorbid conditions. Strength & Limitations: Demonstrates high demand for ED DTC prescribing services using independent market research software and characterizes the number of visits for the first time. Limitations include the lack of individual demographics and lack of information regarding what proportion of unique visits lead to evaluation and treatment using the services. Conclusion: The dramatic increase in visits to DTC prescribing sites that treat ED represents a paradigm shift in ED care, and it is imperative that clinicians and researchers work to understand how patients utilize online telemedicine, the safety and efficacy of online management of ED, and the potential downstream implications of its widespread use.

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INTRODUCTION AND OBJECTIVES: Robot-assisted partial nephrectomy [RAPN] is a complex procedure and surgical outcomes can be influenced by increasing surgical experience [EXP]. The aim of the study is to investigate the effect of EXP on perioperative outcomes to define the surgical learning curve for RAPN, since actual curves are rarely presented.METHODS: 457 patients treated with RAPN for a cT1-2 renal mass by two surgeons with extensive EXP (>300 cases) were assessed into a prospective database were. For each patient, EXP was defined as the total number of RAPN performed by each surgeon before the patient's operation. Outcomes of the study were warm ischemia time [WIT], Clavien-Dindo 2 postoperative complications [CD2] and positive surgical margins [PSM]. Multivariable linear (WIT) and logistic regression (CD2, PSM) models tested the effect of EXP on the outcomes. Restricted cubic splines were used to test for the non-linear nature of the relationship between EXP and the outcomes. Covariates consisted of tumour clinical size and RENAL nephrometry score to account for case mix. Local polynomial smoothing method was used to depict actual curves using model-derived estimated WIT and probability of CD2-free postoperative course.RESULTS: Median EXP was 148 cases (interquartile range [IQR] 65-254). Median WIT was 14 min (IQR 10-19). The rate of CD2 and PSM were 14 and 4%, respectively. Increasing EXP resulted associated with lower ischemia time (1st spline estimate -4.5 minutes per 25 cases; 95% confidence intervals [CI] -2.3,-1.3; p<0.0001) and with higher probability of CD2-free postoperative course (OR 1.01 per 25 cases; CI:1.005,1.02; p<0.001). Conversely, EXP was not associated with PSM (OR 1.00; CI 0.99,1.002; p¼0.5). The relationship between EXP and WIT resulted non-linear, with a steep reduction in WIT from case 1 to case 100 and a plateau observed after 150 cases (Figure 1 panel A). Conversely, the relationship between EXP and CD2 resulted linear without a plateau being observed even after 300 cases (Figure 1 panel B).CONCLUSIONS: Perioperative outcomes after RAPN are importantly affected by surgical experience. After 150 RAPNs, no further improvement is observed with respect to WIT. Conversely, when CD2 are taken into considerations, the learning curve appears endless, without a plateau even after 300 cases.

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