Evolution of Earth's tectonic carbon conveyor belt.

Concealed deep beneath the oceans is a carbon conveyor belt, propelled by plate tectonics. Our understanding of its modern functioning is underpinned by direct observations, but its variability through time has been poorly quantified. Here we reconstruct oceanic plate carbon reservoirs and track the fate of subducted carbon using thermodynamic modelling. In the Mesozoic era, 250 to 66 million years ago, plate tectonic processes had a pivotal role in driving climate change. Triassic-Jurassic period cooling correlates with a reduction in solid Earth outgassing, whereas Cretaceous period greenhouse conditions can be linked to a doubling in outgassing, driven by high-speed plate tectonics. The associated 'carbon subduction superflux' into the subcontinental mantle may have sparked North American diamond formation. In the Cenozoic era, continental collisions slowed seafloor spreading, reducing tectonically driven outgassing, while deep-sea carbonate sediments emerged as the Earth's largest carbon sink. Subduction and devolatilization of this reservoir beneath volcanic arcs led to a Cenozoic increase in carbon outgassing, surpassing mid-ocean ridges as the dominant source of carbon emissions 20 million years ago. An increase in solid Earth carbon emissions during Cenozoic cooling requires an increase in continental silicate weathering flux to draw down atmospheric carbon dioxide, challenging previous views and providing boundary conditions for future carbon cycle models.

Socioeconomic and patient-related factors for the management of male urethral stricture disease.

PURPOSE: We sought to determine the socioeconomic and patient factors that influence the utilization of urethroplasty and location of management in the treatment of male urethral stricture disease. METHODS: A retrospective review using the Healthcare Cost and Utilization Project State Inpatient and Ambulatory Surgery and Services Databases for California and Florida was performed. Adult men with a diagnosis of urethral stricture who underwent treatment with urethroplasty or endoscopic dilation/urethrotomy between 2007 and 2011 in California and 2009 and 2014 in Florida were identified by ICD-9 or CPT codes. Patients were categorized based on whether they had a urethroplasty or serial dilations/urethrotomies. Patients were assessed for age, insurance provider, median household income by zip code, Charlson Comorbidity Index, race, prior stricture management, and location of the index procedure. A multivariable logistic regression model was fit to assess factors influencing treatment modality (urethroplasty vs endoscopic management) and location (teaching hospital vs non-teaching hospital). RESULTS: Twenty seven thousand, five hundred and sixty-eight patients were identified that underwent treatment for USD. 25,864 (93.8%) treated via endoscopic approaches and 1704 (6.2%) treated with urethroplasty. Factors favoring utilization of urethroplasty include younger age, lower Charlson Comorbidity score, higher zip code median income quartile, private insurance, prior endoscopic treatment, and management at a teaching hospital. CONCLUSION: Socioeconomic predictors of urethroplasty utilization include higher income status and private insurance. Patient-specific factors influencing urethroplasty were younger age and fewer medical comorbidities. A primary driver of urethroplasty utilization was treatment at a teaching hospital. Older and Hispanic patients were less likely to seek care at these facilities.

Ventral-onlay buccal mucosal graft urethroplasty for the treatment of female urethral stricture: a step-by-step video for Female Pelvic Reconstructive Surgeons.

INTRODUCTION AND HYPOTHESIS: Female urethral stricture is a relatively uncommon disease. Conservative management with repeated urethral dilation often leads to unsatisfactory results. Although treatment of female urethral stricture with urethral reconstruction using a variety of surgical techniques is a surgical option, female pelvic reconstructive surgeons have limited exposure to these procedures in their training. The purpose of this video is to demonstrate a step-by-step ventral-onlay buccal mucosal graft urethroplasty in a patient with female urethral stricture disease. METHODS: We use a live action surgical video to describe the harvest of a buccal mucosal graft and ventral-onlay urethroplasty. RESULTS: This video provides a step-by-step approach to a ventral urethroplasty using a buccal mucosal graft. It can be used to educate and train those performing female pelvic reconstructive surgery. CONCLUSION: Pelvic surgeons should be familiar with the management of female urethral stricture, including surgical treatment options such as urethral reconstruction. This video may be used to facilitate the reproducibility and comprehension of the ventral urethroplasty procedure.

Surgical Approaches and Long-Term Outcomes in Adults with Complex Reoperative Hypospadias Repair.

PURPOSE: Patients with failed hypospadias repair are a challenging population for pediatric and reconstructive urologists. We describe our long-term outcomes and factors associated with complications of repeat hypospadias repair. MATERIALS AND METHODS: We retrospectively reviewed the records of 32 adult patients with a history of hypospadias repair who required subsequent urethroplasty between 2002 and 2012. Data on the presenting complaint, past medical and surgical history, demographic data, surgical approach, intraoperative findings and complications were collected and analyzed. RESULTS: Median patient age at urethroplasty was 32 years. Stricture of the penile urethra was the most common presentation. Urethroplasty was done in 30 patients as stricture treatment, 1 underwent perineal urethrostomy and 1 underwent diverticulectomy. Two-stage repair was performed in 90% of the men who underwent urethroplasty. The initial success rate was 83% in patients who underwent 1 or 2-stage urethroplasty. At a median followup of 9.5 years complications included 4 recurrent strictures and 1 fistula. Patient age, previous interventions, stricture length, hair present at the time of repair, the need to excise the urethral plate and the number of stages were not associated with complications or recurrence. If a graft was required, skin grafts were significantly associated with recurrence compared to buccal mucosa grafts. CONCLUSIONS: Excellent outcomes can be achieved using a 2-stage approach with replacement or augmentation of the urethral plate in adults with failed hypospadias repair. In our experience buccal mucosa appears to be associated with fewer complications and less stricture recurrence than skin grafts.

Male Urethral Stricture: American Urological Association Guideline.

PURPOSE: The purpose of this Guideline is to provide a clinical framework for the diagnosis and treatment of male urethral stricture. MATERIALS AND METHODS: A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1990 to 12/1/2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional guidance is provided as Clinical Principles and Expert Opinion when insufficient evidence existed. RESULTS: The Panel identified the most common scenarios seen in clinical practice related to the treatment of urethral strictures. Guideline statements were developed to aid the clinician in optimal evaluation, treatment, and follow-up of patients presenting with urethral strictures. CONCLUSIONS: Successful treatment of male urethral stricture requires selection of the appropriate endoscopic or surgical procedure based on anatomic location, length of stricture, and prior interventions. Routine use of imaging to assess stricture characteristics will be required to apply evidence based recommendations, which must be applied with consideration of patient preferences and personal goals. As scientific knowledge relevant to urethral stricture evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

Urethroplasty in radiation-induced strictures.

PURPOSE OF REVIEW: In patients presenting with urethral stricture disease, the mainstay of definitive treatment is urethroplasty. Until recently, it was unclear if urethroplasty was a feasible option in patients with urethral stricture secondary to pelvic radiation exposure. We review the feasibility and outcomes for urethroplasty in patients with radiation-induced urethral stricture. RECENT FINDINGS: Urethroplasty in patients exposed to radiation can be technically challenging secondary to stricture location and tissue damage; however, it still has an acceptable success rate with durable outcomes. Most radiation-induced strictures are limited in length, located in the bulbomembranous region, and are amenable to excision and primary anastomosis. There are higher rates of postoperative urinary incontinence in this cohort when compared with outcomes for urethroplasty without radiation exposure; however, erectile function appears to be preserved. SUMMARY: Recent studies highlight that urethroplasty has acceptable success rates in men with radiation-induced urethral stricture. Patients in this cohort need to be counseled on the potential for urinary incontinence following urethroplasty.

A protocol based, electronic medical record enabled care coordination system improves the timeliness and efficiency of care for patients with hematuria.

PURPOSE: We determined whether including a care coordination system to manage the referral process for hematuria would lead to improved quality of care. MATERIALS AND METHODS: Inflection Navigator, a protocol based, electronic medical record enabled care coordination system, was developed to support primary care physicians evaluating newly discovered hematuria. We studied the system for patients referred for microscopic and gross hematuria from May 2009 to May 2010. We compared outcomes in these 106 patients and in 105 referred to our urology department for hematuria during the same period who did not use the system. RESULTS: Patients in the care coordination group completed the evaluation in a significantly shorter time with more than a 1-month difference in time between referral and the completion of the imaging and cystoscopy components of the assessment (mean 40.9 vs 74.1 days, p <0.05). This system potentially lowered health care costs by decreasing the mean ± SD number of urology visits needed to complete an evaluation from 2.1 ± 1.5 in the standard referral group to 1.6 ± 1.4 in the care coordination group (p <0.05). CONCLUSIONS: A protocol based care coordination system for hematuria decreased the time needed to complete an evaluation and decreased the number of overall visits required to make a final diagnosis. Thus, the Inflection Navigator system is an example of an electronic medical record enabled process innovation that can improve the efficiency of care while potentially lowering health care costs.

Geographic Variation of Infectious Complications Following Prostate Biopsy in The United States: Results From a Population-Based Cohort of Privately Insured Patients.

OBJECTIVE: To elucidate regional trends of infectious complications following transrectal ultrasound prostate biopsy (TRUS-PB) from a national, privately-insured database. MATEREIAL AND METHODS: Using Market Scan, we identified all men who underwent TRUS-PB from 2010 to 2015. Infectious complications (UTI, prostatitis, sepsis) occurring 30 days after the prostate biopsy from emergency room (ER) visits or hospital admissions constituted the primary outcomes. We analyzed unadjusted and adjusted rates of infectious complications from ER visits and hospital admissions per 100 prostate biopsies by state. Multivariable logistic regression analyses were used to identify patient covariates associated with infectious complications. RESULTS: During the study interval, we identified 193,490 patients who underwent TRUS-PB. The mean age was 57.6 years (SD: 5.0). Over time the unadjusted national rates of infectious complications remained similar from 0.4 ER visits per 100 prostate biopsies in 2010 -0.2 in 2015 (P = 0.83), and 1.2 hospital admissions per 100 prostate biopsies in 2010 to 1.1 in 2015 (P= 0.58). Connecticut had the lowest unadjusted infectious complication rate per 100 biopsies at 0.64, whereas West Virginia had the highest at 2.34. Multivariable analysis revealed higher Elixhauser status and patient age were associated with higher odds of infectious complications (P<0.05). CONCLUSIONS: While rates of infectious complications attributable to prostate biopsies remain relatively stable, significant variation exists at the state level regarding this adverse outcome.

Reconstruction of late-onset transplant ureteral stricture disease.

OBJECTIVE: • To describe our experience with surgical management of transplant ureteral strictures over a 6-year period. PATIENTS AND METHODS: • The present study identified patients who underwent open reconstruction for transplant ureteral strictures between March 2002 and May 2008 after kidney or kidney-pancreas transplantation. • Baseline clinical characteristics were documented, including age at transplantation and reconstruction, serum creatinine levels, immunosuppressive drug regimen, and comorbidities. • Postoperative complications were noted, including urinary tract infections, stricture recurrence and graft failure. • Successful reconstructions were defined as stable allograft function with unobstructed outflow not requiring repeat dilation, ureterotomy or stent placement. RESULTS: • Median age at the time of reconstruction was 51 years and the mean time from transplantation was 62 months. • Seven of the 13 patients had failed previous balloon dilation. • The patients were followed for a median of 41 months and a successful repair was achieved in 10 of 13 patients. • Ureteral strictures recurred in two patients who received ureteroneocystostomies, which were subsequently managed with chronic stent exchanges. • Another recurrence involved a 1.5-cm anastomotic stricture 6 months postoperatively, which was balloon-dilated and has remained recurrence-free for 16 months. CONCLUSIONS: • Patients who present > 6 months after renal transplantation with ureteral strictures that are recalcitrant to endoscopic management can safely undergo open surgical ureteral reconstruction without subsequent renal or graft failure. • Further investigation involving a larger patient cohort is required to confirm these initial results.

Workforce Issues in Urology.

The future supply of urologists is not on pace to account for future demands of urologic care. This impending urologic shortage sits on a backdrop of multiple other workforce issues. In this review, we take an in-depth look at several pressing issues facing the urologic workforce, including the impending urology shortage, gender and diversity concerns, growing levels of burnout, and the effects of the coronavirus pandemic. In doing so, we highlight specific areas of clinical practice that may need to be addressed from a health care policy standpoint.

Prospective analysis of ejaculatory function after anterior urethral reconstruction.

PURPOSE: Urethral reconstruction may improve ejaculatory function by relieving urethral obstruction but could worsen it by disrupting the bulbocavernosus muscle. We prospectively evaluated the effects of urethral reconstruction on ejaculatory function. MATERIALS AND METHODS: All men who underwent anterior urethroplasty from September 2006 to June 2009 were asked to complete the ejaculatory function component of the Male Sexual Health Questionnaire (7 questions with a total of 35 points) preoperatively and postoperatively after resuming sexual activity. Postoperatively decreased and improved ejaculation was defined as an increase and a decrease of 5 or more points, respectively. RESULTS: A total of 43 men were included in the study. The overall ejaculatory score did not change postoperatively (25.54 vs 26.94 points, p = 0.17) at a mean +/- SD followup of 8.1 +/- 6.0 months but men with poor preoperative function had significant improvement (15.27 vs 21.22 points, p = 0.01). Overall ejaculatory vigor (3.19 vs 3.56 points, p = 0.25) and volume (3.49 vs 3.88, p = 0.19) did not change significantly. Postoperative function was stable in 30 men (70%), improved in 8 (19%), including 7 with bulbar and 1 with penile urethroplasty, and worse in 5 (11%), including 4 with bulbar and 1 with penile urethroplasty. CONCLUSIONS: Urethral reconstruction appears to have a minimal effect on ejaculatory function when evaluated by the Male Sexual Health Questionnaire. More objective testing may be necessary to fully assess the effect of urethroplasty on ejaculatory function.

Prospective analysis of erectile dysfunction after anterior urethroplasty: incidence and recovery of function.

PURPOSE: Anterior urethroplasty has been shown to negatively impact erectile function. Recovery of function is common but the likelihood and extent of recovery have not been fully elucidated. MATERIALS AND METHODS: Between October 2006 and May 2008 men undergoing anterior urethroplasty were enrolled in a prospective study to evaluate the effects of urethroplasty on erectile function. The International Index of Erectile Function was completed preoperatively and on all subsequent postoperative visits. Preoperative and postoperative erectile function was compared. RESULTS: A total of 52 patients who underwent anterior urethroplasty were included in the study. Repair locations were bulbar (35) and penile (17). Of the patients undergoing bulbar urethroplasty 20 had excision and primary anastomosis, and 15 had augmented anastomotic repair. All penile repairs were ventral onlay repair (11) or inlay repair in 2 stages (6). Postoperative erectile dysfunction was noted in 20 (38%) men, of whom 18 recovered fully at a mean postoperative period of 190 days (range 92 to 398). In patients with normal preoperative erectile function bulbar urethroplasty was more likely than penile urethroplasty to cause erectile dysfunction (76% vs 38%, p = 0.05). Within the bulbar urethra excision and primary anastomosis repairs led to slightly higher erectile dysfunction rates than augmented anastomotic repairs (50% vs 26%, p = 0.16). CONCLUSIONS: Anterior urethroplasty caused erectile dysfunction in approximately 40% of patients, although recovery was seen in most by 6 months. Bulbar urethroplasty appears to affect erectile function to a greater extent than penile urethroplasty, which may be explained by the proximity of the bulbar urethra to the nerves responsible for erection.

Bladder neck contracture after retropubic radical prostatectomy: incidence and risk factors from a large single-surgeon experience.

OBJECTIVE: To examine a large, single-surgeon series of patients with prostate cancer who underwent retropubic radical prostatectomy (RRP) for men with postoperative bladder neck contractures (BNCs). PATIENTS AND METHODS: From 1983 to 2007, 4132 men underwent RRP for prostate cancer by one surgeon. All patients had BN reconstruction with mucosal eversion. The bladder to membranous urethral anastomosis was made using six 2/0 chromic catgut sutures over an 18 F Foley catheter. The catheter was left in place for 10 days. Data from these men is stored in a prospective database, which was reviewed in this study for men with BNCs after RRP. Men with BNCs were compared with all other men in the series to determine risk factors for BNC development. RESULTS: Overall, BNCs developed in 110 patients (2.5%). Examining our last 500 patients there was a contemporary BNC rate of <1%. The median (range) follow-up was 44 (12-233) months. Tumour characteristics were similar in the men with BNCs and those with no BNCs, and the rates of organ-confined disease were also similar (65% vs 70%, P = 0.27). Men with BNCs had higher median preoperative prostate-specific antigen (PSA) levels (6.7 vs 5.7 mg/dL; P = 0.009) and were more likely to have PSA failure after RRP (30% vs 16%, P < 0.001). On multivariate analysis, non-nerve sparing (P = 0.003) and a surgical date before 1992 (P < 0.001) were significant predictors of BNC. Patients with BNCs had lower potency rates (49% vs 63%, P < 0.003) and continence rates (88% vs 94%, P = 0.07) at the 18-month follow-up. CONCLUSIONS: BNCs are rare, occurring in <1% in our modern series. The important surgical factors in preventing BNCs are to avoid closing the BN too tightly and attaining good apposition of the BN with the urethral stump with a watertight closure. BNCs are more common with non-nerve-sparing surgery and early in a surgeon's experience.

Penile and Urethral Reconstructive Surgery.

Penile and urethral reconstructive surgical procedures are used to treat a variety of urologic diagnoses. Urethral stricture disease can lead to progressive lower urinary tract symptoms and may require multiple surgical procedures to improve patient's symptoms. Male stress urinary incontinence is associated with intrinsic sphincter deficiency oftentimes associated with radical prostatectomy. Men suffering from urethral stricture disease and stress urinary incontinence should be referred to a urologist because multiple treatment options exist to improve their quality of life.

Improved surgical outcomes following radical cystectomy at high-volume centers influence overall survival.

OBJECTIVES: Positive surgical margins (PSM) and lymph node yield (LNY) following radical cystectomy (RC) for urothelial carcinoma of the bladder affect survival. Variations in PSM or LNY at different care facilities are poorly described. We evaluated the relationship between hospital surgical volume and academic hospital status with these surgical outcomes and overall survival (OS). METHODS AND MATERIALS: Patients with nonmetastatic urothelial carcinoma of the bladder who underwent RC were identified from the National Cancer Database (2004-2013). Treatment centers were categorized as academic (ACC) and community cancer centers (CCC). Logistic regression was used to identify factors associated with PSM status and LNY, and a multivariate Cox proportional hazards model was used to determine factors associated with OS. RESULTS: In our cohort, 39,274 patients underwent RC. A lower proportion of PSMs (10% vs.12%; P<0.001) and higher median LNY (14 vs. 8, P<0.001) was observed at ACCs compared to CCCs. On logistic regression, there were lower odds of PSM (OR = 0.89, 95% CI: 0.81-0.97) and higher odds of LNY ≥ 10 nodes (OR = 1.84, 95% CI: 1.74-1.96) among patients at ACCs compared to CCCs. Cox proportional hazards analysis demonstrated benefit to OS at high-volume centers (HR = 0.91, 95% CI: 0.87-0.95) but not based on ACC designation. The OS advantage at high-volume centers is attenuated (HR = 0.95, 95% CI: 0.91-0.99) by PSM status and LNY. CONCLUSIONS: ACCs demonstrate improved surgical outcomes following RC, and a survival advantage attributable to high surgical volume is identified. Centralization of care may lead to improved outcomes in this lethal malignancy.

Metagenomic Discovery of 83 New Human Papillomavirus Types in Patients with Immunodeficiency.

Several immunodeficiencies are associated with high susceptibility to persistent and progressive human papillomavirus (HPV) infection leading to a wide range of cutaneous and mucosal lesions. However, the HPV types most commonly associated with such clinical manifestations in these patients have not been systematically defined. Here, we used virion enrichment, rolling circle amplification, and deep sequencing to identify circular DNA viruses present in skin swabs and/or wart biopsy samples from 48 patients with rare genetic immunodeficiencies, including patients with warts, hypogammaglobulinemia, infections, myelokathexis (WHIM) syndrome, or epidermodysplasia verruciformis (EV). Their profiles were compared with the profiles of swabs from 14 healthy adults and warts from 6 immunologically normal children. Individual patients were typically infected with multiple HPV types; up to 26 different types were isolated from a single patient (multiple anatomical sites, one time point). Among these, we identified the complete genomes of 83 previously unknown HPV types and 35 incomplete genomes representing possible additional new types. HPV types in the genus Gammapapillomavirus were common in WHIM patients, whereas EV patients mainly shed HPVs from the genus Betapapillomavirus. Preliminary evidence based on three WHIM patients treated with plerixafor, a leukocyte mobilizing agent, suggest that longer-term therapy may correlate with decreased HPV diversity and increased predominance of HPV types associated with childhood skin warts.IMPORTANCE Although some members of the viral family Papillomaviridae cause benign skin warts (papillomas), many human papillomavirus (HPV) infections are not associated with visible symptoms. For example, most healthy adults chronically shed Gammapapillomavirus (Gamma) virions from apparently healthy skin surfaces. To further explore the diversity of papillomaviruses, we performed viromic surveys on immunodeficient individuals suffering from florid skin warts. Our results nearly double the number of known Gamma HPV types and suggest that WHIM syndrome patients are uniquely susceptible to Gamma HPV-associated skin warts. Preliminary results suggest that treatment with the drug plerixafor may promote resolution of the unusual Gamma HPV skin warts observed in WHIM patients.

National Surgical Trends and Perioperative Outcomes of Midurethral Sling Placement for Stress Urinary Incontinence.

OBJECTIVE: To determine contemporary trends, patient characteristics, and outcomes for midurethral sling placement (MUS) at inpatient and ambulatory facilities from a national database. MATERIALS AND METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified 7767 women who underwent isolated MUS 2006-2012. We stratified patients by hospitalization type (outpatient vs hospitalization). Primary outcomes were 30-day complications, readmissions, and reoperations. Multivariable logistic regression was used to determine patient and surgery factors associated with adverse perioperative outcomes. RESULTS: Among the 7767 women undergoing MUS, 84.3% underwent outpatient surgery (n = 6547), with greater use of outpatient facilities over time (P < .001). Overall, 3.9% of patients (n = 300) experienced one or more postoperative complications. Complications were more likely among inpatients (7.4% vs 3.2%; odds ratio [OR] 0.48, confidence interval [CI] 0.36-0.64, P < .001), with gynecologists as compared to urologists (4.4% vs 3.1%; OR 1.53, CI 1.16-2.02, P = .003), and with resident participation (5.1% vs 3.7%; OR 1.32, CI 1.01-1.73, P = .04). On multivariable analysis, outpatients were less likely to experience readmissions (0.9% vs 2.8%; OR 0.2, CI 0.09-0.56, P = .002) or undergo reoperation (0.3% vs 3.1%; OR 0.10, CI 0.02-0.38, P = .001). CONCLUSION: Use of outpatient surgical centers for MUS is increasing, with lower rates of complications, readmissions, and reoperations compared to inpatient treatment. Although there is a difference in complications by specialty and with resident involvement, overall incidence of complications is low.