Nontransecting Techniques Reduce Sexual Dysfunction after Anastomotic Bulbar Urethroplasty: Results of a Multi-Institutional Comparative Analysis.

PURPOSE: The purpose of this multi-institutional study was to compare outcomes of transecting and nontransecting anastomotic bulbar urethroplasty. MATERIALS AND METHODS: We performed a retrospective, multi-institutional review of the records of 352 patients who underwent transecting or nontransecting anastomotic bulbar urethroplasty performed by 1 of 4 reconstructive urologists from September 2003 to March 2017. Study outcomes were urethroplasty success, defined as urethral patency greater than 16Fr on cystoscopy; de novo sexual dysfunction assessed at 6 months, defined as a 5-point or greater change in the SHIM (Sexual Health Inventory for Men) or a patient reported adverse change; and 90-day complications, defined as Clavien 2 or greater. When appropriate, comparisons were made between the transecting and nontransecting cohorts using the Mantel-Cox test, the t-test or the chi-square test. RESULTS: Of the 352 patients with a mean stricture length of 1.7 cm (range 0.5 to 5) 258 and 94 underwent transecting and nontransecting anastomotic bulbar urethroplasty, respectively. The overall success rate was 94.9% at a mean followup of 64.2 months (range 6 to 170). Of the patients 7.1% experienced a 90-day complication and 11.6% reported sexual dysfunction. When comparing transecting and nontransecting techniques, there was no difference in success (93.8% vs 97.9%, Mantel-Cox test p = 0.18) or postoperative complications (8.1% vs 4.3%, p = 0.25). Patients treated with transecting anastomotic urethroplasty were more likely to report an adverse change in sexual function (14.3% vs 4.3%, p = 0.008). On multivariate analysis only transecting urethroplasty was associated with sexual dysfunction (p = 0.01) while age (p = 0.29), stricture length (p = 0.42), etiology (p = 0.99) and surgeon (p = 0.88) were not. CONCLUSIONS: Anastomotic urethroplasty is a highly effective surgery with relatively minimal associated morbidity. Nontransecting anastomotic urethroplasty compares quite favorably to the transecting technique and likely reduces the risk of associated sexual dysfunction.

Reopening Openness to Experience: A Network Analysis of Four Openness to Experience Inventories.

Openness to Experience is a complex trait, the taxonomic structure of which has been widely debated. Previous research has provided greater clarity of its lower order structure by synthesizing facets across several scales related to Openness to Experience. In this study, we take a finer grained approach by investigating the item-level relations of four Openness to Experience inventories (Big Five Aspects Scale, HEXACO-100, NEO PI-3, and Woo et al.'s Openness to Experience Inventory), using a network science approach, which allowed items to form an emergent taxonomy of facets and aspects. Our results (N = 802) identified 10 distinct facets (variety-seeking, aesthetic appreciation, intellectual curiosity, diversity, openness to emotions, fantasy, imaginative, self-assessed intelligence, intellectual interests, and nontraditionalism) that largely replicate previous findings as well as three higher order aspects: two that are commonly found in the literature (intellect and experiencing; i.e., openness), and one novel aspect (open-mindedness). In addition, we demonstrate that each Openness to Experience inventory offers a unique conceptualization of the trait, and that some inventories provide broader coverage of the network space than others. Our findings establish a broader consensus of Openness to Experience at the aspect and facet level, which has important implications for researchers and the Openness to Experience inventories they use.

Prevalence of Post-Micturition Incontinence before and after Anterior Urethroplasty.

PURPOSE: In this study we aimed to define the prevalence of preoperative and postoperative post-micturition incontinence or post-void dribbling after anterior urethroplasty for urethral stricture disease. We also sought to determine risk factors for its presence. MATERIALS AND METHODS: We retrospectively reviewed a prospectively maintained, multi-institutional urethral stricture database to evaluate post-micturition incontinence using a single question from a validated questionnaire, "How often have you had a slight wetting of your pants a few minutes after you had finished urinating and had dressed yourself?" Possible answers were never-0 to all the time-3. The presence of post-micturition incontinence was defined as any answer greater than 0. Comparisons were made to stricture type and location, repair type and patient medical comorbidities. RESULTS: Preoperative and postoperative post-micturition incontinence questionnaires were completed by 614 and 331 patients, respectively. Patients without complete data available were excluded from study. Preoperative post-micturition incontinence was present in 73% of patients, of whom 44% stated that this symptom was present most of the time. Overall postoperative post-micturition incontinence was present in 40% of patients and again it was not predicted by stricture location or urethroplasty type. Of the 331 patients with followup questionnaires 60% reported improvement, 32% reported no change and 8% reported worsening symptoms. The overall rate of de novo post-micturition incontinence was low at 6.3%. CONCLUSIONS: The prevalence of preoperative post-micturition incontinence is high and likely under reported. In most patients post-micturition incontinence improves after urethroplasty and the prevalence of de novo post-micturition incontinence is low. The presence of post-micturition incontinence was not predicted by stricture length or location, or urethroplasty repair type.

Neurogenic Lower Urinary Tract Dysfunction in Adults with Cerebral Palsy: Outcomes following a Conservative Management Approach.

PURPOSE: Cerebral palsy is characterized by motor impairment following injury to the developing brain. Neurogenic lower urinary tract dysfunction is estimated to affect at least a third of children with cerebral palsy. However there are limited data as patients transition to adulthood. We sought to describe the symptoms, sequelae and management of neurogenic lower urinary tract dysfunction in adults with cerebral palsy. MATERIALS AND METHODS: We retrospectively reviewed the charts of adult patients with cerebral palsy between 2011 and 2014. Patients with prior bladder reconstruction or catheterization based bladder drainage were excluded from study. Cerebral palsy severity was determined using GMFCS (Gross Motor Function Classification System). A conservative evaluation and treatment paradigm was used. Noninvasive treatments were encouraged. Specifically clean intermittent catheterization, which is often not feasible, is avoided unless urinary retention, hydronephrosis or refractory lower urinary tract symptoms develop. RESULTS: There were 121 patients included in final analysis. Median age was 25 and 61 patients (50%) had GMFCS level V. Noninvasive management failed in 28 of 121 patients (23%) as defined by hydronephrosis in 9, persistent urinary retention in 10 and refractory lower urinary tract symptoms/incontinence in 9. Urethral clean intermittent catheterization was poorly tolerated. Of all patients 25% showed evidence of urolithiasis during the study period. Surgical intervention was rare and associated with significant morbidity. CONCLUSIONS: Adults with cerebral palsy may present with variable signs and symptoms of neurogenic lower urinary tract dysfunction. Conservative treatment was successful in more than 75% of patients. Clean intermittent catheterization was poorly tolerated in patients in whom conservative treatment failed. Surgical intervention was rarely indicated and it should be reserved for select individuals.

Commentary: The Development of Creativity--Ability, Motivation, and Potential.

A major question for research on the development of creativity is whether it is interested in creative potential (a prospective approach that uses measures early in life to predict adult creativity) or in children's creativity for its own sake. We suggest that a focus on potential for future creativity diminishes the fascinating creative world of childhood. The contributions to this issue can be organized in light of an ability × motivation framework, which offers a fruitful way for thinking about the many factors that foster and impede creativity. The contributions reflect a renewed interest in the development of creativity and highlight how this area can illuminate broader problems in creativity studies.

Long-term renal function outcomes after radical cystectomy.

PURPOSE: We evaluated the long-term natural history of renal function after radical cystectomy with urinary diversion and determined factors associated with decreased renal function. MATERIALS AND METHODS: We reviewed the records of 1,631 patients who underwent radical cystectomy between 1980 and 2006. The estimated glomerular filtration rate was calculated preoperatively and at various intervals after surgery. A renal function decrease was defined as a greater than 10 ml per minute/1.73 m(2) reduction in the estimated glomerular filtration rate. Multivariate analysis was done to evaluate the association of clinicopathological features, incontinent vs continent diversion type and postoperative complications with decreased renal function. RESULTS: A total of 1,241 patients (76%) underwent incontinent diversion and 390 (24%) underwent continent diversion. Median followup after radical cystectomy in patients alive at last followup was 10.5 years (IQR 7.1, 15.3). The median preoperative estimated glomerular filtration rate was higher in the continent diversion cohort (67 vs 59 ml per minute/1.73 m(2), p <0.0001). This difference was maintained until 7 years postoperatively, after which no difference was noted in renal function by diversion type. By 10 years after radical cystectomy the risk of a renal function decrease was similar for incontinent and continent diversion (71% and 74%, respectively, p = 0.13). On multivariate analysis risk factors associated with decreased renal function included age (HR 1.03, p <0.0001), preoperative estimated glomerular filtration rate (HR 1.05, p <0.0001), chronic hypertension (HR 1.2, p = 0.01), postoperative hydronephrosis (HR 1.2, p = 0.03), pyelonephritis (HR 1.3, p = 0.01) and ureteroenteric stricture (HR 1.6, p <0.0001). CONCLUSIONS: Decreased renal function is noted in most patients during long-term followup after radical cystectomy. Postoperative hydronephrosis, pyelonephritis and ureteroenteric stricture represent potentially modifiable factors associated with a decrease. Choice of urinary diversion was not independently associated with decreased renal function.

The immunopathology of B lymphocytes during stroke-induced injury and repair.

B cells, also known as B lymphocytes or lymphoid lineage cells, are a historically understudied cell population with regard to brain-related injuries and diseases. However, an increasing number of publications have begun to elucidate the different phenotypes and roles B cells can undertake during central nervous system (CNS) pathology, including following ischemic and hemorrhagic stroke. B cell phenotype is intrinsically linked to function following stroke, as they may be beneficial or detrimental depending on the subset, timing, and microenvironment. Factors such as age, sex, and presence of co-morbidity also influence the behavior of post-stroke B cells. The following review will briefly describe B cells from origination to senescence, explore B cell function by integrating decades of stroke research, differentiate between the known B cell subtypes and their respective activity, discuss some of the physiological influences on B cells as well as the influence of B cells on certain physiological functions, and highlight the differences between B cells in healthy and disease states with particular emphasis in the context of ischemic stroke.

FACS to Identify Immune Subsets in Mouse Brain and Spleen.

Flow cytometry enables the multi-parametric quantification of cell types, especially in immunophenotyping of unique immune cell subsets that can either contribute to or ameliorate pathology. For tissues to be used in such analyses, single-cell suspensions must be created. Here we describe protocols for preparing single-cell suspensions of mouse spleen and brain tissue, as well as the steps for fluorescently activated cell staining/sorting (FACS). Specifically, this protocol enables the isolation of lymphocytes for the study of immune responses during various diseases, such as long-term neuroinflammation following ischemic stroke.

Using Operant Reach Chambers to Assess Mouse Skilled Forelimb Use After Stroke.

Skilled forelimb reaching and grasping are important components of rodent motor performance. The isometric pull task can serve as a tool for quantifying forelimb function following stroke or other CNS injury as well as in forelimb rehabilitation. This task has been extensively developed for use in rats. Here, we describe methods of setup and training of an operant reach chamber for mice. Using a reward of peanut oil, mice are adaptively trained to pull a handle positioned slightly outside of an operant chamber, with automated recording of the number of attempts, force generated, success rate, and latency to maximal force.

Updating the Aesthetic Fluency Scale: Revised long and short forms for research in the psychology of the arts.

People's knowledge about the arts shapes how they experience and engage with art. Since its introduction, the 10-item Aesthetic Fluency Scale has been widely used to measure self-reported art knowledge. Drawing from findings and researchers' experience since then, the present work develops and evaluates a Revised Aesthetic Fluency Scale using item response theory to broaden its scope (36 items) and refine its response scale. In a large sample (n = 2,089 English-speaking adults), Study 1 found strong evidence for unidimensionality, good item fit, and a difficulty level suitable for its targeted population; Study 2 (n = 392) provided initial evidence for score validity via relationships with art engagement, Openness to Experience, and aesthetic responsiveness; and Study 3 derived a brief, 10-item form for time-constrained projects. Taken together, the revised scales build upon lessons learned from the original and appear promising for the next generation of research.

Use of an Automated Mouse Touchscreen Platform for Quantification of Cognitive Deficits After Central Nervous System Injury.

Analyzing cognitive performance is an important aspect of assessing physiological deficits after stroke or other central nervous system (CNS) injuries in both humans and in basic science animal models. Cognitive testing on an automated touchscreen operant platform began in humans but is now increasingly popular in preclinical studies as it enables testing in many cognitive domains in a highly reproducible way while minimizing stress to the laboratory animal. Here, we describe the step-by-step setup and application of four operant touchscreen tests used on adult mice. In brief, mice are trained to touch a graphical image on a lit screen and initiate subsequent trials for a reward. Following initial training, mice can be tested on tasks that probe performance in many cognitive domains and thus infer the integrity of brain circuits and regions. There are already many outstanding published protocols on touchscreen cognitive testing. This chapter is designed to add to the literature in two specific ways. First, this chapter provides in a single location practical, behind-the-scenes tips for setup and testing of mice in four touchscreen tasks that are useful to assess in CNS injury models: Paired Associates Learning (PAL), a task of episodic, associative (object-location) memory; Location Discrimination Reversal (LDR), a test for mnemonic discrimination (also called behavioral pattern separation) and cognitive flexibility; Autoshaping (AUTO), a test of Pavlovian or classical conditioning; and Extinction (EXT), tasks of stimulus-response and response inhibition, respectively. Second, this chapter summarizes issues to consider when performing touchscreen tests in mouse models of CNS injury. Quantifying gross and fine aspects of cognitive function is essential to improved treatment for brain dysfunction after stroke or CNS injury as well as other brain diseases, and touchscreen testing provides a sensitive, reliable, and robust way to achieve this.

Examining the Flourishing Impacts of Repeated Visits to a Virtual Art Museum and the Role of Immersion.

Visiting art museums has been associated with a range of flourishing outcomes. However, there have been recent shifts towards increasing digital engagement with art, leading to a radical change in how people experience visual art. Given the now expansive virtual art viewing options, it is important to understand whether digital engagement can also lead to greater flourishing, and, if so, under what conditions. We examined the flourishing effects of viewing art in a virtual gallery in a pre-registered experiment comprising four sessions over four weeks, with varying viewing instructions designed to increase immersion. Participants were recruited from a USA representative sample on Prolific, resulting in a final sample of 687 participants. People were randomly assigned to one of nine experimental conditions. Eight art viewing conditions involved four 15 min virtual gallery visits with viewing instructions varying on two factors: slow-looking and immersive mindset framing. An active control condition involved reading about (but not viewing) art. Participants completed a battery of baseline flourishing measures in week 1, completed experimental art engagement sessions during weeks 1-4, and completed the battery again in week 5. While immersion levels were greater in the viewing conditions than the reading condition, growth in flourishing did not differ across condition. Exploratory analyses, however, showed that immersion during the gallery visits did predict some changes in specific facets of flourishing (e.g., engagement, meaning, autonomy satisfaction). We suggest a number of possible explanations for these null results and point to what is needed in future research.

Aesthetic Preference for Glossy Materials: An Attempted Replication and Extension.

The psychology of art and aesthetics has a long-standing interest in how low-level features, such as symmetry, curvature, and color, affect people's aesthetic experience. Recent research in this tradition suggests that people find glossy, shiny objects and materials more attractive than flat, matte ones. The present experiment sought to replicate and extend research on the attractiveness of images printed on glossy and flat paper. To control for several possible confounding factors, glossiness was manipulated between-person and varied with methods that held constant factors like weight, color quality, and resolution. To extend past work, we explored art expertise and Openness to Experience as potential moderators. A sample of 100 adults viewed landscape photographs on either high-gloss photo paper or on identical paper in which a flat, matte spray finish had been applied. Ratings of attractiveness showed weak evidence for replication. People rated the glossy pictures as more attractive than the matte ones, but the effect size was small (d = -0.23 [-0.62, 0.16]) and not statistically significant. Attractiveness ratings were significantly moderated, however, by individual differences in the aesthetic appreciation facet of Openness to Experience. When aesthetic appreciation was high, people found the images attractive regardless of condition; when it was low, people strongly preferred the glossy images over the matte ones, thus showing the classic glossiness effect. We conclude with some methodological caveats for future research.

Development and Validation of A Male Anterior Urethral Stricture Classification System.

OBJECTIVE: To develop and validate a clinical classification system for urethral stricture disease (USD) based on the retrograde urethrogram (RUG), physical exam, and stricture-specific patient history. MATERIALS AND METHODS: Three elements were chosen to be included in the classification system: 1) Length of urethral stricture (L); 2) Stricture segment/location (S); 3) Stricture Etiology (E) (LSE classification system). Each element was divided into clinically relevant sub-categories. A three-step development and validation process then ensued, culminating in an in-person Trauma and Urologic Reconstruction Network of Surgeons (TURNS) meeting, at which the final classification system was unanimously agreed upon by attendees based on interrater reliability data obtained from the classifying of 22 clinical vignettes. A final validation step involved retrospectively classifying cases in the TURNS database to determine if classification influenced surgical technique and was associated with presumed stricture etiology. RESULTS: The final LSE classification system was found to have an interrater reliability of 0.79 (individual components 0.76, 0.70 and 0.93 respectfully). Retrospective classification of the 2162 TURNS strictures revealed the segment (S) to be strongly associated with urethroplasty type (p = 0.0005) and stricture etiology (E) (p = 0.0005). CONCLUSION: We developed and validated a novel, easy to use, urethral stricture classification system. The system's ability to aid in directing treatments, predict treatment outcomes, and facilitate collaborative research efforts will require further study.

Mental Control in Musical Imagery: A Dual Component Model.

Hearing music in your head is a ubiquitous experience, but the role mental control plays in these experiences has not been deeply addressed. In this conceptual analysis, a dual-component model of mental control in musical imagery experiences is developed and discussed. The first component, initiation, refers to whether the musical imagery experience began voluntarily or involuntarily. The second component, management, refers to instances of control that occur after the experience has begun (e.g., changing the song, stopping the experience). Given the complex nature of this inner experience, we propose a new model combining and integrating four literatures: lab-based auditory imagery research using musical stimuli; involuntary musical imagery; mental rehearsal and composition in musicians; and in vivo studies of musical imagery in everyday environments. These literatures support the contention that mental control of musical imagery is multi-faceted. Future research should investigate these two components of mental control and better integrate the diverse literatures on musical imagery.

Trends in Urethral Stricture Disease Etiology and Urethroplasty Technique From a Multi-institutional Surgical Outcomes Research Group.

OBJECTIVE: To analyze contemporary urethroplasty trends and urethral stricture etiologies over a 7-year study period among urologists from a large multi-institutional surgical outcomes group. METHODS: Review of a multi-institutional, prospectively maintained urethroplasty database was performed on 2098 anterior urethroplasties done between 2010 and 2017 by 10 surgeons. Stricture characteristics, including etiology, length, and anatomic location were analyzed and compared to urethroplasty type over the study period using chi-squared analysis to assess for linear trends within the group and by surgeon. RESULTS: Average stricture lengths for bulbar (2.8 ± 1.8 cm), penile (3.6 ± 2.6 cm), and penile-bulbar strictures (8.7 ± 5.0) remained stable. The most common stricture etiology was idiopathic/unknown in all study years (63%). In the bulbar urethra, the group performed significantly (1) fewer excisional repairs (-31%) and more substitutional repairs (+78%); (2) of substitutional repairs, more grafts are being placed dorsally (+95%) vs ventrally (-75%) (3) of the bulbar excisional repairs, more are being performed without transection of the bulbar urethra (+430%); and in the penile urethra (4) the fasciocutaneous flap is in decline (-86%), while single-stage dorsal repairs are increasing (+280%). CONCLUSION: Anterior urethroplasty techniques continue to evolve in the absence of robust clinical data or randomized controlled trials, with a general movement in this cohort toward an initial dorsal approach for most strictures. Inter- and intrasurgeon variability in the surgical management of similar strictures was noted, and the feasibility of any future randomized controlled trials, without apparent surgical equipoise, must be questioned.

Preoperative Incidence of Deep Venous Thrombosis in Patients With Bladder Cancer Undergoing Radical Cystectomy.

OBJECTIVE: To determine the preoperative incidence of subclinical lower-extremity deep vein thrombosis (DVT), as well as to evaluate the utility of preoperative DVT screening in patients with bladder cancer before undergoing radical cystectomy. MATERIALS AND METHODS: Beginning in 2014, we prospectively instituted a policy of obtaining a screening lower-extremity duplex ultrasound on all patients within 7 days before undergoing radical cystectomy. We reviewed the electronic medical records of all patients at our institution who underwent radical cystectomy for bladder cancer from January 2012 through December 2015. The screened group (n = 65) underwent preoperative screening; the historical control group (n = 78) did not. Primary outcome was a lower-extremity duplex ultrasound positive screening. Secondary outcome measures included the development of symptomatic venous thromboembolism (VTE) postoperatively, and the rate and severity of complications. RESULTS: DVT was identified in 13.9% of patients before undergoing cystectomy. Univariate analysis demonstrated an increased risk of subclinical DVT in patients who were exposed to neoadjuvant chemotherapy (35.3% vs 5.1%, P = .008). Postoperatively, there was a nonsignificant trend of lower DVT rate in the screened group compared to historical control. Overall complication rate and severity were similar between the groups. CONCLUSION: Subclinical DVT is present in a significant number of pre-cystectomy patients, especially those exposed to neoadjuvant chemotherapy. Ultrasound screening in patients before undergoing radical cystectomy may identify opportunities for early intervention to reduce morbidity and mortality associated with perioperative DVT or venous thromboembolism in the cystectomy population.

Extended outpatient chemoprophylaxis reduces venous thromboembolism after radical cystectomy.

PURPOSE: Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism, is a common cause of morbidity and mortality after radical cystectomy. The purpose of our study was to evaluate the utility of extended outpatient chemoprophylaxis against VTE after radical cystectomy-with a focus on any reduction in the incidence of VTE, including DVT and pulmonary embolism. MATERIALS AND METHODS: Beginning in April 2013, we prospectively instituted a policy of extending inpatient VTE prophylaxis with subcutaneous heparin/enoxaparin for 30 days postoperatively. For this study, we reviewed the electronic medical records of all patients who underwent radical cystectomy at our institution from January 2012 through December 2015. The experimental group (n = 79) received extended outpatient chemoprophylaxis against VTE; the control group (n = 51) received no chemoprophylaxis after discharge. The primary outcome was the 90-day incidence of VTE. The secondary outcomes included the overall complication rate, the hemorrhagic complication rate, as well as the rate of readmission within 30 days of hospital discharge. RESULTS: The experimental group experienced a significantly lower rate of DVT (5.06%), assessed as of 90 days postoperatively, than the control group (17.6%): a relative risk reduction of 71.3% (P = 0.021). We found no significant differences in secondary outcomes between the 2 groups, including the overall complication rate (54.4% vs. 68.6%), the hemorrhagic complication rate (3.7% vs. 2.0%), and the readmission rate (21.5% vs. 29.4%). CONCLUSION: Extended outpatient chemoprophylaxis significantly reduced the incidence of VTE.

Multi-institutional Outcomes for Simultaneous and Staged Urinary and Fecal Diversions in Patients Without Cancer.

OBJECTIVE: To compare the morbidity and postoperative recovery between patients treated with urinary diversion after colostomy with patients undergoing simultaneous double diversion (DD). METHODS: A multi-institutional retrospective review was performed in patients treated with urinary diversion after colostomy or simultaneous DD between 2007 and 2014 for noncancerous indications. The Clavien-Dindo system was used to classify complications occurring within 90 days of surgery, and high-grade adverse events (HGAE) were classified grade 3 or higher. RESULTS: A total of 46 patients were identified with fecal and urinary diversions (19 in the after colostomy (AC) group, 27 in the DD group). Common indications for urinary diversion were neurogenic bladder (54%) and urinary fistula (44%). Mean hospital stay and return of bowel function after surgery for entire cohort was 13 and 7 days, respectively, with no differences between AC and DD groups. Almost 50% of patients in the cohort experienced an HGAE but there was no difference in HGAE incidence (8/19 AC, 13/27 DD; P = .69) or complication type between the groups. Increased operative time (5% risk per every 15 minutes over 7 hours, P = .03) was the only independent variable associated with increased risk of HGAE. DD was not independently associated with increased risk of HGAE compared with staged urinary diversion. CONCLUSION: Morbidity and postoperative recovery appeared similar whether urinary diversion is performed after colostomy or during a DD.