The Role of Vibrators in Women's Pelvic Health: An Alluring Tool to Improve Physical, Sexual, and Mental Health.

INTRODUCTION AND HYPOTHESIS: In limited studies vibrators have been shown to improve sexual function and pelvic floor health; however, there are even fewer studies on the effect of vibrator use on overall genitourinary and mental health. To investigate the effect of regular vibrator use on sexual, genitourinary, and mental health in addition to quality of life. METHODS: We performed a prospective pilot study of women aged 18 to 80 years recruited from a urogynecology clinic. Study participants were instructed to use a vibrator according to the protocol. Sexual function, pelvic floor function, mental health, and pelvic examination were assessed at the initial visit and at 3 months' follow-up using validated questionnaires. RESULTS: Of the 79 participants enrolled in the study, 53 women (66%) completed the study. The mean age of the participants was 54.7 years (range 19-80 years), and the majority of participants were white (n = 59, 74.7%), post-menopausal (n = 48, 60.8%), and not receiving systemic (n = 63, 79.7%) or local (n = 63, 79.7%) hormone therapy. Sexual function significantly improved over time (p = 0.002), whereas the rate of bothersome pelvic organ prolapse symptoms and pain scores significantly decreased (p = 0.034 and 0.0008 respectively). Rates of urge urinary incontinence decreased although this was not statistically significant (p = 0.059). There was a significant improvement in the gross appearance of lichen sclerosus lesions (p = 0.025) and in the severity of vaginal atrophy (p = 0.018). Rates of depression were significantly decreased (p = 0.011). CONCLUSIONS: Vibrator use was associated with improved sexual, genitourinary, and mental health.

Can vaginal lactobacillus suppositories help reduce urinary tract infections?

INTRODUCTION AND HYPOTHESIS: Recurrent urinary tract infections (rUTIs) are a burden to patients and the health care economy. Vaginal probiotics and supplements have gained significant attention in mainstream media and lay press as a non-antibiotic alternative. We performed a systematic review to determine whether vaginal probiotics are an effective means of prophylaxis for rUTI. METHODS: A PubMed/MEDLINE article search was performed from inception to August 2022 for prospective, in vivo use of vaginal suppositories for the prevention of rUTIs. Search terms included: vaginal probiotic suppository (34 results), vaginal probiotic randomized (184 results), vaginal probiotic prevention (441 results), vaginal probiotic UTI (21 results), and vaginal probiotic urinary tract infection (91 results). A total of 771 article titles and abstracts were screened. RESULTS: A total of 8 articles fit the inclusion criteria and were reviewed and summarized. Four were randomized controlled trials, with 3 of the studies having a placebo arm. Three were prospective cohort studies, and 1 was a single arm, open label trial. Five of the 7 articles that specifically evaluated for rUTI reduction with vaginal suppositories did find a decreased incidence with probiotic use; however, only 2 had statistically significant results. Both of these were studies of Lactobacillus crispatus and were not randomized. Three studies demonstrated the efficacy and safety of Lactobacillus as a vaginal suppository. CONCLUSION: Current data support the use of vaginal suppositories containing Lactobacillus as a safe, non-antibiotic measure, but actual reduction of rUTI in susceptible women remains inconclusive. The appropriate dosing and duration of therapy remain unknown.

Neovaginal Canal Dissection in Gender-Affirming Vaginoplasty.

PURPOSE: Gender-affirming vaginoplasty creates the vulva and vaginal canal for individuals assigned male sex at birth who have gender dysphoria. Dissection of the neovaginal space can be particularly challenging, with risk of injury to the anal and urethral sphincters, urethra and rectum. We present an anatomically based technique for vaginal canal dissection. MATERIALS AND METHODS: We retrospectively analyzed a cohort of patients who underwent gender-affirming vaginoplasty by a single surgeon between May 2016 and July 2019. We describe our technique for dissection and report relevant outcomes. RESULTS: We performed 200 vaginoplasty procedures during the study period. Patient age ranged from 15-70 years (median 41). Body mass index ranged from 16-50.5 kg/m2 (median 27). The vaginal depth ranged from 10-16 cm, with a median of 14 cm and a mean of 13.7 cm. Vaginal depth was slightly greater for patients with a body mass index of ≥30 vs <30 kg/m2 (p=0.0145). Operative complications were observed in 2 patients (1.0%) with a full thickness rectal injury and in 3 (1.5%) with a partial thickness rectal injury. Two of these patients (1.0%) had progression to a rectovaginal fistula (1 full and 1 partial thickness injury), 1 patient (0.5%) had a urethral injury, 8 patients (4.0%) had vaginal stenosis, 3 patients (1.5%) had introital stenosis and 10 patients (5.0%) had stress urinary incontinence that later resolved. CONCLUSIONS: Neovaginal canal dissection in gender-affirming vaginoplasty is technically challenging. An anatomically based approach is associated with a low complication rate at our center.

Media coverage of the 2019 United States Food and Drug Administration ordered withdrawal of vaginal mesh products for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: On April 16, 2019, the United States Food and Drug Administration announced a withdrawal on sales and distribution of transvaginal mesh products for pelvic organ prolapse. The aim of this study was to asses online user behavior on pelvic-mesh related articles after the withdrawal and to evaluate article accuracy. MATERIALS AND METHODS: We used Google Trends© to identify the terms related to pelvic mesh that experienced increased activity after the FDA announcement. The terms were analyzed for worldwide social media engagement (Facebook, Twitter, Pinterest, and Reddit) between April 16-19, 2019. The top ten lay press articles shared for each term were evaluated. We also examined the top ten Google search results for each term on June 6, 2019, in the US to evaluate what information was available after peak interest subsided. RESULTS: During peak activity in April, 30 unique articles were identified after the FDA announcement. Two (6.7%) did not mention the April 2019 FDA announcement. Seven (23%) discussed mesh for stress urinary incontinence. After peak interest on June 6, 2019, Google identified 26 unique articles for the four terms. Seven (27%) did not mention the FDA announcement, and 3 (12%) mentioned mesh for incontinence. CONCLUSIONS: Internet search patterns and social media behavior following the April 2019 ordered withdrawal on transvaginal mesh for pelvic organ prolapse reveal that some of the most disseminated information did not accurately or thoroughly distinguish the type of mesh discussed. This could lead to negative consequences for other mesh indications in female pelvic medicine and reconstructive surgery.

High dose alkylator therapy for extracranial malignant rhabdoid tumors in children.

BACKGROUND: Extracranial malignant rhabdoid tumor (MRT) is a rare pediatric cancer with a poor prognosis. The kidney is the most common site. Isolated reports have shown improvements in patient survival, but no specific treatment regimen has shown efficacy over others. PROCEDURE: Retrospective review of patients diagnosed with extracranial MRT at Children's Hospital Los Angeles between 1983 and 2012. RESULTS: The median age at presentation for the 21 patients was 13 months (range, 0-108 months). Ten patients had renal primary tumors. The median time to progression was 4 months (range, 0.4-7 months). The 5-year event free survival (EFS) and overall survival (OS) of the entire cohort was 38 ± 10.6%. After 2002, patients diagnosed with extracranial MRT were administered a chemotherapy regimen of vincristine, doxorubicin and high dose cyclophosphamide (VDC). The OS for the patients diagnosed before and after 2002 were 20 ± 12% and 54 ± 15%, respectively. Of the 13 patients who received VDC containing regimen, eight patients achieved a complete radiological remission; five of these patients are long-term survivors. Four patients who received autologous bone marrow transplantation were alive at last follow-up. All patients with unresectable primary tumors died. Patients who had disease progression or relapse did not survive. CONCLUSIONS: Patients with extracranial MRT have a poor prognosis. Treatment with high dose alkylator therapy followed by consolidation with high dose chemotherapy and autologous bone marrow transplant for those patients in radiographic complete remission appears to have a beneficial effect on survival.

Robotic Sacrohysteropexy With Concurrent Rectopexy using Fascia Lata Graft.

INTRODUCTION AND OBJECTIVE: There is limited data regarding the use of mesh for pelvic organ prolapse (POP) repair in young women of childbearing age who wish to preserve their uterus.1 Sacrohysteropexy with concurrent rectopexy can be performed in this population with a biologic graft, to decrease the risk of contamination with colorectal surgery and allow for future pregnancy.2-4 The objective of this video is to present the surgical management of prolapse repair in a young woman with uterine and rectosigmoid prolapse, causing rectal outlet obstruction. MATERIALS AND METHODS: Our patient is a 21-year-old woman with over a decade of severe constipation. Her past medical history includes anxiety, depression and sexual abuse. She previously underwent robotic rectopexy for intra-rectal intussusception and mucosal prolapse with immediate improvement in her symptoms; however, two months after rectopexy, she suffered from persistent abdominal pain and severe difficulty passing stool. Dynamic resonance imaging demonstrated descent of the bladder with significant uterine prolapse, causing impingement of rectum and rectocele, blocking the evacuation of stool. The patient was thus indicated for concurrent sacrohysteropexy and rectopexy. RESULTS: She underwent a robotic procedure. Given her age, in an effort to preserve future child-bearing potential, we performed the surgery with a biologic graft made of fascia lata. For the sacrohysteropexy, the graft was sutured to the posterior cervix. Intraoperatively she was noted to have an intact enterocele repair and posterior rectopexy from her previous surgery; however, there was an angulation at the recto sigmoid. This was corrected by performing a rectopexy to the fascia lata graft. She discharged home the day of surgery without incident. CONCLUSION: Biologic grafts can be used for multi compartment prolapse repair in women of child-bearing age. Fascia lata provides a safe alternative to mesh to allow for future pregnancy. Also, sacrohysteropexy with concurrent rectopexy can be performed with same day discharge.

Addressing Burnout in Urology: A Qualitative Assessment of Interventions.

INTRODUCTION: We characterized physician burnout among urologists to determine the prevalence and efficacy of specific burnout interventions utilized and to determine involvement of workplaces in effective burnout interventions. METHODS: The Western Section of the American Urological Association created an electronic, 29 question workforce survey. Several questions focused on assessing the level of urologist burnout, prevalence of work sponsored burnout interventions and efficacy of specific interventions. RESULTS: A total of 440 responses were received (25.9% response rate); 82.2% of responders were male. The majority of urologists noted some level of burnout (79.5%) with no significant difference between those who reported no burnout vs some level of burnout (p=0.30). The most commonly tried interventions to reduce burnout were participating in regular physical exercise (76.6%), reading nonmedical literature (67.1%) and decreasing or modifying work hours (52.3%). The interventions most frequently cited as "very effective" were hiring a scribe (62.5%), regular exercise (56.1%) and participating in 1-on-1 gatherings with colleagues outside of work (44.6%). There were no significant differences noted when comparing "very effective" interventions by gender. The interventions most frequently cited as not effective were stress or burnout seminars (26.9%) and meditation/mindfulness training (11.5%); 42.5% reported workplace interventions to help prevent or reduce burnout. CONCLUSIONS: Certain practice-changing and personal burnout interventions were noted to be "very effective" in decreasing burnout. Fewer than half of responders noted workplace sponsorship of interventions. Organizational support may lead to increased participation and effectiveness of burnout interventions.

Social media engagement, perpetuating selected information, and accuracy regarding CA SB-201: Treatment or intervention on the sex characteristics of a minor.

INTRODUCTION: Disorders/differences of sex development (DSD) is a medical term used to encompass patients born with congenital conditions that lead to atypical development of the genitalia and reproductive structures. OBJECTIVE: To evaluate the factual accuracy of shared articles from popular social media platforms regarding the California State Bill, SB-201, Treatment or Intervention: Sex Characteristics of a Minor. DESIGN: We used the BuzzSumo© search engine to analyze the terms "SB 201", "intersex," "DSD," and "surgery ban" for worldwide social media engagement (Facebook, Twitter, Pinterest, and Reedit) one month before and after bill introduction on January 31, 2019, and final hearing on January 13, 2020. Articles were categorized based on source, opinion of the author, accuracy of scientific information, use of term intersex versus disorder/difference of sex development (DSD), definition of intersex, advocacy group quoted, reference to surgical "gender assignment," mention of negative consequences of the bill/other banned surgeries, the definition of medical necessity, parental rights, psychosocial concerns, and photographic content. RESULTS: Twenty unique articles with peak activity were analyzed. Eighteen were from news and two from editorial web sources. All mentioned SB-201.50% were classified as one-sided, meaning both arguments for and against were not presented. 60% of articles were perpetuating selected information correlating with the author's opinion. 65% of articles were misleading in terms of factual accuracy. All articles used the term intersex. 20% of articles used scientific terms such as atypical genitalia (2), DSD (2), and born with variations of sex characteristics (1). A urologist was quoted in 45% of articles, while 75% quoted intersex advocacy groups. 55% of articles referred to the surgeries as "gender normalizing," and 75% referred to "assigning gender". Three articles mentioned other non-DSD surgeries that SB-201 would ban in addition to any that "normalize appearance." 45% (9) included any definition of medical necessity, the most common being inability to urinate (7), which is incompatible with post-natal viability. DISCUSSION: Our study demonstrates that some of the most disseminated information on social media surrounding the introduction and hearing of SB-201 that did not include input from the medical community, perpetuated selected information, and lacked appropriate factual content. CONCLUSION: Misinformation in the media can be harmful to patients and the general public. This study highlights the need for balanced and accurate reporting on medical topics that can have emotional and political consequences when speaking to broader audiences.

Transvaginal Repair of a Peritoneal-Vaginal Fistula.

OBJECTIVE: Pelvic organ prolapse is an increasingly reported complication following anterior pelvic exenteration and usually consists of an anterior enterocele.1-4 We present the surgical management of a peritoneal-vaginal fistula in a woman who presented with an acute enterocele 16 months following vaginal sparing, robot-assisted laparoscopic anterior pelvic exenteration. METHODS: Our patient is an 85-year-old female with history of upper tract urothelial carcinoma who underwent a left nephroureterectomy in 2008, and vaginal sparing robot-assisted laparoscopic anterior pelvic exenteration for BCG-refractory carcinoma in situ of the bladder in August 2016. She presented in November 2017 with new onset vaginal bleeding and discharge. On physical examination, she had a dehisced vaginal cuff apex with a bulging enterocele. There were no signs of active evisceration or strangulation. The patient was no longer sexually active and desired surgical treatment. At the time of surgery, a mature peritoneal-vaginal fistula was identified, and the fistula and prolapse were surgically managed with colpectomy and colpocleisis. RESULTS: Intraoperatively found to have a partial vaginal cuff dehiscence covered with granulation tissue, resulting in a 5 mm peritoneal-vaginal fistula. The granulation-covered enterocele sac was trimmed, dissected free, closed, and reduced with serial purse-string sutures. In this fashion, the sutures were used to not only reduce the fistula, but to also perform a colpocleisis and colpectomy. The colpocleisis and colpectomy were performed due to lack of supportive apical vaginal structures and patient desire. The serial purse-string sutures not only provided additional apical support, but also reduced the likelihood of fistula recurrence by covering the peritoneum. CONCLUSION: Transvaginal peritoneal-vaginal fistula repair with serial purse-string sutures and partial colpectomy provides a technique for repair in patients who do not have supportive apical tissue following exenterative surgery. The ideal prevention of this problem at the time of cystectomy and management for when it occurs remains unclear.

Gender-affirming Vaginectomy-Transperineal Approach.

OBJECTIVE: Gender-affirming vaginectomy treats gender dysphoria associated with the presence of a vagina in transgender males.1,2 Prior reported approaches include transperineal vaginectomy, mucosal fulguration, and robotic-assisted. We present key steps in transperineal gender-affirming vaginectomy in a 39-year-old transgender male. METHODS: Informed consent for video recording was obtained. The patient underwent a first-stage phalloplasty 6 months prior. He was placed in high lithotomy Tredelenberg position. After Foley placement, an incision was made along the mucocutaneous junction laterally and posteriorly. The anterior sulci were incised and a transverse incision made anteriorly at the bladder neck. The vaginal mucosa was excised, except for the distal anterior vaginal wall mucosa which would be mobilized as a flap for urethral lengthening later. The paravaginal space was closed with a series of purse-string sutures starting at the apex. The anterior vaginal wall flap is mobilized with the base of the flap at the urethral meatus. Cystoscopy confirms ureteral patency and no lower urinary tract involvement. A suprapubic tube was placed. The procedure then proceeded with a second-stage phalloplasty that included urethral lengthening and scrotoplasty. RESULTS: The demonstrated procedure took 110 minutes and estimated blood loss was 75 mL. In our published series of 40 vaginectomies for 27 phalloplasties and 13 metoidioplasties, median operative time was 135 minutes and median estimated blood loss was 250cc.3 No complications related to the vaginectomy, including mucocele, fistulae to the vaginal space, or visceral injuries occurred. Peritoneal entry occurred in 44% of the cases and was closed primarily without further sequelae. Two patients required blood transfusion and 1 patient had C. difficile colitis. The anterior vaginal wall mucosa flap was incorporated in 83% of the time. CONCLUSION: Transperineal vaginectomy results in low periprocedural complications, takes approximately 2 hours after a learning curve. Detailed results from our series of these procedures have been previously reported.3.

An institutional assessment of sperm cryospreservation and fertility counselling in pubertal male cancer survivors.

INTRODUCTION: Improved survivorship after treatment of pediatric malignancies has dramatically increased, while pre-treatment fertility preservation in this population has not kept pace. New guidelines emphasize fertility preservation in young adolescents, but the impact of these guidelines is unknown. OBJECTIVES: We sought to evaluate the rate of fertility preservation among at-risk adolescents diagnosed with cancer at our institution, as well as evaluate barriers to fertility preservation. DESIGN: We performed an IRB-approved historical cohort study of adolescent males 13 years and older evaluated in the Pediatric Hematology-Oncology clinic at Doernbecher Children's Hospital from 2010 to 2018. Electronic chart review was used assess discussion of fertility preservation and barrier to successful preservation in boys with a new diagnosis of cancer who received systemic chemotherapy and/or gonadal or pelvic irradiation. RESULTS: 82 boys were included in the study. Forty-two (51%) received counselling about fertility preservation, and of those 29 (70%) successfully banked sperm. Neither counseling for fertility preservation nor success at sperm banking differed by patient age, but both differed by malignancy. Patients with Hodgkin's lymphoma had the highest rate of counselling, while those with leukemia had the lowest. Acute illness as a barrier to preservation was found in 40% of those who did not receive counselling. DISCUSSION: Our study demonstrates a stagnant rate of fertility counseling and preservation despite increased advocacy. The retrospective nature of our study limited our ability to assess the counselling that occurred, and the lack of granular race data limited study of the implicit selection bias that may be involved in such counseling. As more institutions move toward a multi-disciplinary care model, we believe that pediatric urologists or fertility specialists must play a vocal role in the care of these at-risk adolescents. CONCLUSION: Despite increasing advocacy for fertility preservation, our data shows no significant change in previously reported trends. Patients with Hodgkin's lymphoma have a higher rate of counseling and cryopreservation in comparison to those with other malignancies.

Penile Inversion Vaginoplasty Technique.

Penile inversion vaginoplasty is a technique of gender-affirming genital surgery that uses primarily genital skin to construct the vulva and neovagina for patients assigned male sex at birth. This article presents present the authors' techniques and other contemporary techniques for this surgery, with particular attention to neovaginal canal construction, neoclitoral construction, and urethroplasty.

A Simple Neobladder Using a Porcine Model: The Double Limb U-Pouch.

OBJECTIVE: To create a simple neobladder and determine whether the double-limb U-Pouch (D-LUP) has the same capacity and compliance as a Studer or Camey I neobladder. To develop an orthotopic diversion that can be applied to robotic surgery with laboratory data supporting the concept. MATERIALS AND METHODS: Kidneys, ureters, bladders, and small intestine were obtained from pigs at the time of scheduled autopsy after completion of institutionally approved investigational trauma protocols. A Camey I neobladder, spherical neobladder, and D-LUP, were constructed from 40-cm segments of small intestine. They were compared for capacity, compliance, and pouch-to-urethra anastomotic distance. RESULTS: The cystometric capacity at 30 cm H2O for the Camey I, Studer, and D-LUP neobladders were 250 mL, 350 mL, and 430 mL, respectively. The pouch-to-urethra anastomotic distance was 0 cm for the Camey I, 10 cm for the spherical reservoir, and 0 cm for the D-LUP. Compliance was 10 mL/cm H20 for the Camey 1, 15 mL/cm H2O for the sphere, and 16 mL/cm H20 for the D-LUP. CONCLUSION: The D-LUP neobladder was simple to construct, had a more dependent ileo-urethrostomy site, larger capacity, and similar compliance when compared with a spherical neobladder.