Pyoderma gangrenosum of the penis.

Pyoderma gangrenosum (PG) is a cutaneous inflammatory disorder that results in painful ulcers. Isolated penile PG is an exceedingly rare entity that has only been reported in a handful of cases. This case highlights the course of a 71-year old man with a locally destructive, nonhealing penile ulceration who was ultimately diagnosed with PG. He underwent extensive work up to reach the diagnosis. His disease progression was halted with systemic steroids and Methotrexate. We present his clinical course and a review of the literature to highlight the need for early recognition of this potentially devastating condition and to outline management options.

Nationwide Procedural Trends for Renal Trauma Management.

OBJECTIVE: To characterize national trends in procedural management of renal trauma. BACKGROUND: Management of renal trauma has evolved to favor a more conservative approach. For patients requiring intervention, there is a paucity of information to characterize the nature of procedural therapy administered. METHODS: A retrospective cross-sectional analysis was performed using data contained within the National Trauma Data Bank. The National Trauma Data Bank is a voluntary data repository managed by the American College of Surgeons, containing data regarding trauma admissions at 747 level I to V trauma centers throughout the United States and Canada. Participants included any patient with renal trauma requiring intervention from 2002 to 2012. They were identified according to International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, with codes 866.00 through 866.03 for blunt renal trauma, and codes 866.10 through 866.13 for penetrating trauma. Cases were separated into those requiring nephrectomy, renorrhaphy, or endovascular repair based on ICD-9 procedure code. The number of cases performed each year and yearly trends as measured by linear regression. RESULTS: A total of 4296 cases were reported during the study period. Of these cases, 2635 involved blunt trauma and 1661 involved penetrating injury. There was a significant increase in the percentage of cases managed by endovascular means for both blunt and penetrating trauma (R = 0.92, P < 0.01; and R = 0.86, P < 0.01, respectively). This was primarily at the expense of nephrectomy, with cases showing significant decline in both groups. CONCLUSIONS: National trends for procedural management of renal trauma are toward less invasive interventions. These trends suggest favorable change towards renal preservation and decreased morbidity, potentially facilitated, in part, by improved radiographic staging and endovascular techniques, and also increased provider awareness of the safety and value of conservative management.

The Gender Gap in Promotions: Inhibitors and Catalysts, Strategies to Close the Gap.

The gender gap is an amalgam of gender disparity issues in the workplace ranging from fewer opportunities to network, decreased funding for research, microaggressions, nebulous promotional criteria and difficulty achieving the perception of professionalism because of inherent gender bias. Contributing home factors include more substantial household duties for women typically, spouses who also have a career, and the inherent delay associated with maternity leave for those who choose to have children. This article subdivides gender disparity that impedes promotion into experiences inside and outside the workplace. Disparities within the workplace are divided into directly quantified versus qualitative differences.

Male infertility and the human microbiome.

The historical belief in urology was that the genitourinary system should be sterile in a normal, healthy, asymptomatic adult. This idea was perpetuated for decades until research revealed a diverse microbiota existing in human anatomical niches that contributed to both human health and disease processes. In recent years, the search for an etiology and modifiable risk factors in infertility has turned to the human microbiome as well. Changes in the human gut microbiome have been associated with changes in systemic sex hormones and spermatogenesis. Certain microbial species are associated with higher levels of oxidative stress, which may contribute to an environment higher in oxidative reactive potential. Studies have demonstrated a link between increased oxidative reactive potential and abnormal semen parameters in infertile men. It has also been hypothesized that antioxidant probiotics may be able to correct an imbalance in the oxidative environment and improve male fertility, with promising results in small studies. Further, the sexual partner's microbiome may play a role as well; studies have demonstrated an overlap in the genitourinary microbiomes in sexually active couples that become more similar after intercourse. While the potential applications of the microbiome to male fertility is exciting, there is a need for larger studies with uniform microbial sequencing procedures to further expand this topic.

Histologic Analysis of Buccal Graft Quality Stratified by Tobacco Use in Patients Undergoing Substitution Urethroplasty.

OBJECTIVE: To determine if there are histologic differences relative to tobacco exposure in buccal mucosa. Substitution urethroplasty outcomes may be worse in tobacco users and we investigate if the buccal graft is inherently damaged due to chronic tobacco exposure. METHODS: Subjects undergoing substitution urethroplasty with buccal graft harvest were prospectively consented in this IRB approved study. Subjects with poor dentition were excluded. A detailed tobacco use history was obtained. Cotinine testing was performed day of surgery to confirm or exclude active tobacco use. Trimmed portions of harvested graft were sent for tissue processing. Standard hematoxylin and eosin staining was performed. A single blinded pathologist performed analysis of the slides. Using a scale of none, mild, moderate, or severe slides were analyzed for cytologic atypia, architectural complexity, inflammation, and keratinization. Evidence of vascular damage was noted and the type of inflammation if present was classified. RESULTS: Twenty-five buccal grafts were analyzed. No evidence of vascular damage or cytologic atypia were noted in any grafts. While mild architectural complexity and mild inflammation, typically lymphocytic, were noted in several of the buccal mucosa sections, this did not appear to correlate with tobacco exposure. The majority of grafts demonstrating increased keratinization correlated with significant tobacco exposure, but this was not consistently noted in all those with tobacco use. CONCLUSIONS: Buccal mucosa in patients with tobacco exposure did not show significant histologic alterations. Outcomes of substitution urethroplasty may be more impacted by persistent systemic exposure causing local ischemia as opposed to the graft tissue itself.

Women in Academic Urology: A Qualitative Analysis of the Relationship Between Pregnancy, Parenting, and Delayed Promotion.

OBJECTIVE: To determine the role that the burden of childbearing, including pregnancy and maternity leave, plays in academic promotion for women in urology, which has been shown to be delayed as compared to their male counterparts. METHODS: Female academic urologists of varying academic rank who have children were invited to participate in a semistructured interview. A representative sample from multiple subspecialties and geographic locations were targeted. Topics addressed included pregnancy, maternity leave, parenting, and promotion in academic urology. Transcripts of the interview were analyzed using grounded theory methodology. RESULTS: Eleven participants were interviewed, including 3 assistant, 5 associate, and 3 full professors. The majority of participants chose to time pregnancy with training either during less strenuous portions or avoiding residency altogether. Nearly half endorsed self-inflicted hardships during pregnancy or early postpartum to prevent inconveniencing colleagues or to "pull their weight" in accordance with surgical culture. Outsourcing of childcare and household duties, along with spousal support, were discussed as contributing to success. Lack of transparency for promotional criteria was identified as a significant obstacle to promotion. Sponsorship and self-motivated information gathering were identified as critical components to success in promotion. CONCLUSION: A culture of support created by administration and colleagues is critical for a positive experience with childbearing, and return to clinical practice or training postpartum. Explicit promotional criteria that are accessible in early career development and sponsorship from members of the academic department or subspecialty community are crucial for all urologists, but for women in particular.

Surgical Preparation by Urology Trainees in 2021: The Interplay of Video and Print Resources.

INTRODUCTION: We investigate urology trainee preparation for surgical procedures by querying type and degree of video sources used and combination with traditional print materials for preparation of surgical procedures. METHODS: An Institutional Review Board-approved 13-question REDCap® survey was distributed to 145 American College of Graduate Medical Education-accredited urology residency programs. Social media were also used to recruit participants. Results were collected anonymously and analyzed using Excel®. RESULTS: A total of 108 residents completed the survey. The majority (87%) reported using videos for surgical preparation including, YouTube (93%), American Urological Association (AUA) Core Curriculum videos (84%) and institutional or attending-specific videos (46%). Video selection was based on quality (81%), length (58%) and the site of video creation (37%). Video preparation was reported predominantly for minimally invasive surgery (95%), subspecialty procedures (81%) and open procedures (75%). The most common print sources reported include Hinman's Atlas of Urologic Surgery (90%), Campbell-Walsh-Wein Urology (75%) and the AUA Core Curriculum (70%). When asked to rank their overall top 3 sources, 25% of residents reported YouTube as their primary source and 58% included it in their top 3. Only 24% of residents reported being aware of the AUA YouTube channel, while 77% were aware of the video section of the AUA Core Curriculum. CONCLUSIONS: Urology residents use video resources to prepare for surgical cases, with a heavy reliance on YouTube. AUA-curated video sources should be highlighted in the resident curriculum as the quality and educational content of YouTube videos are variable.

Physiology of Erection and Pathophysiology of Erectile Dysfunction.

The science of penile erection, including recent advances in its molecular physiology and neuroanatomic pathways, is described. The pathophysiology of erectile dysfunction is presented, acknowledging associated disease states, and accordingly follows a practical classification scheme: vasculogenic, neurogenic, endocrine, and psychogenic.

Widely Variable Parental Leave Practices for Urology Residency Programs in the United States.

OBJECTIVE: To query a cohort of program directors to better understand the contemporary landscape of parental leave for urology trainees. The American Board of Urology mandates that a resident must work 46 weeks annually in order to not extend residency. We hypothesize that formal parental leave policies may vary by institution and may not be easily accessible. METHODS AND MATERIALS: A 22 question survey designed to assess parental leave policies was distributed to 144 American College of Graduate Medical Education accredited Urology residency program directors in the United States via e-mail. Results were collected anonymously. RESULTS: A total of 65 program directors completed the survey for a response rate of 43%. The median age of program directors was 49 and 78% were male. Only 12% reported no formal maternity leave policy, while 21% reported no formal paternity leave policy. Maternity leave duration varied greatly with 6 (49%) and 12 weeks (27%) as the most common duration, while paternity leave was most commonly reported as 2 (39%), 6 (18%) and 12 weeks (19%) in length. Most parental leave policies were available via an institutional website (81%), with only 39% available on a public website. While most leave policies covered compensation, few addressed call expectations or procedural safety precautions. CONCLUSION: Parental leave policies across Urology training programs in the United States are variable, and may not cover critical components of pregnancy or leave. An opportunity exists to create a comprehensive, standardized parental leave policy.

Management of common iatrogenic iris defects induced by cataract surgery.

The proximity of the iris to the instruments and currents of cataract surgery makes iatrogenic damage to the iris a common complication of cataract surgery. This article discusses techniques to prevent or minimize this damage. When damage does occur, the surgeon must decide if, when, and how to repair the damage. Principles governing these decisions and techniques for repair are discussed. Figures and videos, included as online Supplemental Data files, illustrate cases of iatrogenic damage and repair techniques.

Urinary tract foreign body: A case of panurethral and intravesical spray foam insulation.

Foreign bodies are inserted into the genitourinary tract for various reasons, and may present a challenge to remove. We report a case of foam insulation injected into the urethra almost entirely occluding the urethra and filling the bladder. Ultimately both a cystotomy and perineal urethrotomy were required for removal.

Histamine-releasing factor/translationally controlled tumor protein (HRF/TCTP)-induced histamine release is enhanced with SHIP-1 knockdown in cultured human mast cell and basophil models.

Previously, we demonstrated a negative correlation between histamine release to histamine-releasing factor/translationally controlled tumor protein (HRF/TCTP) and protein levels of SHIP-1 in human basophils. The present study was conducted to investigate whether suppressing SHIP-1 using small interfering (si)RNA technology would alter the releasability of culture-derived mast cells and basophils, as determined by HRF/TCTP histamine release. Frozen CD34+ cells were obtained from the Fred Hutchinson Cancer Research Center (Seattle, WA, USA). Cells were grown in StemPro-34 medium containing cytokines: mast cells with IL-6 and stem cell factor (100 ng/ml each) for 6-8 weeks and basophils with IL-3 (6.7 ng/ml) for 2-3 weeks. siRNA transfections were performed during Week 6 for mast cells and Week 2 for basophils with siRNA for SHIP-1 or a negative control siRNA. Changes in SHIP-1 expression were determined by Western blot. The functional knockdown was measured by HRF/TCTP-induced histamine release. siRNA knockdown of SHIP-1 in mast cells ranged from 31% to 82%, mean 65 +/- 12%, compared with control (n=4). Histamine release to HRF/TCTP was increased only slightly in two experiments. SHIP-1 knockdown in basophils ranged from 34% to 69%, mean 51.8 +/- 7% (n=4). Histamine release to HRF/TCTP in these basophils was dependent on the amount of SHIP knockdown. Mast cells and basophils derived from CD34+ precursor cells represent suitable models for transfection studies. Reducing SHIP-1 protein in cultured mast cells and in cultured basophils increases releasability of the cells.

Human IgE+ and IgE- are not equivalent to mouse highly cytokinergic IgE.

BACKGROUND: We have previously defined IgE+ as the IgE on basophils from a subset of highly allergic asthmatic subjects that release histamine after stimulation with histamine-releasing factor (HRF). The mechanism of IgE+ remains an enigma. Recently, there have been reports of monomeric highly cytokinergic IgEs causing mediator release, cytokine release, and phosphorylation events in cultured rodent and human mast cells in the absence of antigen. OBJECTIVE: We investigated whether human IgE+ might exist as highly cytokinergic IgE in the human system. METHODS: IgE+ was defined as causing greater than 10% histamine release by using HRF as a stimulus of human basophils. By definition, IgE- did not support histamine release to HRF. Once defined, serum and various purified human IgEs were used to stimulate purified human basophils or cultured human mast cells. The cells were examined for histamine release, extracellular signal-regulated kinase (ERK) phosphorylation, and IL-13 secretion. RESULTS: We found that neither IgE+ nor IgE- induced ERK phosphorylation, histamine release, and IL-13 release from freshly isolated basophils in the absence of a specific antigen. However, human IgE alone did stimulate ERK phosphorylation in cultured human mast cells and IL-3-primed human basophils. CONCLUSION: Human IgE+ is not an equivalent of the mouse highly cytokinergic IgE. However, human IgE did have effects on cultured mast cells and basophils. The effect of highly cytokinergic IgE on ERK phosphorylation and cytokine secretion might be due to the priming effect of human basophils and mast cells.

Phacoemulsification of posterior polar cataracts.

Posterior polar cataracts present a unique challenge for the cataract surgeon. This review describes the steps a surgeon can take to overcome these challenges for the successful phacoemulsification of the posterior polar cataract. Proper preoperative examination and diagnostics will allow appropriate preoperative counseling and surgical planning to increase the likelihood of success. Specific techniques for each stage of the procedure are described, all with the aim of protecting the posterior capsule and preserving intraocular lens (IOL) fixation options. Posterior polar cataracts present dilemmas in preoperative evaluation, surgical management, and IOL fixation.

A phase III randomized, double-blind, placebo-controlled study evaluating dextromethorphan plus slow-release morphine for chronic cancer pain relief in terminally ill patients.

This multicenter trial examined the efficacy and safety of dextromethorphan (DM) as an enhancer of analgesia and modulator of opioid tolerance in cancer patients with pain. Eligible patients were randomized to slow-release morphine plus DM or slow-release morphine plus placebo. The initial DM dose was 60 mg four times daily for seven days, with an increase to 120 mg four times daily, if tolerated, for another seven days. During the study, patients recorded medications and scores for pain, nausea, drowsiness, and insomnia. Sixty-five patients were randomized. Although average pain scores (12.6 vs. 15.8), number of breakthrough doses (9 vs. 11.3), and change in total morphine consumption (550.9 mg vs. 597.1mg) were less in the DM group than placebo group, the differences were not statistically significant (P=0.31-0.33). Side-effect scores were not statistically significantly different. Dizziness was greater in the DM (58%) than placebo (36%) group. This study showed a statistically nonsignificant enhancement of analgesia or modulation of opioid tolerance in cancer patients with pain when DM was added to morphine. Participants receiving the DM also had more toxicity, particularly dizziness. This toxicity and the limited evidence of effect do not support the use of DM to enhance opioid analgesia or to modulate opioid tolerance in cancer patients.

History of Histamine-Releasing Factor (HRF)/Translationally Controlled Tumor Protein (TCTP) Including a Potential Therapeutic Target in Asthma and Allergy.

Histamine-releasing factor (HRF) also known as translationally controlled tumor protein (TCTP) is a highly conserved, ubiquitous protein that has both intracellular and extracellular functions. Here we will highlight the subcloning of the molecule, its clinical implications, as well as an inducible-transgenic mouse. Particular attention will be paid to its extracellular functioning and its potential role as a therapeutic target in asthma and allergy. The cells and the cytokines that are produced when stimulated or primed by HRF/TCTP will be detailed as well as the downstream signaling pathway that HRF/TCTP elicits. While it was originally thought that HRF/TCTP interacted with IgE, the finding that cells not binding IgE also respond to HRF/TCTP called this interaction into question. HRF/TCTP or at least its mouse counterpart appears to interact with some, but not all IgE and IgG molecules. HRF/TCTP has been shown to activate multiple human cells including basophils, eosinophils, T cells, and B cells. Since many of the cells that are activated by HRF/TCTP participate in the allergic response, the extracellular functions of HRF/TCTP could exacerbate the allergic, inflammatory cascade. Particularly exciting is that small molecule agonists of the phosphatase SHIP-1 have been shown to modulate the P13 kinase/AKT pathway and may control inflammatory disorders. This review discusses this possibility in light of HRF/TCTP.

Periurethral Gland Calculus Discovered on Workup for Dyspareunia.

A 55-year-old woman with a history of chronic dysuria in the absence of infection was found to have an unusual lesion below the urethral meatus. This was subsequently determined to be a periurethral gland containing a sizeable calculus. Pathologic analysis found the composition to be car bonate apatite (dahllite). Only one prior report of a female periurethral calculus has been noted in the English peer-reviewed literature.