Understanding the drivers of mortality in African savannah elephants.

Populations of African savannah elephants (Loxodonta africana) have been declining due to poaching, human-elephant conflict, and habitat loss. Understanding the causes of these declines could aid in stabilizing elephant populations. We used data from the Great Elephant Census, a 19-country aerial survey of savannah elephants conducted in 2014 and 2015, to examine effects of a suite of variables on elephant mortality. Independent variables included spatially explicit measures of natural processes and human presence as well as country-level socioeconomic measures. Our dependent variable was the carcass ratio, the ratio of dead elephants to live plus dead elephants, which is an index of recent elephant mortality. Carcass ratios are inversely proportional to population growth rates of elephants over the 4 yr prior to a survey. At the scale of survey strata (n = 275, median area = 1,222 km2 ), we found strong negative associations for carcass ratios with vegetation greenness at the time of the survey, overseas development aid to the country, and distance to the nearest international border. At the scale of ecosystems (n = 42, median area = 12,085 km2 ), carcass ratios increased with drought frequency and decreased with human density and overseas development aid to the country. Both stratum- and ecosystem-scale models explained well under one-half of the variance in carcass ratios. The differences in results between scales suggest that the drivers of mortality may be scale-specific and that the corresponding solutions may vary by scale as well.

Using species traits to predict detectability of animals on aerial surveys.

In animal surveys, detectability can vary widely across species. We hypothesized that detectability of animals should be a function of species traits such as mass, color, and mean herd size. We also hypothesized that models of detectability based on species traits can be used to predict detectability for new species not in the original data set, leading to substantial benefits for ecology and conservation. We tested these hypotheses with double-observer aerial surveys of 10 mammal species in northern Botswana. We combined all 10 species and modeled their detectability with species traits (mass, mean herd size, color) as predictors while controlling for observer effects, vegetation, and herd size. We found support for effects of mass and an interaction between herd size and mean herd size on detectability. This model accurately predicted the ratio of herds detected by two observers vs. one observer for 8 of 10 species. To test whether a model based on species traits could be applied to a new species, we serially deleted each species from the data set, fit a trait-based model to the remaining nine species, and used this model to predict detectability for the deleted species. The model was able to reproduce the species-trait model for seven species and accurately predicted the ratio of detections by one or two observers for a different set of seven species; the model was successful by both measures for five species. To our knowledge, this represents the first time that a mechanistic model for detectability of animals has been used to predict detectability for new species. Prediction failed for species with extreme values of traits, suggesting that predicting detectability is not possible near or beyond the boundaries of one's data set. The approach taken in this paper can potentially be used with a variety of taxa and may provide new opportunities to apply detectability corrections where they have not been possible before.

Characteristics of Participants in the American Urological Association Quality (AQUA) Registry and Early Impact of Participation on Quality of Care.

INTRODUCTION: The American Urological Association Quality Registry (AQUA) is an approved Qualified Clinical Data Repository that was created in 2013 to serve as a platform of quality assessment and improvement. Little is known about how such specialty specific platforms are adopted and used. We describe AQUA participants and report early impact on quality metrics. METHODS: We compared characteristics of practices and urologists participating in AQUA from 2014-2017 to those of the broader urologist workforce as reported in the 2017 American Urological Association Census, and examined pass rates of 4 measures reported to the Centers for Medicare and Medicaid Services after participation in AQUA. RESULTS: Participation increased during the first 4 years and included >125 practices and 1,148 urologists (9.2% of practicing U.S. urologists). Of AQUA participants 97.6% were in private practice, 1.9% were in academic practice and the rest (0.5%) were employed by private or public hospitals, compared to 59.1%, 25.5% and 11.2%, respectively, of urologists nationally. Among AQUA participants 95.9% lived in metropolitan areas, compared to 89.9% of urologists nationally. A total of 17 quality measures were reported to the Centers for Medicare and Medicaid Services through AQUA, of which 4 were urology specific and 13 were crosscutting. The average pass rate across the 4 select urological measures was 31.1% prior to AQUA dashboard access and 48.8% after access was gained, a 56.9% improvement (17.1% absolute difference). CONCLUSIONS: Early participants in AQUA were mostly community practitioners. Participation in AQUA seemed to facilitate quality score improvements, although whether this was due to improved measurement vs clinical care is unknown at this time.

Levamisole in ascariasis. A multicenter controlled evaluation.

An analysis is presented of 10 clinical studies from various countries where levamisole 50--150 mg was compared to pyrantel, piperazine, and placebo in a total of 1,734 patients, mostly children (levamisole: 830, controls: 904), suffering from ascariasis either as a single infection or usually mixed with other nematode infections. Degree of infection and efficacy of treatment were determined by quantitative coproparasitological methods. Levamisole produced higher cure rates (91%) and egg reduction rates (98%) than pyrantel, piperazine, or placebo. The efficacy of levamisole was unrelated to the patients' sex and age, the severity of infection, the presence of another worm infection, the type of associated worm infections, or the egg-counting technique. The overall incidence of reported adverse reactions was lower after levamisole than after piperazine, pyrantel or placebo; abdominal pain and headache, the most frequent complaints after levamisole, were related to the initial severity of ascariasis. Follow-up examinations 6 months after treatment suggested that levamisole might delay reinfection.

Repair of obliterative vesicourethral stricture after radical prostatectomy: a technique for preservation of continence.

We present the open surgical repair of complete obstruction of the bladder neck unresponsive to endoscopic management. By combining abdominal and perineal dissection, partial pubectomy, and omental wrapping, repeat anastomosis is possible without the need for bladder tubularization. Two patients have been repaired successfully. Although both men presented with indwelling suprapubic tubes and a defect of greater than 1.5 cm, they are now voiding normally at 18 and 7 months post-operatively without the need for pads, medication, or instrumentation. Complete obliteration of the bladder neck after radical prostatectomy can be functionally reconstructed. Postoperative continence will depend on the function of the membranous urethra. If incontinence occurs, this can be managed in a reconstructed open urethra.

Investigations on urinary bladder reinnervation. Historical perspective and review.

Although nerve crossover surgery to bypass a spinal cord lesion and recentralize the decentralized bladder was first conceptualized in 1907, surprisingly few studies concerning this goal have been reported since. In addition to direct implantation of nerves into the detrusor, the studies reviewed have investigated the crossover of mixed roots (with and without nerve grafts), dorsal roots, ventral roots, pelvic, obturator and hypogastric nerves both in animal models, in human cadavers, and in human patients. Restoration of the micturition reflex through the use of nonsacral nerves has been achieved in cats. In addition, we have shown that the axons of a suprasacral mixed root (L7) when anastomosed to a sacral mixed root (S1) via a nerve graft can regenerate and recentralize the unilaterally decentralized bladder in the cat. The return of the micturition reflex after reconstruction of severed pelvic nerves has been documented, while the results of obstruction or hypogastric crossover have given diminished returns of bladder function. The direct implantation of nerves into the detrusor has not resulted in restoration of function. In addition, return of useful bladder function in humans after nerve crossover surgery has not been predictable. In part, present inability to achieve restoration of urinary bladder function may be a consequence of the complexity of micturition reflex organization and the inability to use techniques in humans that have given success in animals. Although, some of the technical aspects of nerve crossover surgery to bypass a spinal cord injury and restore functional micturition in those with neurogenic bladder dysfunction have been elucidated, further work is required to develop techniques that will enhance appropriate axonal regeneration to achieve reinnervation and return of useful function. Indeed, restoration of function may be limited by current microsurgical methodologies. Studies directed at understanding the neuropathophysiology of nerve injury and nerve surgery may be more fruitful in identifying factors than can be manipulated to achieve consistent return of useful function. In general, however, the results of the animal and human studies surveyed may be viewed with cautious optimism.

Conservative surgical therapy for penile and urethral carcinoma.

OBJECTIVES: Invasive penile and urethral tumors are traditionally treated with aggressive excision that requires involved organ and adjacent organ sacrifice. An alternative approach seeks to completely excise the tumor with adequate margins while preserving form and function of the organ. We present 6 patients who underwent such organ-sparing surgery. METHODS: Six selected cases (4 penile and 2 urethral) are presented with operative photographs and pertinent data. RESULTS: Three distal tumors of the penis were treated with excision limited to the glans with histopathologic findings of verrucous carcinoma, melanoma, and angiosarcoma. One patient with squamous cell carcinoma of the distal shaft refused partial penectomy and underwent a local wedge resection. A patient with locally advanced bulbourethral transitional cell carcinoma (TCC) refused cystourethrectomy and underwent an anterior urethrectomy and perineal urethrostomy. A 48-year-old woman with an adenocarcinoma contained in a very distal urethral diverticulum underwent simple diverticulectomy and excision of distal urethra. Postoperative voiding and sexual function were well preserved. Follow-up was 12 to 48 months. The patient with angiosarcoma died of lung metastases at 48 months with no local disease, and the patient with bulbourethral TCC developed pelvic disease at 12 months with no local recurrence and died of metastases at 25 months. CONCLUSIONS: Organ-sparing surgery is appropriate in selected patients on the basis of stage and location, high risk of distant failure, and patient disposition. Close follow-up is necessary. Comanagement with reconstructive and oncologic specialists optimizes results and outcomes.

Transplantation of horseshoe kidney into single recipient.

A case of successful en bloc transplantation of a horseshoe kidney into a single recipient is reported. The literature is briefly reviewed. The use of horseshoe kidneys in transplantation is recommended in selected cases.

CO2 laser welding versus conventional microsuture repair in patch-graft urethroplasty.

This study evaluates the repair of urethral tissue using microsurgery and a combination of laser welding techniques. Using the rat as a model, a patch-graft urethroplasty was performed with either conventional microsuture repair, laser-assisted microsuture repair, or laser-assisted microsuture with protein solder. Repairs were assessed at various time periods (days 0, 1, 7, and 21). Analysis of success rate, bursting strength, histology, and operative time were completed. The laser with protein solder had the highest success rate at each time period and demonstrated advanced healing with the least amount of inflammation. Operative time was decreased by 30 percent using the laser. In conclusion, the laser solder repair was significantly better than either laser alone or conventional microsutures.

Laser tissue welding in genitourinary reconstructive surgery: assessment of optimal suture materials.

OBJECTIVES: Laser tissue welding in genitourinary reconstructive surgery has been shown in animal models to decrease operative time, improve healing, and decrease postoperative fistula formation when compared with conventional suture controls. Although the absence of suture material is the ultimate goal, this has not been shown to be practical with current technology for larger repairs. Therefore, suture-assisted laser tissue welding will likely be performed. This study sought to determine the optimal suture to be used during laser welding. METHODS: The integrity of various organic and synthetic sutures exposed to laser irradiation were analyzed. Sutures studied included gut, clear Vicryl, clear polydioxanone suture (PDS), and violet PDS. Sutures were irradiated with a potassium titanyl phosphate (KTP)-532 laser or an 808-nm diode laser with and without the addition of a light-absorbing chromophore (fluorescein or indocyanine green, respectively). A remote temperature-sensing device obtained real-time surface temperatures during lasing. The average temperature, time, and total energy at break point were recorded. RESULTS: Overall, gut suture achieved significantly higher temperatures and withstood higher average energy delivery at break point with both the KTP-532 and the 808-nm diode lasers compared with all other groups (P < 0.05). Both chromophore-treated groups had higher average temperatures at break point combined with lower average energy. The break-point temperature for all groups other than gut occurred at 91 degrees C or less. The optimal temperature range for tissue welding appears to be between 60 degrees and 80 degrees C. CONCLUSIONS: Gut suture offers the greatest margin of error for KTP and 808-nm diode laser welding with or without the use of a chromophore.

Comparison of transrectal fine-needle aspiration cytology and core needle biopsy in diagnosis of prostate cancer.

One hundred sixty-nine transrectal fine-needle aspirations of the prostate gland were performed in 166 patients over a two-year period. The results were compared with simultaneous core needle biopsy performed in all but 4 patients. Forty-seven (28%) aspirations were either unsatisfactory or inconclusive. Of the remaining 122 (72%) patients in whom a cytologic diagnosis could be made, core biopsy was available in 120. Aspiration cytology was 87 percent sensitive and 96 percent specific with an overall agreement of 93 percent with core biopsy. No major complications occurred. We conclude that fine-needle aspiration of the prostate is accurate, safe, and cost-effective, and greater application of this technique is encouraged.

Complex urethral reconstruction.

Modern tissue transfer techniques, often incorporating penile or scrotal skin islands based on a dartos fascia pedicle, have revolutionized urethral reconstruction. There are certain situations, however, that require a more creative and complex approach. The majority of these cases involve patients with panurethral stricture disease or those who have undergone multiple previous procedures for urethral stricture disease or hypospadias and their subsequent complications. In this article, the authors discuss the various aspects of these two conditions and outline several techniques for urethral reconstruction in these challenging patients.

[General principles in treatment of urethral strictures]. / Prinzipien der Behandlung von Harnröhrenstrikturen.

This manuscript outlines the important points in the evaluation and treatment of urethral stricture disease. The algorithms described within are not presented as strict guidelines but rather are intended to give a logical thought progression which incorporates the basic principles of urethral reconstruction. It is important to determine the therapeutic goal before applying these principles. There are basically two arms of consideration, the first is to attempt to cure the patient of urethral stricture disease and the second is to simply manage the patient's urethral stricture disease without intent of cure. Applying the current knowledge of anatomy with modern tissue transfer techniques will achieve a highly successful, single stage reconstruction in most patients. Although approaching urethral stricture disease with the intent to cure is preferred, management may not be unreasonable in certain cases. Some patients have entensive co-morbidities or may prefer a trial of conservative measures before definitive treatment is undertaken. If the goal established is urethral reconstruction, the gold standard is to perform a single stage procedure that is highly successful and durable. Excision of the urethral stricture with primary anastomosis (EPA) represents this gold standard. However, ist application is limited by stricture location or length. An accurate evaluation of the stricture location, length, and associated spongiofibrosis is mandatory in forming viable options for repair. By exploiting the advantages of differing techniques, the proper course of action can be chosen which generally will solve even the most complex problem in one stage. The reconstructive surgeon come to the operative suite armed with the full knowledge and understanding of the principals and techniques which will result in a favorable outcome. It is not uncommon for intra-operative findings to guide the decision for the best alternative for urethral reconstruction. We also offer some helpful hints regarding positioning, sutures, exposure, and retractors.

Bucket handle tears of the medial meniscus: meniscal intrusion rather than meniscal extrusion.

OBJECTIVE: To determine the frequency of medial meniscal extrusion (MME) versus "medial meniscal intrusion" in the setting of bucket handle tears. Images were evaluated for previously reported risk factors for MME, including: medial meniscal root tear, radial tear, degenerative joint disease and joint effusion. METHODS: Forty-one consecutive cases of bucket handle tear of the medial meniscus were reviewed by consensus by two musculoskeletal radiologists. Imaging was performed using a 1.5 GE Signa MR unit. Patient age, gender, medial meniscal root integrity, MME, medial meniscal intrusion, degenerative joint disease, effusion and anterior cruciate ligament (ACL) tear were recorded. RESULTS: Thirteen females and 27 males (age 12-62 years, median=30 years) were affected; one had bucket handle tear of each knee. Effusion was small in 13, moderate in 9 and large in 18. Degenerative joint disease was mild in three, moderate in two and severe in one. 26 ACL tears included three partial and three chronic. Medial meniscal root tear was complete in one case and partial thickness in two. None of the 40 cases with an intact or partially torn medial meniscal root demonstrated MME. MME of 3.1 mm was seen in the only full-thickness medial meniscal root tear, along with chronic ACL tear, moderate degenerative joint disease and large effusion. Medial meniscal intrusion of the central bucket handle fragment into the intercondylar notch was present in all 41 cases. CONCLUSION: Given an intact medial meniscal root in the setting of a "pure" bucket handle tear, there is no MME.

Men with congenital absence of the vas deferens often have seminal vesicles.

The absence of semen fructose and low ejaculate volume in men with congenital absence of the vas deferens have been attributed to an associated agenesis of the seminal vesicles. Because vasography and retrograde seminal vesiculography cannot be performed in these men, this association has never been confirmed reliably. Therefore, we performed computerized tomographic scans of the seminal vesicles on 26 men with absence of the vas deferens. We found seminal vesicles bilaterally in 12 of these men, unilateral hypoplasia or absence in 8 and bilateral hypoplasia or absence in 6. Four men with normal seminal vesicles and 1 with unilateral hypoplasia underwent exploration in an attempt to find reconstructable vasa. We failed to identify a vas deferens in any of these men. These observations suggest that negative semen fructose and low ejaculate volume in men with absence of the vas deferens may be owing to agenesis or obstruction of the ejaculatory ducts rather than absent seminal vesicles.

Tissue welding with lasers.

Over the last several years, several exciting developments have occurred that may facilitate the use of the laser in reconstructive surgery. The goal of future research should be to make the procedure less operator-dependent (dye enhanced or automated welding). Another avenue of research would be to give the operator instantaneous feedback to assess parameters at the weld site to allow modification of the energy delivered. Currently, only color change of the tissue and experience provide the endpoints. With future research into these and other areas, laser welding continues to hold promise to become a useful adjunct in reconstructive surgery.

The role of the epididymis in testicular descent.

In 54 patients with 70 undescended testes hospitalized for orchiopexy epididymal anatomy was examined intraoperatively. Of the testes 66 per cent had abnormal epididymides, which suggests a possibly significant role for the epididymis in the process of testicular descent.

The mechanism of unilateral post-obstructive diuresis.

We report 2 cases of a pathological urinary water loss of clinical relevance after relief of unilateral ureteral obstruction following pyeloplasty. The mechanism of this unilateral post-obstructive diuresis is based on the combination of preservation of glomerular filtration rate of the obstructed kidney and distal tubular damage.