Sexually transmitted infections and the vaginal microbiome after vaginoplasty.

PURPOSE OF THE REVIEW: Transgender and gender-diverse individuals (TGD) are at risk for sexually transmitted infections. Gender affirmation surgery is a cornerstone of care for many TGD individuals. For genital gender affirmation, the surgical creation of a vagina may be performed through a number of techniques. Those who have undergone vaginoplasty have unique anatomical and biopsychosocial considerations, which we discuss. RECENT FINDINGS: While sexually-transmitted infections including HPV, HSV, HIV, gonorrhea, and chlamydia, have been described in TGD individuals after vaginoplasty, the reports are very rare, and the provider should maintain an index of suspicion and maintain a broad differential for symptoms including neovaginal discharge. We discuss the association of the neovaginal microbiota composition with bacterial vaginosis, and how its modulation could potentially reduce bacterial vaginosis and sexually transmitted infection risk. SUMMARY: We examine the literature regarding sexually-transmitted infections following vaginoplasty, and the neovaginal microbiome and its similarities and differences relative to the natal vaginal microbiome.

Wound related complications and the anterior rectus sheath versus Gibson approach to kidney transplantation: A single center randomized controlled trial.

INTRODUCTION: Wound related complications (WRC) are a significant source of morbidity in kidney transplant recipients, and may be mitigated by surgical approach. We hypothesize that the anterior rectus sheath approach (ARS) may decrease WRC and inpatient opiate use compared to the Gibson Approach (GA). METHODS: This double-blinded randomized controlled trial allocated kidney transplant recipients aged 18 or older, exclusive of other procedures, 1:1 to ARS or GA at a single hospital. The ARS involves a muscle-splitting paramedian approach to the iliopsoas fossa, compared to the muscle-cutting GA. Patients and data analysts were blinded to randomization. RESULTS: Seventy five patients were randomized to each group between August 27, 2019 and September 18, 2020 with a minimum 12 month follow-up. There was no difference in WRC between groups (p = .23). Nine (12%) and three patients (4%) experienced any WRC in the ARS and GA groups, respectively. Three and one Clavien IIIb complications occurred in the ARS and GA groups, respectively. In a multiple linear regression model, ARS was associated with decreased inpatient opioid use (ß = -58, 95% CI: -105 to -12, p = .016). CONCLUSIONS: The ARS did not provide a WRC benefit in kidney transplant recipients, but may be associated with decreased inpatient opioid use.

The role of pulse width manipulation compared to program changes alone for unsatisfactory sacral neuromodulation therapy: A retrospective matched-cohort analysis.

AIM: Pulse width (PW) influences neuromodulation by its impact on nerve fiber recruitment. A paucity of data regarding the manipulation of PW in sacral neuromodulation (SNM) exists. This study describes the clinical features and outcomes of PW manipulation for unsatisfactory SNM therapy. METHODS: A retrospective, single-institution review was performed of reprogrammed SNM patients between 2010 and 2019. Two cohorts were created: those with PW changes ± program changes and age-matched controls with program changes alone. Patients lacking follow-up and non-InterStim II models were excluded. RESULTS: Out of 710 SNM interrogations, 147 (20.7%) had PW changes and 80 met inclusion criteria. Most PW changes were shortened (61/80, 76.3%). Clinical features did not differ between cohorts except by indication for reprogramming. The most common indication for PW change was painful stimulation (34/80, 43%), whereas in controls it was suboptimal efficacy (76/80, 95%). Clinical success was stratified by indication. There was a higher improvement in efficacy in the PW cohort (61%, 17/28 vs. 36%, 27/76, p = .02). PW manipulation successfully relieved painful stimulation in 50% (17/34 vs. 0/3, p = .23), which was more likely with a shortened compared to extended PW (14/15, 93.3% vs. 0/6, 0%, p < .01). PW resulted in improvement in localization of the stimulus in 94% (17/18 vs. 0/1, p = .10). The subsequent lead revision or explant was significantly higher in the PW cohort (43% vs. 25%, p = .03). CONCLUSION: PW manipulation may aid the salvage of unsatisfactory SNM therapy. These findings represent an initial assessment of the role of PW in SNM, particularly regarding the efficacy and painful stimuli. The further prospective investigation is warranted.

Contemporary management of advanced prostate cancer: an evolving landscape.

Recent population-based studies suggest that the incidence of advanced and metastatic prostate cancer may be increasing. Concurrently with this apparent stage migration toward advanced disease, several major developments have occurred in the treatment paradigm for men with advanced prostate cancer. These include the US Food and Drug Administration approval of 8 novel agents over the last decade. In addition to novel pharmaceuticals, rapidly evolving diagnostic tools have emerged. This review provides a primer for clinicians who treat men with advanced prostate cancer, including medical oncologists, radiation oncologists, and urologists.

Large Single Institution Comparison of Perioperative Outcomes and Complications of Open Radical Cystectomy, Intracorporeal Robot-Assisted Radical Cystectomy and Robotic Extracorporeal Approach.

PURPOSE: Bladder cancer management options include open radical cystectomy and robot-assisted radical cystectomy with intracorporeal or extracorporeal urinary diversion. The existing literature shows no difference in the major complication rate between open radical cystectomy and extracorporeal urinary diversion. However, the emerging popularity of intracorporeal urinary diversion has exposed the need to compare a completely intracorporeal method to alternative approaches. To our knowledge the robotic intracorporeal advantage regarding major complications has not yet been established in an evaluation of all 3 modalities. We compared outcomes and complications of open, intracorporeal and extracorporeal cystectomy techniques at a high volume institution. MATERIALS AND METHODS: We queried a prospectively maintained database for patients who underwent radical cystectomy from 2011 to 2018 for an oncologic indication. Perioperative and pathological outcomes, and 30 and 90-day major complications were assessed. Statistical analyses were done using the Pearson chi-square, Kruskal-Wallis and Kaplan-Meier tests, and multivariable regression. RESULTS: A total of 948 patients met the study criteria, including 272, 301 and 375 treated with open radical cystectomy, intracorporeal urinary diversion and extracorporeal urinary diversion, respectively. Median followup was 26 months. Intracorporeal urinary diversion cases had lower estimated blood loss (p <0.001), shorter hospitalization (p <0.001) and a lower ileus rate (p=0.023) than extracorporeal urinary diversion and open radical cystectomy cases. Importantly, intracorporeal urinary diversion was associated with lower 30 and 90-day major complication rates vs extracorporeal urinary diversion and open radical cystectomy (90-day Clavien-Dindo III-V 16.9% vs 24.8% and 26.1%, respectively, p=0.015). There was no significant difference in the readmission rate according to the surgical approach. Multivariable predictors of increased 90-day major complications were patient age, the Charlson Comorbidity Index and operative time. On multivariable analysis intracorporeal urinary diversion was associated with reduced 90-day major complications (OR 0.58, p=0.037). CONCLUSIONS: In a 3-way comparison intracorporeal urinary diversion demonstrated a lower major complication rate and perioperative benefits compared to extracorporeal urinary diversion and open radical cystectomy.

Prostate Cancer Diagnosis on Repeat Magnetic Resonance Imaging-Transrectal Ultrasound Fusion Biopsy of Benign Lesions: Recommendations for Repeat Sampling.

PURPOSE: Urologists face a dilemma when a lesion identified on multiparametric magnetic resonance imaging is benign on image guided fusion biopsy. We investigated the detection rate of prostate cancer on repeat fusion biopsy in multiparametric magnetic resonance imaging lesions initially found to be pathologically benign on fusion biopsy. MATERIALS AND METHODS: We reviewed the records of all patients from 2007 to 2014 who underwent multiparametric magnetic resonance imaging and image guided fusion biopsy. We identified men who underwent rebiopsy of the same discrete lesion after initial fusion biopsy results were benign. Data were documented on a per lesion basis. We manually reviewed UroNav system (Invivo, Gainesville, Florida) needle tracking to verify accurate image registration. Multivariate analysis was used to identify clinical and imaging factors predictive of prostate cancer detection at repeat fusion biopsy. RESULTS: A total of 131 unique lesions were rebiopsied in 90 patients. Of these 131 resampled lesions 21 (16%) showed prostate cancer, which in 13 (61.9%) was Gleason 3 + 3. On multivariate analysis only lesion growth on repeat multiparametric magnetic resonance imaging was significantly associated with prostate cancer detection at repeat biopsy (HR 3.274, 95% CI 1.205-8.896, p = 0.02). CONCLUSIONS: Pathologically benign multiparametric magnetic resonance imaging lesions on initial image guided fusion biopsy are rarely found to harbor clinically significant prostate cancer on repeat biopsy. When prostate cancer was identified, most disease was low risk. An increase in lesion diameter was an independent predictor of prostate cancer detection. While these data are retrospective, they may provide some confidence in the reliability of negative initial image guided fusion biopsies despite a positive multiparametric magnetic resonance imaging finding.

Reproducibility of Multiparametric Magnetic Resonance Imaging and Fusion Guided Prostate Biopsy: Multi-Institutional External Validation by a Propensity Score Matched Cohort.

PURPOSE: As the adoption of magnetic resonance imaging/ultrasound fusion guided biopsy expands, the reproducibility of outcomes at expert centers becomes essential. We sought to validate the comprehensive NCI (National Cancer Institute) experience with multiparametric magnetic resonance imaging and fusion guided biopsy in an external, independent, matched cohort of patients. MATERIALS AND METHODS: We compared 620 patients enrolled in a prospective trial comparing systematic biopsy to fusion guided biopsy at NCI to 310 who underwent a similar procedure at Long Island Jewish Medical Center. The propensity score, defined as the probability of being treated outside NCI, was calculated using the estimated logistic regression model. Patients from the hospital were matched 1:1 for age, prostate specific antigen, magnetic resonance imaging suspicion score and prior negative biopsies. Clinically significant disease was defined as Gleason 3 + 4 or greater. RESULTS: Before matching we found differences between the cohorts in age, magnetic resonance imaging suspicion score (each p <0.001), the number of patients with prior negative biopsies (p = 0.01), and the overall cancer detection rate and the cancer detection rate by fusion guided biopsy (each p <0.001). No difference was found in the rates of upgrading by fusion guided biopsy (p = 0.28) or upgrading to clinically significant disease (p = 0.95). A statistically significant difference remained in the overall cancer detection rate and the rate by fusion guided biopsy after matching. On subgroup analysis we found a difference in the overall cancer detection rate and the rate by fusion guided biopsy (p <0.001 and 0.003) in patients with prior negative systematic biopsy but no difference in the 2 rates (p = 0.39 and 0.51, respectively) in biopsy naïve patients. CONCLUSIONS: Improved detection of clinically significant cancer by magnetic resonance imaging and fusion guided biopsy is reproducible by an experienced multidisciplinary team consisting of dedicated radiologists and urologists.

The role of MRI in active surveillance for prostate cancer.

Approximately one in seven American men will be diagnosed with prostate cancer during his lifetime, and at least 50% of newly diagnosed patients will present with low-risk disease. In the last decade, the decision-making paradigm for management has shifted due to high rates of disease detection and overtreatment, attributed to prostate-specific antigen screening, with more men deferring definitive treatment for active surveillance. The advent of multiparametric magnetic resonance imaging (MP-MRI) and MRI/ transrectal ultrasound-guided fusion-guided prostate biopsy has refined the process of diagnosis, identifying patients with clinically-significant cancer and larger disease burden who would most likely benefit from intervention. In parallel, the utilization of MP-MRI in the surveillance of low-grade, low-volume disease is on the rise, reflecting support in a growing body of literature. The aim of this review is to appraise and summarize the data evaluating the role of magnetic resonance imaging in active surveillance for prostate cancer.

Lymph node staging in prostate cancer.

Nodal staging is important in prostate cancer treatment. While surgical lymph node dissection is the classic method of determining whether lymph nodes harbor malignancy, this is a very invasive technique. Current noninvasive approaches to identifying malignant lymph nodes are limited. Conventional imaging methods rely on size and morphology of lymph nodes and have notoriously low sensitivity for detecting malignant nodes. New imaging techniques such as targeted positron emission tomography (PET) imaging and magnetic resonance lymphography (MRL) with iron oxide particles are promising for nodal staging of prostate cancer. In this review, the strengths and limitations of imaging techniques for lymph node staging of prostate cancer are discussed.

Gender-affirming Clitoroplasty and Construction of the Clitoro-urethral Complex: An Anatomy Guided Selection of Two Techniques.

OBJECTIVE: To present 2 clitoroplasty techniques-the preputial skin and urethral flap-and describe our rationale for using each technique to construct the clitoro-urethral complex in gender-affirming vaginoplasty. METHODS: For uncircumcised patients or circumcised patients with greater than 2 cm of inner preputial skin and at least 8 cm of shaft skin proximal to the circumcision scar, we use the preputial skin clitoroplasty, a modification of the Ghent style clitoroplasty. The entire corona is used after medial glans and urethral mucosa is excised. The corona is brought together 1 cm from midline to create the visible ovoid clitoris; the remaining coronal tissue remains lateral to the clitoris for erogenous sensation as clitoral corpora. The clitoris is anchored to the proximal tunica, positioned at the level of the adductor longus tendon. The folded neurovascular bundle is fixed in the suprapubic area. The ventral urethral is spatulated and urethral flap approximated to the clitoris. Preputial skin is sutured proximally as tension allows. The clitoro-urethral complex is inset into an opening created in the penile skin flap. For patients with less skin, we use the urethral flap clitoroplasty. More corpus spongiosum is used, as the urethra creates the clitoral hood; this is described in the literature and attributed to Pierre Brassard. The clitoris is inset following a dorsal urethrotomy, with a small collar of preputial skin sewn to the spongiosum and urethral mucosa. The urethra is transected about 1 cm distally. The ventral urethra is then spatulated and the urethroplasty completed. RESULTS: We prefer the preputial skin flap technique for its' greater coronal tissue volume for erogenous sensation and better esthetics, in our opinion. Circumcised patients should have at least 2 cm of skin distal to the circumcision scar. To avoid using skin graft for the introitus-a risk for introital stenosis-shaft skin proximal to the circumcision line should be at least 8 cm. CONCLUSION: We present 2 technical options for clitoroplasty and construction of the clitoro-urethral complex in gender-affirming vaginoplasty.

Bilateral Cavernosal Artery Ligation to Treat Ischemic Priapism Following Inflatable Penile Prosthesis Implantation.

OBJECTIVE: To describe the first known case of recurrent acute priapism after penile prosthesis implantation. MATERIALS AND METHODS: A 60-year-old gentleman with a history of recurrent ischemic priapism without hemoglobinopathy presented with refractory erectile dysfunction and underwent uncomplicated penile prosthesis placement. His course was complicated by early acute ischemic priapism confirmed via ultrasound. Due to his pain, attempts to relieve the priapism using ultrasound-guided phenylephrine injections were attempted but were unsuccessful. RESULTS: He subsequently underwent exploration with confirmation of distal ischemic priapism followed by brisk bright red blood from the proximal corpora upon device externalization. A perineal exploration was performed and the bilateral cavernosal arteries were suture ligated with immediate relief. The device was reimplanted and the patient recovered uneventfully. CONCLUSION: We report the first known case of ischemic priapism following inflatable penile prosthesis implantation. The details of this case challenge the dogma that priapism is a binary event and instead supports an imbalance between unopposed cavernosal artery inflow possibly due to vascular calcifications and compromised venous outflow due to the presence of the device. Prosthetic urologists should be aware of this rare phenomenon and consider all available approaches on an individualized case-by-case basis.

Penile and testicular prosthesis following gender-affirming phalloplasty and scrotoplasty: a narrative review and technical insights.

Background and Objective: Transgender and gender diverse (TGD) individuals may seek gender-affirming phalloplasty with specific functional goals, including erectile function sufficient for penetrative sexual intercourse. Individuals seeking penile prosthesis placement must accept the potential risks to their phallic anatomy. Methods: We review current practices at our center and narrative review of literature discussing techniques for penile prosthesis and testicular prosthesis placement after phalloplasty and scrotoplasty, as well as surgical outcomes, and quality of life outcomes where available. Key Content and Findings: Early discussion of a staged approach to phallic construction with a last step of implant placement is important during initial phalloplasty counseling. Pre-operative counseling at our multi-disciplinary center includes: discussion of surgical history, complications, goals and priorities; physical exam to evaluate phallic size and position, scrotal size, and other anatomic findings that may influence prosthesis selection; urinary evaluation, including uroflowmetry with post-void residual, and a cystoscopy with retrograde urethrogram if indicated based on symptoms or urinary studies, and discussion of surgical risks, benefits and alternatives. Although none of the commercially available penile prosthesis devices in the United States are designed for phalloplasty, modern inflatable and malleable prostheses are adapted for use in the post-phalloplasty setting. Due to the lack of native corpora cavernosa, highly variable phallic anatomy, and the need to adapt implants designed for natal penile anatomy, complication rates of prosthesis placement after phalloplasty remain high, with reported ranges of complications from 20% to 80%. Conclusions: Major complications requiring surgical revision are common relative to implant placement in natal penile anatomy, and include: infection requiring explantation, device extrusion, erosion, migration or malposition, inadequate rigidity, poor aesthetic result, pain, decrease or loss of erogenous and/or tactile sensation, device failure, injury to the urethra, and injury to the neurovascular supply of the penis with resultant partial or complete flap loss. This broad range of complication rates represents the variability with which results are reported and reflect a lack of clear reporting guidelines, significant variability in techniques, and need for more standardization. To optimize outcomes, it is important that surgeons have an in-depth understanding of phalloplasty anatomy and are equipped to manage potential complications in the short- and long-term.

Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy.

Transgender and non-binary (TGNB) individuals are seeking penile reconstruction in greater numbers; many pursue urethral lengthening surgery with a goal of voiding while standing. Changes in urinary function and urologic complications-i.e., urethrocutaneous fistulae and urinary stricture-are common. Familiarity with presenting symptoms and management strategies for urinary complaints after genital gender-affirming surgery (GGAS) can improve patient counseling and outcomes. We will describe current gender-affirming penile construction options with urethral lengthening and review associated urinary complications that present as urinary incontinence. The incidence and impact of lower urinary tract symptoms after metoidioplasty and phalloplasty are poorly characterized due to limited post-operative follow-up. Post-phalloplasty, urethrocutaneous fistula is the most common urethral complication, ranging in incidence from 15-70%. Assessment of concomitant urethral stricture is necessary. No standard technique exists for management of these fistula or strictures. Metoidioplasty studies report lower rates of stricture and fistula, 2% and 9% respectively. Other common voiding complaints include dribbling, urethral diverticula and vaginal remnants. History and physical exam in the post-GGAS evaluation require understanding of prior surgeries and attempted reconstructive efforts; adjuncts to physical exam include uroflowmetry, retrograde urethrography, voiding cysto-urethrogram, cystoscopy, and MRI. Following gender-affirming penile construction, TGNB patients may experience a host of urinary symptoms and complications that impact quality of life. Due to anatomic differences, symptoms require tailored evaluation which can be done by urologists in an affirming environment.

Causes of death among people with myelomeningocele: A multi-institutional 47-year retrospective study.

PURPOSE: This study aimed to analyze organ system-based causes and non-organ system-based mechanisms of death (COD, MOD) in people with myelomeningocele (MMC), comparing urological to other COD. METHODS: A retrospective review was performed of 16 institutions in Canada/United States of non-random convenience sample of people with MMC (born > = 1972) using non-parametric statistics. RESULTS: Of 293 deaths (89% shunted hydrocephalus), 12% occurred in infancy, 35% in childhood, and 53% in adulthood (documented COD: 74%). For 261 shunted individuals, leading COD were neurological (21%) and pulmonary (17%), and leading MOD were infections (34%, including shunt infections: 4%) and non-infectious shunt malfunctions (14%). For 32 unshunted individuals, leading COD were pulmonary (34%) and cardiovascular (13%), and leading MOD were infections (38%) and non-infectious pulmonary (16%). COD and MOD varied by shunt status and age (p < = 0.04), not ambulation or birthyear (p > = 0.16). Urology-related deaths (urosepsis, renal failure, hematuria, bladder perforation/cancer: 10%) were more likely in females (p = 0.01), independent of age, shunt, or ambulatory status (p > = 0.40). COD/MOD were independent of bladder augmentation (p = >0.11). Unexplained deaths while asleep (4%) were independent of age, shunt status, and epilepsy (p >= 0.47). CONCLUSION: COD varied by shunt status. Leading MOD were infectious. Urology-related deaths (10%) were independent of shunt status; 26% of COD were unknown. Life-long multidisciplinary care and accurate mortality documentation are needed.

Reducing Readmissions Following Radical Cystectomy: Moving Beyond Enhanced Recovery.

OBJECTIVE: To assess readmission outcomes of a traditional ER pathway as well as a targeted postdischarge intervention aimed at reducing hospital readmissions following RC. METHODS: A prospectively maintained clinical database was used to identify patients undergoing RC before and after implementation of an ER protocol at our institution. An additional intervention aimed at reducing hospital readmission included close postdischarge follow-up and outpatient intravenous hydration (ER+). Inpatient length of stay (LOS) and readmission rates were compared between groups using Wilcoxon Rank Sum and chi-square, respectively. Univariate and multivariate logistic regression was used to identify factors associated with hospital readmission. RESULTS: A total of 320 patients underwent RC, including 111 and 209 patients before and after ER implementation. Median (IQR) LOS decreased from 8.0 (6.0-11.0) days to 5.0 (4.0-7.0) days following ER implementation (P <.0001). Readmissions, however, were unchanged following ER implementation (P = .49). An additional targeted readmission reduction intervention (ER+) was associated with significantly reduced hospital readmissions compared to traditional ER alone (ER+ 5.9%, traditional ER 20.3%, P = .017). CONCLUSION: ER protocols consistently demonstrate reductions in LOS, and should be the standard of care following RC. In order to reduce readmissions, the urologic community must expand beyond traditional ER pathways. We report significant reductions in hospital readmission among RC patients receiving a targeted postdischarge intervention beyond traditional ER alone.

Posterior Vaginal Wall Prolapse: Suture-Based Repair.

Pelvic organ prolapse is common in parous women, although few report symptoms. The incidence of posterior compartment prolapse, or rectocele, is less well-reported. Posterior vaginal wall prolapse is associated with pain, constipation, and splinting. Surgery is the mainstay of therapy for symptomatic rectoceles. Though several surgical techniques have been described, no clear indications for type of repair have emerged. This article reviews the management strategies and draws conclusions about suture-based and site-specific techniques.

Ectopic expression of L1CAM ectodomain alters differentiation and motility, but not proliferation, of human neural progenitor cells.

Adult human neural progenitor and stem cells have been implicated as a potential source of brain cancer causing cells, but specific events that might cause cells to progress towards a transformed phenotype remain unclear. The L1CAM (L1) cell adhesion/recognition molecule is expressed abnormally by human glioma cancer cells and is released as a large extracellular ectodomain fragment, which stimulates cell motility and proliferation. This study investigates the effects of ectopic overexpression of the L1 long ectodomain (L1LE; ˜180 kDa) on the motility, proliferation, and differentiation of human neural progenitor cells (HNPs). L1LE was ectopically expressed in HNPs using a lentiviral vector. Surprisingly, overexpression of L1LE resulted in reduced HNP motility in vitro, in stark contrast to the effects on glioma and other cancer cell types. L1LE overexpression resulted in a variable degree of maintenance of HNP proliferation in media without added growth factors but did not increase proliferation. In monolayer culture, HNPs expressed a variety of differentiation markers. L1LE overexpression resulted in loss of glutamine synthetase (GS) and ß3-tubulin expression in normal HNP media, and reduced vimentin and increased GS expression in the absence of added growth factors. When co-cultured with chick embryonic brain cell aggregates, HNPs show increased differentiation potential. Some HNPs expressed p-neurofilaments and oligodendrocytic O4, indicating differentiation beyond that in monolayer culture. Most HNP-L1LE cells lost their vimentin and GFAP (glial fibrillary acidic protein) staining, and many cells were positive for astrocytic GS. However, these cells rarely were positive for neuronal markers ß3-tubulin or p-neurofilaments, and few HNP oligodendrocyte progenitors were found. These results suggest that unlike for glioma cells, L1LE does not increase HNP cell motility, but rather decreases motility and influences the differentiation of normal brain progenitor cells. Therefore, the effect of L1LE on increasing motility and proliferation appears to be limited to already transformed cells.

Kidney, Ureteral, and Bladder Cancer: A Primer for the Internist.

Malignancies of the urinary tract (kidney, ureter, and bladder) are distinct clinical entities. Hematuria is a unifying common presenting symptom for these malignancies. Surgical management of localized disease continues to be the mainstay of treatment, and early detection is important in the prognosis of disease. Patients often require life-long follow-up and assessment for recurrence.