To mesh or not mesh "apical prolapse," that is the question!

Surgical approaches for pelvic organ prolapse have evolved over the last 30 years and is a popular topic for debate, particularly when discussing apical prolapse. Transvaginal native tissue repairs remain the mainstay of POP surgeries, however, transabdominal approaches continue to evolve. Use of interposition material, such as synthetic polypropylene mesh, is the standard when performing an abdominal sacrocolpopexy, however, use of autologous fascia can be considered. This debate article provides an overview of this subject and highlights the value of different approaches to apical prolapse. The authors were asked to support their approach in various scenarios including:extremes of age, prior hysterectomy and intact uterus, desire to avoid mesh, sexual activity, and presence of comorbidities. In discussing common patient scenarios, ultimate decision making on specific POP surgeries is determined by patient preference and goals.

Assessing the spatial distribution of elemental concentrations in surface sediments of Lake Victoria, Kenya: implications for ecological health and management.

Lacustrine sediment quality indicates the effects of both natural and anthropogenic activities on the ecosystem and communities. Despite its ecological importance, myriad complexities, and potential contaminant sources, the spatial distribution of surficial sediments in Lake Victoria's Winam Gulf has never been comprehensively documented. The purpose of this study was to assess the spatial distribution, pathways, and ecological risk of metal elements in the lake using a sediment matrix. Sediment samples were collected throughout the gulf in November 2022. The concentrations of Al, As, Cd, Co, Cr, Cu, Fe, K, Mn, Mo, Ni, P, Pb, Sb, Sn, Ti, Tl, U, and Zn were compared to different contamination metrics and ecological risk assessment indices. The average concentrations were in the following decreasing order: Zn > > > Cr > > Cu > Ni > Pb > Co > As > Cd with mean (± SD) of 185 ± 45 mg kg-1, 56 ± 15 mg kg-1, 45 ± 16 mg kg-1, 37 ± 11 mg kg-1, 24 ± 5 mg kg-1, 20 ± 7 mg kg-1, 3.9 ± 1.3 mg kg-1, 0.30 ± 0.09 mg kg-1, respectively, with strong indications of anthropogenic sources. Average concentrations were in the following decreasing order: Zn > > > Cr, Cu, Ni, Pb, Co, As, and Cd levels (mean ± SD) were 185 ± 45 mg kg-1, 56 ± 15 mg kg-1, 45 ± 16 mg kg-1, 37 ± 11 mg kg-1, 24 ± 5 mg kg-1, 20 ± 7 mg kg-1, 3.9 ± 1.3 mg kg-1 and 0.30 ± 0.09 mg kg-1 with strong indications of anthropogenic sources. The geo-accumulation index (Igeo) and enrichment factor categorisation schemes, respectively, classified these as uncontaminated (level 0) and depletion to minimal enrichment (level 1), while the ecological risk analysis classified them as "low risk". The mouth of the Nyando River, as well as Kisumu, Kendu, and Homa bays, were the most element-enriched and should be prioritised for focused monitoring and remediation. As a result, targeted land management of urban, industrial, transportation, and agricultural areas offers the opportunity to reduce sediment inputs into the lake ecosystem.

Charting achievements: a two-year retrospective of the society for environmental geochemistry and health (SEGH) and the evolving strategies.

Emerging from the shadow of the COVID-19 pandemic, it is time to ground ourselves and retrospectively assess the recent achievements of SEGH over the past years. This editorial serves as a comprehensive report on the progress made in comparison to the aspirations and goals set by the society's board in 2019 (Watts et al., Environ Geochem Health 42:343-347, 2019) (Fig. 1) and reflects on the state of the SEGH community as it reached its 50th anniversary at the close of 2021 (Watts et al. Environ Geochem Health 45:1165-1171, 2023). The focus lies on how the SEGH community navigated through the extraordinary challenges posed by the COVID-19 pandemic since early 2020, and to what extent the 2023 targets have been met.

Considerations for environmental biogeochemistry and food security for aquaculture around Lake Victoria, Kenya.

The impact of population expansion through economic growth and development has been identified as one of the key drivers of both water and sediment contamination from potentially harmful elements (PHEs). This presents a major hazard not only to aquatic ecosystems but local riparian communities and beyond who rely heavily on this natural resource for drinking water and fish-a valuable source of dietary micronutrients and protein. The present study measured biogeochemical concentration of PHEs in water, sediment and fish from locations pooled into four zones within Winam Gulf and Lake Victoria area of Kenya. Captured fish were used as a sentinel receptor of lake health to evaluate potential risks to fisheries and aquaculture food security. In water, concentrations of arsenic (As), cadmium (Cd), chromium (Cr), copper (Cu) and lead (Pb) were observed above the United States Environmental Protection Agency (US EPA) maximum contamination level drinking water guidelines (MCL), with aluminium (Al) observed above the Aquatic Life Criteria in all four zones. Similarly, sediment concentrations in all four zones exceeded the US EPA Effects range low (ERL) threshold guidelines for Cu, nickel (Ni), zinc (Zn) and Pb, with Cu, Zn and Pb classed at moderate contamination levels using the contamination factor. Fish tissue concentrations from the four zones were calculated using recommended daily intakes (RDI) and for PHEs as provisional maximum tolerable intakes (PMTIs) and indicated most macro- and micronutrients were at or below 10% RDI from aquaculture and wild fish, with Se indicating a greater RDI (16-29%) in all the zones. Contributions of PHEs to PMTIs were below threshold guidelines for both aquaculture and wild fish with only Cd, Cr and Pb levels being above the PMTI thresholds. There is a need to assess the long-term effects of persistent anthropogenic PHE input into Winam Gulf and the wider Lake Victoria basin. Continued monitoring of PHEs using both historical and more recent data will enable future management policies to be implemented through improved mitigation strategies to reduce their impact on water quality, fish health and subsequent human health.

Editorial: The society for environmental geochemistry and health (SEGH): 50 years and beyond.

When the SEGH international board released a short editorial paper back in 2019, we described an aim to increase the membership offering, whilst improving the diversity of input regionally, by scientific discipline and to ensure greater and more regular contact across the regions from 2020 onwards. Wider aspirations described in 2019 (Watts et al. 2019) are discussed within this short communication at the end of 2021 to evaluate progress made. In particular, how the SEGH community adapted to the unprecedented circumstances that have challenged each and every one of us throughout the COVID-19 pandemic since early 2020 and are likely to influence our activities for the foreseeable future.

Contemporary multicenter outcomes of continent cutaneous ileocecocystoplasty in the adult population over a 10-year period: A Neurogenic Bladder Research Group study.

AIMS: Evidence is sparse on the long-term outcomes of continent cutaneous ileocecocystoplasty (CCIC). We hypothesized that obesity, laparoscopic/robotic approach, and concomitant surgeries would affect morbidity after CCIC and aimed to evaluate the outcomes of CCIC in adults in a multicenter contemporary study. METHODS: We retrospectively reviewed the charts of adult patients from sites in the Neurogenic Bladder Research Group undergoing CCIC (2007-2017) who had at least 6 months of follow-up. We evaluated patient demographics, surgical details, 90-day complications, and follow-up surgeries. the Mann-Whitney U test was used to compare continuous variables and χ² and Fisher's Exact tests were used to compare categorical variables. RESULTS: We included 114 patients with a median age of 41 years. The median postoperative length of stay was 8 days. At 3 months postoperatively, major complications occurred in 18 (15.8%), and 24 patients (21.1%) were readmitted. During a median follow-up of 40 months, 48 patients (42.1%) underwent 80 additional related surgeries. Twenty-three patients (20.2%) underwent at least one channel revision, most often due to obstruction (15, 13.2%) or incontinence (4, 3.5%). Of the channel revisions, 10 (8.8%) were major and 14 (12.3%) were minor. Eleven patients (9.6%) abandoned the catheterizable channel during the follow-up period. Obesity and laparoscopic/robotic surgical approach did not affect outcomes, though concomitant surgery was associated with a higher rate of follow-up surgeries. CONCLUSIONS: In this contemporary multicenter series evaluating CCIC, we found that the short-term major complication rate was low, but many patients require follow-up surgeries, mostly related to the catheterizable channel.

Iodine uptake, storage and translocation mechanisms in spinach (Spinacia oleracea L.).

Iodine is an essential micronutrient for human health; phytofortification is a means of improving humans' nutritional iodine status. However, knowledge of iodine uptake and translocation in plants remains limited. In this paper, plant uptake mechanisms were assessed in short-term experiments (24 h) using labelled radioisotopes; the speciation of iodine present in apoplastic and symplastic root solutions was determined by (HPLC)-ICP-QQQ-MS. Iodine storage was investigated in spinach (Spinacia oleracea L.) treated with I- and IO3-. Finally, translocation through the phloem to younger leaves was also investigated using a radioiodine (129I-) label. During uptake, spinach roots demonstrated the ability to reduce IO3- to I-. Once absorbed, iodine was present as org-I or I- with significantly greater concentrations in the apoplast than the symplast. Plants were shown to absorb similar concentrations of iodine applied as I- or IO3-, via the roots, grown in an inert growth substrate. We found that whilst leaves were capable of absorbing radioactively labelled iodine applied to a single leaf, less than 2% was transferred through the phloem to younger leaves. In this paper, we show that iodine uptake is predominantly passive (approximately two-thirds of total uptake); however, I- can be absorbed actively through the symplast. Spinach leaves can absorb iodine via foliar fertilisation, but translocation is severely limited. As such, foliar application is unlikely to significantly increase the iodine content, via phloem translocation, of fruits, grains or tubers.

Quality of life outcomes in peri-urethral calcium hydroxylapatite injection.

INTRODUCTION AND HYPOTHESIS: Peri-urethral calcium hydroxylapatite injection is an established treatment for patients with stress urinary incontinence. Information is limited regarding calcium hydroxylapatite treatment and quality of life (QOL) outcomes. We hypothesize that patients might improve QOL after peri-urethral calcium hydroxylapatite injection, which was reflected in validated questionnaires. METHODS: The peri-urethral calcium hydroxylapatite injection billing code was used to identify patients who underwent injection from 2011-2013. Female patients who completed the American Urological Association Symptom Score (AUASS), the AUASS QOL and Michigan Incontinence Symptom Index (M-ISI), and the bother score (M-ISI bother), or pad count at baseline and follow-up were included. Change in questionnaire scores and pads were assessed using the paired t test. RESULTS: Sixty patients underwent 1 (30), 2 (63) or 3 (7 %) peri-urethral calcium hydroxylapatite injections performed by a single surgeon. Thirty-seven patients provided questionnaires and 38 provided pad counts, all with a mean age of 75 years. The overall AUASS, AUASS QOL, and overall M-ISI scores improved in 67.6, 54.8, and 61.3 % respectively (4.5 ± 7.9, 1.3 ± 1.7 and 5.5 ± 8.6 respectively). The M-ISI bother score improved in 44.8 % with a mean improvement of 0.5 ± 2.9, but did not reach significance. There was a 1.7 ± 3.7 decrease in the mean number of pads used daily after the procedure (p = 0.006) and 19 % experienced transient urinary retention. CONCLUSIONS: Peri-urethral calcium hydroxylapatite injections can improve urinary QOL scores in patients with initial and recurrent stress urinary incontinence. This short-term retrospective analysis suggests that larger long-term studies focusing on QOL outcomes are needed to evaluate the effect of peri-urethral calcium hydroxylapatite has on incontinence-specific QOL.

A Primer for Primary Care Physicians Managing Neurogenic Bladder Patients.

Primary care plays an important role in caring for neurogenic bladder patients. Clinicians should assess neurogenic bladder patients for common urologic symptoms/signs and refer to urology if refractory or safety issues are identified.

Differences in sacral neuromodulation device infection rates based on preoperative antibiotic selection.

INTRODUCTION AND HYPOTHESIS: After SNM implantation the most significant complication that can occur is wound infection, which typically requires removal of all components. Such infections have been reported in 5-11 % of patients, but little is known about risk factors. The objective of this analysis is to determine our postoperative wound infection rate after SNM implantation, and examined various potential predictive factors. Our hypothesis is that perioperative antibiotic selection is related to the risk of infections. METHODS: A retrospective review was performed of all patients who underwent SNM implantation by one of three surgeons from 2007 to 2010. Preoperative antibiotics were administered according to surgeon preference, and included cefazolin alone, vancomycin alone, or vancomycin with gentamicin. Predictors of wound infection were evaluated using multivariate techniques. Variables examined included preoperative antibiotic regimen, surgeon, location (outpatient surgery center vs university hospital), gender, comorbidities (diabetes mellitus, immunosuppression and smoking), history of urinary tract infections, and preoperative skin preparation. RESULTS: A total of 136 patients underwent SNM implantation, and 8 (5.9 %) experienced infections that required device explantation. Cefazolin alone was less effective in preventing infection compared with the other antibiotic regimens (p = 0.03). The odds of having an infection in cefazolin-treated patients was 7.3 times that of other patients treated with another antibiotic regimen. Seven out of the eight infections with explant grew Staphylococcus aureus resistant to cephalosporins. None of the other variables proved to be a statistically significant contributor. CONCLUSIONS: Preoperative antibiotic selection was a significant factor in preventing subsequent infection and explantation following SNM placement.

Diversity in Urology, Are We Moving in the Right Direction?: Analysis of American Urologic Association Urology Residency Match Statistics 2019-2023.

Analysis of the urology match statistics provides a window into the future of the urology workforce. Match statistics from 2019 to 2023 were analyzed to determine whether the efforts to promote diversity in 2020 have been impactful. The popularity in the field of urology among all racial/ethnic groups peaked interest in application in 2022. However despite an increase in URIM applicants over the last 5 years, 2023 URM applicants have 1/3 the odds of matching into urology as white applicants.

Genital Sparing Robot-Assisted Radical Cystectomy with Intracorporeal Neobladder & Paravaginal Repair.

OBJECTIVE: Vaginal prolapse is a known complication after radical cystectomy, requiring additional procedures in 10% of the patients.1 This results from loss of level I and II vaginal support due to the removal of pelvic structures. In addition, a neobladder urinary diversion, with Valsalva voiding, predisposes to vaginal prolapse. A genital-sparing approach with paravaginal repair can help prevent such complications. METHODS: The genital sparing technique preserves the uterus, fallopian tubes, ovaries, and vagina, while paravaginal repair involves suturing of the lateral vaginal wall to the arcuate fascia located on the medial aspect of the obturator internus muscle. The procedure begins by placing the patient in a lithotomy position, with a steep Trendelenburg. Standard 6 port cystectomy configuration is utilized with an additional 15 mm port for bowel anastomosis. Initially, the ureters and lateral bladder space are mobilized. Posteriorly a dissection plane is developed separating the bladder from the anterior vaginal wall. Distal dissection is carefully performed in that plane to avoid disrupting the urethral-external sphincter complex. Then the bladder is dropped from anterior attachments, the Dorsal venous complex (DVC) and bladder neck are exposed. Urethra is transected distal to the bladder neck, after circumferential mobilization, to complete the cystectomy, again avoiding disruption of the continence mechanism, and opening the endo-pelvic fascia. Cystectomy and pelvic lymph node dissection are completed in a standard fashion. The arcuate fascia is identified bilaterally for level I paravaginal repair. The lateral aspect of the paravaginal tissue is secured to this ligament, using 3 interrupted Polydioxanone (PDS) sutures, bilaterally. An ileal "Hautman's W pouch" neobladder is constructed using 50 cm of the small intestine, similar to the previously reported technique.2 Bricker-type uretero-ileal anastomosis is performed over a double J stent. Bowel continuity is restored by a side-to-side anastomosis using endo-GIA (gastrointestinal anastamosis EndoGIATM ) staplers. RESULTS: No intra or postoperative complications were noted. Robot dock time was 8 hours and 23 minutes with an EBL of 100 mL. The patient was discharged on post operative day (POD) 6 and Foley catheter with ureteral stents was removed on POD 27 after a cystogram confirmed no leaks. At 6-month follow-up, the patient reported good continence using a single pad, voiding every 3-4 hours. Fluoro-urodynamics demonstrated 651 mL capacity, low-pressure voiding, minimal residual urine, and no reflux. No prolapse was noted on fluoroscopy and pelvic examination with the Valsalva maneuver. The patient reported a good satisfaction level, regarding her urinary symptoms. CONCLUSION: We report satisfactory short-term outcomes of a feasible technique to prevent postcystectomy prolapse; however, long-term follow-up of a larger cohort can help establish its efficacy.

Workforce Diversity in Female Pelvic Medicine and Reconstructive Surgery: An Analysis of the American Urological Association Census Data.

OBJECTIVE: To describe the current state of workforce diversity in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) using the 2014-2019 American Urological Association (AUA) census data. MATERIALS: We evaluated FPMRS workforce diversity using the AUA census data from 2014 to 2019. Underrepresented in medicine (URiM) groups were categorized as individuals who self-identified as non-Hispanic Black/African American, Hispanic, Multiracial, and Other. The FPMRS workforce was then compared to the overall urologic workforce and the other urologic subspecialties (oncology, pediatric urology, and endourology) and assessed by AUA section. RESULTS: In 2019, 602 urologists self-identified as FPMRS providers. Of these 12.4% (n = 74) were categorized as URiM urologists compared to 8% of the overall urologic workforce. Women who represent 9.9% of all urologists were overrepresented in FPMRS workforce (46.5%). FPMRS had the largest proportion of URiM and women urologists when compared to the other subspecialty areas. CONCLUSION: The FPMRS urologic subspecialty has the highest percentage of women and URiM urologists compared to all other urologic subspecialty areas. Engagement initiatives and targeted programs may offer insights into this trend. Further research is required to determine the impact of such programs in attracting URiM and women to FPMRS.

Comparison of Urinary Tract Infection Incidence Following Intradetrusor OnabotulinumtoxinA in Office Versus Operating Room Settings.

IMPORTANCE: Urinary tract infection (UTI) is a known complication of intradetrusor onabotulinumtoxinA (BTX) injection. However, whether administering intradetrusor BTX in different clinical settings affects the risk of postprocedural UTI has not been investigated. OBJECTIVES: The objective of this study was to assess differences in the incidence of postprocedural UTI in women who received intradetrusor BTX in an outpatient office versus an operating room (OR). STUDY DESIGN: We performed a retrospective chart review of intradetrusor BTX procedures at a single institution between 2013 and 2020. Demographic data, comorbidities, and perioperative data were abstracted. The primary outcome was UTI defined as initiation of antibiotics within 30 days following BTX administration based on clinician assessment of symptoms and/or urine culture results. Univariate analysis of patients with and without UTI was performed. RESULTS: A total of 446 intradetrusor BTX procedures performed on female patients either in an outpatient office (n = 160 [35.9%]) or in an OR (n = 286 [64.1%]) were included in the analysis. Within 30 days of BTX administration, UTI was diagnosed after 14 BTX procedures (8.8%) in the office group and 29 BTX procedures (10.1%) in the OR group ( P = 0.633). De novo postprocedural urinary retention occurred in more women who were treated in the office than in the OR (13 [9.6%] vs 3 [1.3%], P < 0.001). CONCLUSIONS: Selecting the appropriate setting for BTX administration is dependent on multiple factors. However, the clinical setting in which intradetrusor BTX is administered may not be an important factor in the development of postprocedural UTI, and further research is warranted.

Should an anti-incontinence procedure be routinely performed at the time of pelvic organ prolapse repair? An evidence-based review.

The concept of prophylactic anti-incontinence surgery for women undergoing prolapse repair has been a popular and controversial debate in recent years. This article provides an evidence-based review of the current literature to determine the proper evaluation of the patient with prolapse, the predictive quality of preoperative urodynamics, and the selection of the appropriate anti-incontinence procedure. Based on this review, the midurethral sling predominates as the procedure of choice; however, there is poor evidence to suggest that routine usage of a prophylactic sling is warranted in treatment of the patient with pelvic organ prolapse.

Investigating the use of microdialysis and SEC-UV-ICP-MS to assess iodine interactions in soil solution.

Element cycling in the terrestrial environment is heavily reliant upon processes that occur in soil solution. Here we present the first application of microdialysis to sample iodine from soil solution. In comparison to conventional soil solution extraction methods such as Rhizon™ samplers, centrifugation, and high-pressure squeezing, microdialysis can passively sample dissolved compounds from soil solution without altering the in-situ speciation of trace elements at realistic soil moisture conditions. In order to assess the suitability of microdialysis for sampling iodine, the permeability factors and effect of perfusion flowrate on I- and IO3- recovery was examined in stirred solutions. Furthermore, microdialysis was used to sample native soluble iodine at a range of water contents and iodine-enriched soils to investigate iodine soil dynamics. Total iodine concentrations were measured using ICP-MS. Inorganic species and the molecular weight distribution of organically bound iodine were determined by anion exchange and size exclusion chromatography (SEC) coupled to an ICP-MS, respectively. The most effective recovery rates in stirred solution were observed with the slowest perfusion flowrate yielding 66.2 ±â€¯7.1 and 70.5 ±â€¯7.1% for I- and IO3-, respectively. Microdialysis was proven to be capable of sampling dissolved iodine from the soil solution, which accounted for <2.5% of the total soil iodine and speciation followed the sequence: organic-I > I- > IO3-. The use of SEC coupled to (i) UV and (ii) ICP-MS analysis provided detail regarding the molecular weight distribution of dissolved org-I compounds. Dissolved org-I was detected with approximate molecular weights between 0.1 and 4.5 kDa. The results in this study show that microdialysis is a suitable technique for sampling dissolved iodine species from soils maintained at realistic moisture contents. In addition, inorganic iodine added to soils was predominately bound with relatively low molecular weight (<4.5 kDa) soluble organic matter.

Iodine soil dynamics and methods of measurement: a review.

Iodine is an essential micronutrient for human health: insufficient intake can have multiple effects on development and growth, affecting approximately 1.9 billion people worldwide. Previous reviews have focussed on iodine analysis in environmental and biological samples, however, no such review exists for the determination of iodine fractionation and speciation in soils. This article reviews the geodynamics of both stable 127I and the long-lived isotope 129I (t1/2 = 15.7 million years), alongside the analytical methods for determining iodine concentrations in soils, including consideration of sample preparation. The ability to measure total iodine concentration in soils has developed significantly from rudimentary spectrophotometric analysis methods to inductively coupled plasma mass spectrometry (ICP-MS). Analysis with ICP-MS has been reported as the best method for determining iodine concentrations in a range of environmental samples and soils due to developments in extraction procedures and sensitivity, with extremely good detection limits typically <µg L-1. The ability of ICP-MS to measure iodine and its capabilities to couple on-line separation tools has the significance to develop the understanding of iodine geodynamics. In addition, nuclear-related analysis and recent synchrotron light source analysis are discussed.

Evaluating and managing urinary incontinence after prostatectomy: beyond pads and diapers.

Men who become persistently incontinent after undergoing prostatectomy have a variety of options for regaining control, ranging from behavioral changes to surgery. To determine the best therapy, one should define the problem with a thorough urologic evaluation.