Making a Statement: Positions of Professional Medical Organizations Towards Gender-Affirming Care.

OBJECTIVE: Despite politically charged media coverage and legislation surrounding gender affirming care (GAC), many organizations have released position statements to provide scientifically backed clinical practice standards, combat misinformation, and inform medicolegal policies. The purpose of this study is to objectively assess the availability and the content of the official position statements of relevant medical professional organizations regarding GAC. SUMMARY BACKGROUND DATA: A list of U.S. medical professional organizations with likely involvement in GAC based on medical or surgical specialties was compiled. METHODS: For included organizations, we evaluated the availability, content, and publication year of positions on GAC through October 2023. When available, formal positions were categorized as supportive or unsupportive. RESULTS: A total of 314 professional medical organizations were screened for our study based on specialty, relevance to GAC, and issuance of patient guidelines or position statements. Inclusion criteria were met by 55 organizations. Most organizations (35, 63.6%) had formal position statements on GAC. Support for GAC was described in 97.1% (n=34). Further, 94.2% (n=33) of available statements explicitly addressed GAC in individuals less than 18 years old and were largely supportive (96.9%, n=32). CONCLUSIONS: This cross-sectional analysis demonstrates that a majority of multidisciplinary professional medical organizations with relevance to GAC have issued formal position statements on the topic. Available positions were overwhelmingly supportive of individualized access to gender-affirming therapies in adult and adolescent populations. However, silence from some organizations continues to represent a modifiable disparity in the provision of GAC.

Semiquantitative Tissue Perfusion Assessment Using Indocyanine Green in Complex Open Urethral Reconstruction.

OBJECTIVE: Current assessment of critical tissue in genitourinary reconstruction, including graft beds and tissue flaps, primarily relies upon qualitative visual and tactile assessment by experienced surgeons. Here we explore the feasibility of using intravenous indocyanine green (ICG) for semiquantitative assessment of perfusion in complex open urethral reconstruction. METHODS: A standardized protocol for intravenous use of ICG and near-infrared fluorescence was established. Black and white mode was used for qualitative assessment of perfusion based on signal brightness. Quantitative perfusion mode was used to assess relative perfusion to tissue of interest compared to a control area with similar tissue type outside of the studied area. Real-time perfusion was visualized as percentage of perfusion relative to control. RESULTS: In case 1, the graft bed was assessed during dorsal onlay graft substitution urethroplasty. Perfusion to graft bed was compared to that of erectile bodies proximally. A proposed perfusion cutoff of 60% was noted to correlate with clinical judgment of graft bed quality. In case 2, tissue perfusion of Blandy flap in perineal urethrostomy was assessed before and after mobilization. A cutoff of 40% was proposed based on existing flap-based reconstruction literature with the goal to tailor flap and ultimately avoid tissue ischemia and necrosis. In case 3, in a complex staged substitution urethroplasty after hypospadias repair, the use of ICG facilitated a limited excision and shorter graft inlay in this staged reconstruction. CONCLUSION: The application of near-infrared fluorescence tools in open genitourinary reconstruction has the potential to advance quantitative assessment of graft, flaps, and other critical tissue planes, and help establish meaningful perfusion threshold and correlate with clinical outcomes.

Evaluating Adherence to Guideline-based Injury Grading in Pediatric Renal Trauma: How Are Patients Being Worked Up Prior to Transfer to a Level 1 Trauma Center?

OBJECTIVE: To determine whether children with renal trauma who are transferred to a level I trauma center (TC) receive appropriate imaging studies before transfer and whether this impacts care. The American Urologic Association (AUA) Urotrauma guidelines state clinicians should perform IV contrast-enhanced CT with immediate and delayed images when renal trauma is suspected. Adherence to these guidelines in pediatric patients is unknown. METHODS: Children treated for renal trauma at our TC between 2005 and 2019 were identified. Comparisons between patients with initial imaging at a transferring hospital (TH) and patients with initial imaging at our TC were performed using logistic regression. RESULTS: Of the included 293 children, 67% (197/293) were transferred into our TC and 61% (180/293) received initial imaging at the TH. Patients with initial imaging at the TH were more likely to have higher-grade renal injuries (P = .001) and were less likely to have guideline-recommended imaging (31% vs 82%, P < .001). Of patients who were imaged at the TH, 28% (50/180) underwent an additional CT imaging shortly after transfer. When imaging was incomplete at the TH, having an additional scan upon transfer was associated with emergent urologic surgery (P = .004). CONCLUSION: Adherence to the AUA Urotrauma guidelines is low, with most pediatric renal trauma patients not receiving complete staging with delayed-phase imaging before transfer to a TC. Furthermore, patients initially imaged at THs were more likely to receive more CT scans per admission and were exposed to higher amounts of radiation. There is a need to improve imaging protocols for complete staging of renal trauma in children before transfer.

Management of male stress urinary incontinence in high-risk patients: a narrative review.

Background and Objective: The artificial urinary sphincter (AUS) remains the gold standard for treatment of stress urinary incontinence (SUI). However, highly complex patients such as those with bulbar urethral compromise, bladder pathology, and lower urinary complications pose a particular challenge for the surgeon. In this article, we will address critical risk factors and synthesize existent data across relevant disease states to support surgeons in successful management of SUI in high-risk patients. Methods: A comprehensive review of current literature was performed utilizing the search term "artificial urinary sphincter" in conjunction with any of the following additional terms: "radiation", "urethral stricture", "posterior urethral stenosis", "vesicourethral anastomotic stenosis", "bladder neck contracture", "pelvic fracture urethral injury", "penile revascularization", "inflatable penile prosthesis", and "erosion". Guidance is provided based upon expert opinion where existing literature was sparse or nonexistent. Key Content and Findings: Several known patient risk factors are associated with AUS failure and can ultimately lead to device explantation. Each risk factor requires careful consideration and investigation, or intervention as appropriate, prior to device placement. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients. Several surgical strategies to decrease device complications can be considered: optimization of testosterone, avoidance of 3.5 cm AUS cuff, transcorporal AUS cuff placement, relocation of AUS cuff site, use of lower pressure-regulating balloon, penile revascularization, and intermittent nocturnal deactivation. Conclusions: A number of patient risk factors are associated with AUS failure and can ultimately lead to device explantation. We present an algorithm for management of high-risk patients. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients.

Blunt traumatic female urethral and bladder neck injuries: a 15-year single-institution experience.

PURPOSE: To describe our experience in the management and outcomes of female patients with urethral or bladder neck (BN) injury at a high-volume Level 1 trauma center. METHODS: A retrospective chart review of all female patients with urethral or BN injury by blunt trauma mechanism admitted to a Level 1 trauma center between 2005 and 2019 was performed. RESULTS: Ten patients met study criteria with median age 36.5 years. All had concomitant pelvic fractures. All injuries were confirmed operatively, with no delayed diagnoses. Two patients were lost to follow up. One patient was not eligible for early repair of urethral injury and had two repairs of a urethrovaginal fistula. Two of seven (29%) patients who underwent early repair of their injury had an early Clavien grade > 2 complication, with none reporting long-term complications at median follow-up of 15.2 months. CONCLUSIONS: Intraoperative evaluation is critical in the diagnosis of female urethral and BN injury. In our experience, acute surgical complications are not uncommon after the management of such injuries. However, there were no reported long-term complications in those patients who had prompt management of their injury. This aggressive diagnostic and surgical strategy is instrumental in attaining excellent surgical outcomes.

Functional outcomes of Fournier's gangrene: a multi-institutional experience.

INTRODUCTION: Fournier's gangrene (FG), is a progressive, necrotizing soft tissue infection of the external genitalia, perineum, and/or anorectal region. How treatment and recovery from FG impacts quality of life related to sexual and general health is poorly characterized. Our purpose is to evaluate the long term impact of FG on overall and sexual quality of life using standardized questionnaires through a multi-institutional observational study. MATERIALS AND METHODS: Multi-institutional retrospective data were collected by standardized questionnaires on patient-reported outcome measures including the Changes in Sexual Functioning Questionnaire (CSFQ) and the Veterans RAND 36 (VR-36) survey of general health-related quality of life. Data were collected via telephone call, email, and certified mail, with a 10% response rate. There was no incentive for patient participation. RESULTS: Thirty-five patients responded to the survey, with 9 female and 26 male patients. All patients in the study underwent surgical debridement between 2007-2018 at three tertiary care centers. Further reconstructions were performed for 57% of respondents. Values for respondents with overall lower sexual function were reduced in all component categories (pleasure, desire/ frequency, desire/interest, arousal/excitement, orgasm/ completion), and trended toward male sex, older age, longer time from initial debridement to reconstruction, and poorer self-reported general health-related quality of life metrics. CONCLUSION: FG is associated with high morbidity and significant decreases in quality of life across general and sexual functional domains.

Ureteral Injuries Secondary to Blunt Abdominal Trauma: A 15-Year Review of Presentation, Management, and Outcomes at a Level 1 Trauma Center.

OBJECTIVE: To report our contemporary experience with ureteral injuries secondary to blunt trauma, with diagnostic methods and management stratified according to injury severity. MATERIALS AND METHODS: We performed a retrospective 15-year study (4/2005-4/2020) at a regional level I trauma center. Patients were categorized as having a partial or complete transection injury. Treatment success was defined as the absence of hydronephrosis or obstruction on follow-up imaging. RESULTS: Eighteen patients suffered 10 partial and 9 complete ureteral transections. All 16 patients who underwent initial evaluation with computed tomography were correctly graded as having partial or complete transections, and there were no missed injuries. Treatment of partial transections included observation (3/9), retrograde double-J stent placement (4/9), and Heineke-Mikulicz pyeloplasty (2/9). At a median follow-up of 9 (IQR 2-59) months, 8/9 (89%) partial transections were treated successfully. Treatment of complete transections included pyeloplasty (3/9), ureteroureterostomy (4/9), and ureteroneocystostomy (1/9). One patient who underwent attempted reconstruction 6 days after trauma required nephrectomy. At a median follow-up of 32 (IQR 4-82) months, 7/8 (89%) reconstructed complete transections were treated successfully. CONCLUSION: Computed tomography with delayed phase imaging is a sensitive test to detect ureteral injuries after blunt trauma, and computed tomography can distinguish between partial and complete transections. Partial transection injuries secondary to blunt trauma may be amenable to ureteral stent placement or close observation in select cases. Good intermediate-term outcomes can be achieved with early surgical intervention in the case of complete transections.

Computed tomography-based volume calculations of renal ischemia predicts post-traumatic renal function after renal infarction injury.

OBJECTIVES: To describe a systematic method to quantify the severity of renal infarction injury and assess its association with post-traumatic renal function after blunt trauma. METHODS: We retrospectively reviewed all patients who suffered an AAST grade IV renal infarction injury without active bleeding secondary to blunt trauma between 1/2010 and 10/2020. Only patients with a pre-traumatic eGFR within 12 months of injury and post-traumatic eGFR within 3-12 months were included. Percentage of renal ischemia was defined as: (ischemic volume/total volume) × 100%. Two radiologists reviewed computed tomography images to determine ischemic and overall cross-sectional areas using the polygon region of interest tool. These areas were multiplied by slice thickness to obtain ischemic and total volumes. Intraclass correlation coefficient was used to assess consistency between radiologists. Linear regression analyses were used to assess the association between percentage of renal ischemia and post-traumatic renal function. RESULTS: Thirty-five of 140 (25.0%) patients met inclusion criteria. The median (IQR) pre-trauma eGFR was 107.7 ml/min/1.73m2 (90.6-121.8), percentage of renal ischemia was 8.4% (2.9-30.1), and decrease in eGFR after trauma was 12.9 ml/min/1.73m2 (0.4-32.6). There was excellent reliability in calculating ischemic volume (ICC = 0.987) and total kidney volume (ICC = 0.995) between two radiologists. When adjusting for pre-traumatic eGFR, patient age, and injury severity score, a 10% increase in ischemic volume was associated with a post-injury eGFR value that was 8.0 ml/min/1.73 m2 (95% CI - 11.2, - 4.7) lower. CONCLUSIONS: CT-based volume calculation of renal ischemia may be utilized to quantify kidney injury and be associated with post-traumatic renal function loss.

Outcomes of mohs microgrpahic resection for cutaneous malignancy involving the scrotum.

INTRODUCTION: Squamous cell carcinoma (SCC) and extramammary Paget's Disease (EMPD) of the scrotum are exceedingly rare. Given their propensity for local invasion and treatment with wide local excision, they can be highly morbid conditions. Outcomes of Mohs Micrographic Surgery (MMS) for scrotal cutaneous malignancy is not well described in current literature. We hypothesized that MMS for scrotal cutaneous malignancy would provide equivalent or improved oncologic outcomes while limiting the morbidity associated with wide excision. MATERIALS/METHODS: This is a retrospective review and analysis of a prospectively maintained database spanning entries from 2005 to 2019. Collected data included general patient characteristics and surgical characteristics reported on a per lesion basis. MMS was performed by our institution's department of dermatology using their standard technique. RESULTS: Overall, a total of 26 consecutive patients with 28 lesions (SCC or EMPD) were analyzed. Out of our cohort of 15 patients with 16 scrotal SCC lesions, 10 (66%) patients were current or former smokers, 4 (26%) were immunosuppressed, and 2 (13%) had HPV infections. The median preoperative and postoperative size of SCC lesions were 5.7cm [2] and 20.2cm [2] respectively. There was one (6%) oncologic recurrence of SCC of the scrotum and one (6%) local wound complication. Our cohort also included 11 patients with 12 scrotal EMPD lesions. One patient (9%) had an underlying associated malignancy (prostate cancer). The preoperative and postoperative area of lesions were 50.6cm [2] and 96.4cm [2] respectively. One (9%) EMPD lesion had a positive final margin at resection requiring reoperation. After achieving negative surgical margins, no patients in this cohort had an oncologic recurrence. 3 (26%) scrotal EMPD cases had local wound postoperative complications, only one required reoperation. CONCLUSION: To our knowledge, this is the first case series focused on MMS for both SCC and EMPD with scrotal involvement. Our data suggests that MMS for scrotal cutaneous malignancy may improve oncologic outcomes and may decreases local post-operative reconstructive issues when compared to reported outcomes of treatment with wide local excision. When able, scrotal cutaneous malignancy patients should be referred to urologists at centers with MMS capabilities as it likely will improve their outcomes. The urologist should maintain active involvement with these patients to coordinate this complex and advanced pattern of care.

Implementing a patient safety culture survey to identify and target process improvements in academic ambulatory urology practices: a multi-institutional collaborative.

INTRODUCTION: A shared professional culture focused on patient safety is critical to delivering high-quality care. There is a need for objective metrics to help identify target areas for improvement in patient safety culture. The Medical Office Survey on Patient Safety Culture (SOPS) was developed and validated by the United States Agency for Healthcare Research and Quality to measure patient safety culture in the ambulatory setting. In this study we report on safety culture and practices in six academic urology clinics utilizing this validated questionnaire. MATERIALS AND METHODS: The SOPS was administered to all staff in ambulatory urology practices affiliated with participating centers. Percent positive responses were calculated for each of 10 validated composite domains and were compared between sites and respondent roles. Nonparametric statistical analyses were performed to identify differences between groups. RESULTS: The survey was administered to 185 staff members, with an overall response rate of 66%. Within each domain there was substantial variability between sites, with significant differences observed in staff training (p = 0.034), office processes/standardization (p = 0.008), patient care tracking (p = 0.047), communication about errors (p = 0.001), and organizational learning (p = 0.015). Similar variation was seen between respondent roles with significant differences for patient care tracking (p = 0.002) and communication about errors (p = 0.014). CONCLUSIONS: The SOPS is a clinically useful tool to identify issues impacting a practice's safety culture. Substantial variability was observed within each composite domain at the levels of practice site and respondent role. Comparing composite domain results between clinics will allow leadership to identify gaps and evaluate policies and resources of higher performing peer sites.

Historical and Current Practices in the Management of Fossa Navicularis Strictures.

PURPOSE OF REVIEW: Fossa navicularis strictures represent a surgically challenging disease process that requires detailed preoperative planning and an understanding of each patient's goals in order to achieve a satisfactory long-term outcome. This review summarizes the various approaches used in the management of fossa navicularis strictures over the past several decades. RECENT FINDINGS: In addition to existing evidence to support open flap- and graft-based reconstruction, recent studies suggest a potential role for limited open repair via a transurethral approach. Open repair of fossa navicularis strictures has become the standard of care with high success rates using local skin flaps or tissue grafts. There remains a very limited role for minimally invasive techniques in definitive management of this disease.

Transitional Urology.

The field of transitional urology has taken on an increasing importance in recent years as more individuals with congenital urologic issues are living and thriving into adulthood. This article reviews the transitional process itself including barriers to successful transition and the consequences of failing to properly transition. Also provided is a broad overview of the urologic issues faced by patients who may benefit from lifelong care and the providers who will be helping them with transition and assuming their care.

Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting.

AIM: To describe a technique for surgical correction of adult buried penis, including a technique for skin graft harvesting from the escutcheonectomy specimen itself, with an emphasis on remaining open questions in the literature. METHODS: We present our method for surgical correction of adult buried penis with a review of the literature. MAIN OUTCOME MEASURE: Components of successful buried penis repair include return of directed voiding, elimination of local skin inflammation and infection, improvement in hygiene, return of sexual functioning, cosmesis, and patient satisfaction. To date, there are no broadly accepted tools for comprehensive measurement of outcomes after buried penis repair. RESULTS: Adult buried penis repair is generally associated with excellent rates of satisfaction and improvement in functioning. Currently available data are extremely limited; however, they do suggest that, when in doubt, more aggressive debridement of diseased tissue combined with split-thickness skin grafting may provide superior outcomes. Split-thickness skin grafts are associated with excellent rates of successful graft take, even in cases of severe preoperative pathology and patient comorbidity. Although these grafts come at the cost of some increased surgical morbidity, they are associated with low rates of major complications. Morbidity can be further significantly decreased by harvesting the graft from the excised escutcheon itself, a technique that we present here. CONCLUSION: Surgical correction of adult buried penis is safe and effective; however, future work is required to further optimize outcomes and reduce surgical morbidity. Strother MC, Skokan AJ, Sterling ME, et al. Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting. J Sex Med 2018;15:1198-1204.

Advances and Challenges in Transitional Urology: Caring for Adolescents and Young Adults with Lifelong Complex Genitourinary Conditions.

PURPOSE OF REVIEW: As long-term survival with complex congenital and pediatric diseases has improved, more patients with congenital genitourinary conditions are living into adulthood. These patients can continue to face lifelong issues related to their conditions, including urinary incontinence, recurrent urinary tract infections, chronic kidney disease, and difficulties with sexual health and function. RECENT FINDINGS: The practice of transitional urology continues to grow nationwide and abroad, and it will be important to develop evidence-based practices for coordinated transition of these patients into the adult health care setting. This review describes the broader attention to transitions of care in medicine and specifically evaluates spina bifida as a model disease system for implementation of transitional practices in urology.

Tissue Preservation Techniques at the Time of Urethroplasty for Urethral Stricture Disease.

Reconstructive surgery for urethral stricture disease seeks to re-establish long-lasting urethral patency while minimizing associated adverse effects. In recent years, genitourinary reconstructive surgeons have developed and refined a number of techniques that seek to decrease the impact of urethroplasty on local tissues including blood supply and innervation. This review presents an outline of recent advances in urethral reconstructive techniques that seek to minimize surgical impact, including tissue preservation, tissue engineering, and minimally invasive approaches and reviews the current state of the literature related to these techniques.