Airway Involvement and Intervention in Non-ACE-Inhibitor-Induced Angioedema.

OBJECTIVES: Characterize the presentation of patients with non-angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema and determine risk factors associated with patient disposition and possible need for airway intervention. METHODS: The medical records of adult patients in the Emergency Department (ED) and diagnosed with non-ACEI-induced angioedema over 4.5 years were included. Demographics, vital signs, etiology, timeline, presenting symptoms, physical exam including flexible laryngoscopy, medical management, and disposition were examined. Statistical analyses were conducted using SPSS V 23.0 software calculating and comparing means, standard deviations, medians, and correlation of categorical and ordinate variables. RESULTS: A total of 181 patients with non-ACEI-induced angioedema were evaluated with flexible laryngoscopy by otolaryngology. Notably, 11 patients (6.1%) required airway intervention and were successfully intubated. Statistically significant factors (p ≤ 0.05) associated with airway intervention included the diastolic blood pressure (DBP) and mean arterial pressure (MAP) (p = 0.006 and 0.01 respectively), symptoms of dysphonia (p = 0.018), the presence of oropharyngeal, supraglottic, and hypopharyngeal edema (p ≤ 0.001 for each site), and the number of edematous anatomic subsites documented on physical exam (p < 0.001). Other patient demographics, prior history of angioedema, heart rate, systolic blood pressure, symptom onset, number of symptoms at presentation, and medication administered in the ED did not correlate with airway intervention. CONCLUSION: Dysphonia, DBP, MAP, anatomic location of edema and edema in multiple sites are associated with airway intervention and a higher level of care in non-ACEI-induced angioedema and can be useful in risk assessment in patient management. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:2282-2287, 2024.

Systematic review and meta-analysis to study the outcomes of proactive versus delayed management in children with a congenital neurogenic bladder.

PURPOSE: To review the urological outcomes of proactive versus delayed management of children with a neurogenic bladder (NB). METHODS: We performed a literature search on EMBASE, MEDLINE, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials between January 1, 2000 to August 21, 2023 for studies investigating the management of spina bifida-associated NB in pediatric patients (0-18 years of age). Proactive management was defined as use of clean intermittent catheterization, and/or anticholinergics at presentation, or based on initial high-risk urodynamic findings by 1 year of age. Delayed management was defined as beginning management after 1 year of age or no intervention. Outcomes included incidence or diagnosis of secondary vesicoureteral reflux (VUR), urinary tract infection (UTI), and renal deterioration, which included renal scarring, loss of differential renal function on a nuclear scan, or a decrease in renal function defined by glomerular filtration rate or serum creatinine estimation. Forest plots were synthesized using the Inverse Variance method with random-effect model. The Risk of Bias was assessed using the ROBINS-I tool. RESULTS: We included 8 observational studies on 652 pediatric patients with spina bifida-associated NB (mean follow-up - 7 years). Proactive management following initial assessment was associated with significantly lower risks of secondary VUR (OR 0.37 [0.19, 0.74], p = 0.004), non-febrile UTI (OR 0.35 [0.19, 0.62], p = 0.0004), and renal deterioration (OR 0.31 [0.20, 0.47], p < 0.00001). DISCUSSION: Delayed management of NB potentially has 3 times higher risks of secondary VUR, non-febrile UTI, and renal deterioration. However, the evidence is limited by the high risk of bias due to lack of randomization and standardized reporting in observational studies. CONCLUSION: While further well-defined prospective studies with long-term follow-up should be conducted to confirm this finding, this study supports the EAU/ESPU recommendations for early intervention in children with NB.

Systematic Analysis of Metabolic Bottlenecks in the Methylerythritol 4-Phosphate (MEP) Pathway of Zymomonas mobilis.

Zymomonas mobilis is an industrially relevant aerotolerant anaerobic bacterium that can convert up to 96% of consumed glucose to ethanol. This highly catabolic metabolism could be leveraged to produce isoprenoid-based bioproducts via the methylerythritol 4-phosphate (MEP) pathway, but we currently have limited knowledge concerning the metabolic constraints of this pathway in Z. mobilis. Here, we performed an initial investigation of the metabolic bottlenecks within the MEP pathway of Z. mobilis using enzyme overexpression strains and quantitative metabolomics. Our analysis revealed that 1-deoxy-d-xylulose 5-phosphate synthase (DXS) represents the first enzymatic bottleneck in the Z. mobilis MEP pathway. DXS overexpression triggered large increases in the intracellular levels of the first five MEP pathway intermediates, of which the buildup in 2-C-methyl-d-erythritol 2,4-cyclodiphosphate (MEcDP) was the most substantial. The combined overexpression of DXS, 4-hydroxy-3-methylbut-2-enyl diphosphate (HMBDP) synthase (IspG), and HMBDP reductase (IspH) mitigated the bottleneck at MEcDP and mobilized carbon to downstream MEP pathway intermediates, indicating that IspG and IspH activity become the primary pathway constraints during DXS overexpression. Finally, we overexpressed DXS with other native MEP enzymes and a heterologous isoprene synthase and showed that isoprene can be used as a carbon sink in the Z. mobilis MEP pathway. By revealing key bottlenecks within the MEP pathway of Z. mobilis, this study will aid future engineering efforts aimed at developing this bacterium for industrial isoprenoid production. IMPORTANCE Engineered microorganisms have the potential to convert renewable substrates into biofuels and valuable bioproducts, which offers an environmentally sustainable alternative to fossil-fuel-derived products. Isoprenoids are a diverse class of biologically derived compounds that have commercial applications as various commodity chemicals, including biofuels and biofuel precursor molecules. Thus, isoprenoids represent a desirable target for large-scale microbial generation. However, our ability to engineer microbes for the industrial production of isoprenoid-derived bioproducts is limited by an incomplete understanding of the bottlenecks in the biosynthetic pathway responsible for isoprenoid precursor generation. In this study, we combined genetic engineering with quantitative analyses of metabolism to examine the capabilities and constraints of the isoprenoid biosynthetic pathway in the industrially relevant microbe Zymomonas mobilis. Our integrated and systematic approach identified multiple enzymes whose overexpression in Z. mobilis results in an increased production of isoprenoid precursor molecules and mitigation of metabolic bottlenecks.

A cumulative sum (CUSUM) analysis studying operative times and complications for a surgeon transitioning from laparoscopic to robot-assisted pediatric pyeloplasty: Defining proficiency and competency.

INTRODUCTION: The transition from laparoscopic to robot-assisted procedures leads to potential increase in operative times and health care costs. Cumulative sum (CUSUM) analysis can objectively study the learning curve to detect significant changes in operative timing and monitor complication rates. OBJECTIVE: The objective of this study is to investigate the total and step-specific times for pediatric robot-assisted pyeloplasty (RAP) to investigate the learning curve of a single surgeon transitioning from laparoscopic to RAP. STUDY DESIGN: This prospective cohort study included 50 consecutive RAP procedures performed since the inception of our robotic program from June 2013 to January 2019. The CUSUM of RAP total operative time (OT) was calculated to determine the breakpoints between learning phases using piecewise linear regression. Cumulative-observed-minus-expected failure chart with 80% and 95% reassurance boundary lines was constructed using 5% acceptable and 10% unacceptable complication rates. Step-specific operative times were prospectively recorded by an independent observer for port placement, dissection and hitch stitch placement, pelvis dismemberment and spatulation, suturing and port removal. RESULTS: Piecewise linear regression for OT identified breakpoints at case 13 and 29 suggesting transition at these points between Learning to Proficiency, and Proficiency to Competency. The overall mean OT was 142.2 ± 46.0 min. There was a significant difference in the mean OT between Learning (203.9 ± 35.3 min, the initial 13 cases), Proficiency (159.2 ± 18.6 min, the middle 16 cases), and Competency (126.6 ± 19.7 min, the last 21 cases) phases (p < 0.001). The complication rate for RAP stabilized around the acceptable level of 5% up to case 41 before finalizing at 8% overall. The step-specific analysis suggested that suturing entered the Competency phase at case 27, with a 50% decrease in suturing time from Learning to Proficiency and Competency. DISCUSSION: Our study suggests that by case 30 a surgeon transitioning to RAP can achieve a significant decrease in OT. Complication rates remained within acceptable limits throughout, indicating that RAP can be safely adopted, even in low volume RAP centres. Suturing competency seems to be a significant advantage of the robotic platform as suggested by early significant decrease in suturing times noted between the Learning and Proficiency phases. CONCLUSION: Future studies can confirm these findings and establish reference operative times to aid surgeons and trainees transitioning from laparoscopic pyeloplasty to RAP. Moreover, total OT decreases significantly and relatively soon after transition to RAP.

Priapism or Prolonged Erection: Is 4 - 6 Hours of Cavernous Ischemia the Time Point of Irreversible Tissue Injury?

INTRODUCTION: Ischemic priapism remains a significant cause of morbidity among men. To date, the precise time when penile ischemia results in permanent, non-reversible cavernosal smooth muscle injury, compromising subsequent erectile integrity, remains ill-defined. OBJECTIVES: To review the medical literature pertaining to ischemic priapism, focusing on factors that predict the exact timeline of irreversible cavernous tissue injury. METHODS: A comprehensive literature search was performed. Our search included both publications on animal models and retrospective clinical series through January 2022. Articles were eligible for inclusion if they contained original data regarding nonreversible tissue injury on histology and/or provided a timeline of erectile function loss or preservation and had full text available in English. RESULTS: Innovative studies in the 1990s using invitro models with strips of rabbit, rat, canine and monkey corpus cavernosal tissue demonstrated that anoxia eliminated spontaneous contractile activity and reduced tissue responsiveness to electrical field stimulation or pharmacological agents. The same models demonstrated that the inhibitory effects of field stimulated relaxation, were mediated by nitric oxide. Subsequent studies using similar models demonstrated that exposure of corpus cavernosum smooth muscle to an acidotic environment impairs its ability to contract. A pH of 6.9 was chosen for these experiments based on a case series of men with priapism, in whom a mean pH of 6.9 was measured in corporal blood after 4-6 hours of priapism. Invivo animal studies demonstrated that after erection periods of 6-8 hours, microscopy shows sporadic endothelial defects but otherwise normal cavernous smooth muscle. In these studies, greater durations of ischemic priapism were shown to result in more pronounced ultrastructural changes and presumably irreversibility. In studies involving human corporal tissues, samples were obtained from men who had experienced priapism for at least 12 hours. Overall, erectile function outcome data is deficient in priapism reporting, especially within treatment windows less than 6 hours. Some reports on ischemic priapism have documented good erectile function outcomes with reversal by 12 hours. CONCLUSION: Based on our extensive review of animal models and clinical reports, we found that many clinical papers rely on the same small set of animal studies to suggest the time point of irreversible ischemic damage at 4-6 hours. Our review suggests an equal number of retrospective clinical studies demonstrate that ischemic priapism reversed within 6-12 hours may preserve erectile function in many patients. Dekalo S, Stern N, Broderick GA, et al. Priapism or Prolonged Erection: Is 4 - 6 Hours of Cavernous Ischemia the Time Point of Irreversible Tissue Injury? Sex Med Rev 2022;10:660-668.

Portable Endoscopic Simulator for Urologic Training: A Face/Content and Construct Validity Study.

Mastering a surgical skill requires experience and repetition, yet opportunities for surgical trainees to gain real experience are variable and limited by case load. Surgical simulators have emerged in an attempt to overcome these limitations. However, the few currently available skills simulators for flexible endoscopy are costly, have limited accessibility and versatility, lack portability, and require dedicated time for practice. The use of a portable skills simulator to teach flexible endoscopy may provide a feasible alternative. This study introduces a novel, low-cost, portable, endoscopic simulation system for training basic endoscopic skills. Using custom software, the simulator presents a virtual environment featuring 3D models of anatomy, endoscopes, and endoscopic tools. The virtual endoscope and its tools are directly controlled in the simulation by motion input from a custom-manufactured portable endoscopic controller that communicates data via a Bluetooth interface. This two-part study presents proof of concept and initial pilot data examining the face/content validity and preliminary construct validity of the portable endoscopic simulator. In part 1, experts (n = 2) and novices (n = 6) provided ratings of fidelity and utility as a training tool. In part 2, experts (n = 4) and novices (n = 4) completed 10 simulated sequential basic endoscopic tasks, and time to completion was assessed. Findings indicate that the simulator has good utility as a training tool, but some features require modification to be more realistic. Furthermore, both novices and experts improved on the task with repeated measurements (p < 0.001), but there were no significant differences between experts and novices in time to completion. Although more robust validation is required, this simulator appears promising as a feasible and cost-effective tool for providing simulation training on basic endoscopic skills.

Priapism or Prolonged Erection: Is 4 - 6 Hours of Cavernous Ischemia the Time Point of Irreversible Tissue Injury?

INTRODUCTION: Ischemic priapism remains a significant cause of morbidity among men. To date, the precise time when penile ischemia results in permanent, non-reversible cavernosal smooth muscle injury, compromising subsequent erectile integrity, remains ill-defined. OBJECTIVES: To review the medical literature pertaining to ischemic priapism, focusing on factors that predict the exact timeline of irreversible cavernous tissue injury. METHODS: A comprehensive literature search was performed. Our search included both publications on animal models and retrospective clinical series through January 2022. Articles were eligible for inclusion if they contained original data regarding nonreversible tissue injury on histology and/or provided a timeline of erectile function loss or preservation and had full text available in English. RESULTS: Innovative studies in the 1990s using invitro models with strips of rabbit, rat, canine and monkey corpus cavernosal tissue demonstrated that anoxia eliminated spontaneous contractile activity and reduced tissue responsiveness to electrical field stimulation or pharmacological agents. The same models demonstrated that the inhibitory effects of field stimulated relaxation, were mediated by nitric oxide. Subsequent studies using similar models demonstrated that exposure of corpus cavernosum smooth muscle to an acidotic environment impairs its ability to contract. A pH of 6.9 was chosen for these experiments based on a case series of men with priapism, in whom a mean pH of 6.9 was measured in corporal blood after 4-6 hours of priapism. Invivo animal studies demonstrated that after erection periods of 6-8 hours, microscopy shows sporadic endothelial defects but otherwise normal cavernous smooth muscle. In these studies, greater durations of ischemic priapism were shown to result in more pronounced ultrastructural changes and presumably irreversibility. In studies involving human corporal tissues, samples were obtained from men who had experienced priapism for at least 12 hours. Overall, erectile function outcome data is deficient in priapism reporting, especially within treatment windows less than 6 hours. Some reports on ischemic priapism have documented good erectile function outcomes with reversal by 12 hours. CONCLUSION: Based on our extensive review of animal models and clinical reports, we found that many clinical papers rely on the same small set of animal studies to suggest the time point of irreversible ischemic damage at 4-6 hours. Our review suggests an equal number of retrospective clinical studies demonstrate that ischemic priapism reversed within 6-12 hours may preserve erectile function in many patients.

Role of Pectoralis Major Myocutaneous Flap in Laryngectomy Surgery: Single Surgeon Experience.

Objective To analyze the effectiveness of the pectoralis major myocutaneous (PMMC) flap in preventing pharyngocutaneous fistula (PCF) formation for salvage total laryngectomy patients. Study design Retrospective chart review of all post-surgical laryngectomy patients for a single surgeon. Methods Inclusion criteria were adult patients 18 years and older who were diagnosed with laryngeal cancer and treated with a salvage total laryngectomy. Exclusion criteria were any laryngectomy patient treated without the PMMC flap or those with incomplete medical records. Results A total of 31 patient charts were identified, and 16 remained after exclusion criteria. The patient age range was 42-71 years (mean = 58.19; SD = 8.093). Greater than 85% of patients had T3 and T4 laryngeal cancers. Without PCF group were 13 patients and with PCF group were only three patients. The mean hospital days in without PCF group were 9.54 and in with PCF group were 16.33. Conclusion In this single surgeon's experience, PCF was prevented by using the PMMC flap in salvage total laryngectomy patients.

Management of Patients With Normal Physical Exams and Ultrasound Evidence of Isolated Septal and Punctate Penile Scarring.

INTRODUCTION: Atypical penile tunical lesions including isolated septal (ISS) and punctate scarring (PS) are an under recognized and difficult to treat subset of Peyronie's disease (PD) that often present with normal physical exams. Current guidelines provide little direction in the treatment of these men. AIM: To review the results of our treatment approach in men with ISS and PS. METHODS: Data from all men undergoing duplex ultrasonography for either Peyronie's disease and/or erectile dysfunction over a 3-year period were reviewed. All men with ISS or PS and normal physical exams were included. First- and second-line treatment preferences and satisfaction with treatment in men with ISS and PS were retrospectively reviewed. Logistic regression was used to investigate associations between scar features and treatment preference MAIN OUTCOME MEASURES: Treatment preference patterns, treatment satisfaction. RESULTS: A total of 217 men with ISS and 197 men with PS were identified. Of these, 71 ISS and 86 PS patients had normal physical exams. Majority of men in both ISS (70.4%) and PS (81.4%) cohorts initially opted for non-invasive management through either observation, oral therapy, or traction therapy. After initial management 84.5% of ISS and 93% of PS patients were satisfied with their results. A significant trend toward inflatable prostheses as second line therapy was seen in men with PS. CONCLUSIONS: There is a mounting need for clinical guidance in order to best manage men with atypical PD in the absence of societal guidelines and high-quality studies. This series provides guidance to clinicians on the management of these men, suggesting that conservative therapy and education may be sufficient. A standardized approach of increasing invasiveness showed reasonable rates of satisfaction with minimally invasive therapies playing a prominent role. Stern N, Punjani N, Brock G, Management of Patients With Normal Physical Exams and Ultrasound Evidence of Isolated Septal and Punctate Penile Scarring. Sex Med 2021;9:100346.

Instituting robotic pediatric urologic surgery in the Canadian healthcare system: Evaluating the feasibility and outcomes of robot-assisted pyeloplasty and ureteric reimplantation.

INTRODUCTION: Robotic pediatric urologic surgery has gained wide-spread adoption over the last decade. This article describes our experience in instituting the first pediatric urologic robotic surgery program in Canada. We evaluated the feasibility and safety of instituting pediatric robot-assisted urologic surgery and report our early outcomes for robot-assisted pyeloplasty (RAP) and ureteric reimplantation (RUR). METHODS: We prospectively evaluated all patients undergoing RAP and RUR by a single surgeon from June 2013 to March 2019. Demographic and clinical data were prospectively collected and included sex, age, and preoperative grade of hydronephrosis or reflux. Descriptive statistics were performed, and comparisons were made using Student's t-tests where appropriate. Success was defined as resolution or significant improvement of hydronephrosis following RAP and absence of recurrent urinary tract infection (UTI) and/or persistent vesicoureteric reflux (VUR) following RUR. Complications were described using the Clavien-Dindo system. RESULTS: A total of 52 RAPs and 24 RURs were performed with a minimum of six months followup. Forty-five RAP patients met criteria for success, while diagnostic imaging of success in the form of MAG-3 Lasix renograms was documented in the remaining seven for an overall success of 100%. Sixteen RUR patients met criteria for success and seven showed resolution of VUR on imaging following their first UTI, for an overall success rate of 96%. Operative times progressively improved from 204±35 minutes to 121±15 minutes in the RAP group and from 224±52 to 132±39 minutes in the RUR group. In the RAP cohort, one Clavien grade II and four Clavien grade III complications were noted, while three Clavien grade III complications were noted in the RUR cohort. CONCLUSIONS: Despite limited case volumes, robotic pediatric urologic surgery can be integrated into the Canadian healthcare system with success rates comparable to reported literature. However, compared to open surgery, RAP, and especially RUR, warrant further study to ensure lack of significant complications noted in our study.

Development, implementation, and evaluation of a competency-based didactic and simulation-focused boot camp for incoming urology residents: Report of the first three years.

INTRODUCTION: The Royal College of Physicians and Surgeons of Canada's Competence by Design (CBD) initiative presents curricula challenges to ensure residents gain proficiency while progressing through training. To prepare first-year urology residents (R1s), we developed, implemented, and evaluated a didactic and simulation-focused boot camp to implement the CBD curriculum. We report our experiences and findings of the first three years. METHODS: Urology residents from two Canadian universities participated in the two-day boot camp at the beginning of residency. Eleven didactic and six simulation sessions allowed for instruction and deliberate practice with feedback. Pre-and post-course multiple-choice questionnaires (MCQs) and an objective structured clinical exam (OSCE) evaluated knowledge and skills uptake. For initial program evaluation, three R2s served as historical controls in year 1. RESULTS: Nineteen residents completed boot camp. The mean age was 26.4 (±2.8) and 13 were male. Participants markedly improved on the pre- and post-MCQs (year 1: 62% and 91%; year 2: 55% and 89%; year 3: 58% and 86%, respectively). Participants scored marginally higher than the controls on four of the six OSCE stations. OSCE scores remained >88% over the three cohorts. All participants reported higher confidence levels post-boot camp and felt it was excellent preparation for residency. CONCLUSIONS: During its first three years, our urology boot camp has demonstrated high feasibility and utility. Knowledge and technical skills uptake were established via MCQ and OSCE results, with participants' scores near or above those of R2 controls. This boot camp will remain in our CBD curriculum and can provide a framework for other urology residency programs.

Immediate Postoperative Complications in Adult Tracheostomy.

Objective Tracheostomy is one of the oldest operations for the management of airway obstruction. With time, indications expanded to prolonged mechanical ventilation, and currently, the majority of tracheostomies are done for this reason. There are several techniques used in a tracheostomy procedure, depending on surgeon preference. Immediate complications such as bleeding, pneumothorax, pneumomediastinum, airway fire, and posterior tracheal wall perforation with esophageal injury are rare, although they do occur, and must be managed accordingly. This study aimed to assess differences in types and rates of immediate postoperative complications in patients undergoing tracheostomy when performed under general anesthesia and local anesthesia (awake tracheostomies) at a large academic institution. This is a continuing ongoing literature reporting tracheostomy adverse events. Methods A retrospective chart review was performed to identify patients who underwent tracheostomy placement between January 1, 2013 and December 31, 2019 at the Detroit Medical Center, USA. Postoperative complications such as bleeding, pneumothorax, pneumomediastinum, airway fire, and posterior tracheal perforation were collected along with gender, age, and revision tracheostomy status. IBM SPSS Statistics (IBM Inc., Armonk, USA) was used for statistical analysis with the statical significance defined as a p<0.05. Results A total of 1,469 patient charts were reviewed. Of these, 1,342 met the inclusion and exclusion criteria, of which, males were 57.2% (n=768), and females were 42.8% (n=574). The age range was 18 years to 96 years (mean=58.03; SD= 15.97), and BMI range was 12-83 (mean=28.77; SD=7.885). Multinomial logistic regression was performed to determine whether age, BMI, sex, and revision tracheostomies were represented across both general and awake tracheostomy groups proportionally to their numbers in the total sample. It showed non-significant value for age (χ2=0.776, p=0.378), BMI (χ2=0.004, p=0.947), but significant value for sex (χ2=4.645, p=0.031), revision tracheostomy (χ2=18.282, p<0.001), indicating that males and revision tracheostomies over-represented in awake tracheostomies. Next, Pearson correlation analysis was performed to determine any significant linear relationship between age, sex, and tracheostomy complications. It showed a significant positive correlation between age and tracheal stomal infection [r(1,340)=0.062, p=0.022]. An independent sample t-test showed a statistically significant difference between the mean pneumothorax and pneumomediastinum of general (n=1,277, mean=0.01, SD=0.088) and awake tracheostomies (n=65, mean=0.08, SD=0.269, t=2.069, p=0.043). Pneumothorax pneumomediastinum complications between the general tracheostomy and awake tracheostomy odds ratio (OR)-6.22, indicates the chance of pneumothorax /pneumomediastinum complication is 6.22 times more in awake tracheostomy than general tracheostomy. Based on the above statistical analysis, we rejected the null hypothesis. Conclusions Tracheostomy is the procedure of choice to relieve the upper airway obstruction and treat patients requiring prolonged mechanical ventilation. A slightly higher number of Immediate postoperative complications in awake tracheostomy were noticed in patients with more surgically challenging revision tracheostomies.

Combined Pharyngeal Laceration and Laryngeal Fracture Secondary to Dog Bite: A Case Report.

Dog bites are the most common animal bites, typically occurring in the head and neck region or extremities. The majority of dog bite-related injuries are superficial and require minimal medical intervention. Less commonly, dog bite injuries can be very serious when involving the airway, major blood vessels, or extensive tissue loss. To this day, there are very few case reports in the medical literature that describe severe dog bites and outline their management. We present a case of successfully treating an extensive pharyngeal laceration with a laryngeal cartilage fracture produced by an unvaccinated dog bite.

Salvage open radical prostatectomy for recurrent prostate cancer following MRI-guided transurethral ultrasound ablation (TULSA) of the prostate: feasibility and efficacy.

Introduction: MRI-guided transurethral ultrasound ablation (TULSA) is a novel modality for minimally invasive ablation in patients with localised prostate cancer (PCa). A multi-national Phase 1 (30 patients) and subsequent Phase 2 (115 patients) study showed TULSA to be feasible, safe and well tolerated. However, technical viability and safety of salvage prostatectomy for those who failed TULSA is unclear. Herein, we report the feasibility and morbidity of salvage radical prostatectomy (sRP) post-TULSA.Methods: Four patients with biopsy-proven residual cancer following TULSA underwent open retropubic sRP within 39 months of TULSA. Peri-and post-operative morbidity were reported. Detailed histopathologic assessment is reported.Results: Median follow-up was 43 months after sRP. Mean operating times, blood loss, and length of stay were 210 min, 866 ml, and 3.5 days, respectively. Intraoperative finding of some fibrotic reaction of endopelvic and Denonvilliers fascia was characteristic. There were no perioperative complications. Whole-mount pathology sections showed one pT2b and three pT3a, suggesting under-staging pre-TULSA. Location of disease was compatible with persistent cancer mostly in the untreated peripheral safety region. One man received an artificial urinary sphincter. All men experienced erectile dysfunction responsive to treatment. Two patients with positive surgical margins had PSA progression requiring salvage radiation, with one requiring long-term androgen deprivation therapy.Conclusions: RP is a viable and safe salvage option if TULSA fails. Technical difficulty and perioperative morbidity were negligible and attributable to minimal peri-prostatic reaction from TULSA.

Erectile Dysfunction: A Primer for in Office Management.

Introduction: Optimizing erectile dysfunction (ED) remains a clinically significant endeavor as insufficient outcomes from oral, injectable and even surgical approaches to treatment remain less than ideal. In this report, we integrate evolving knowledge and provide an algorithmic approach for the clinician to fine-tune management. Methods: We performed a PubMed and Medline search of Erectile Dysfunction treatment optimization, enhanced patient efficacy for ED, and why men fail ED treatment. All relevant papers for the past two decades were reviewed. Results: Establishing the goals and objectives of the patient and partner while providing detailed instructions for treatment can minimize failures and create an environment that allows treatment optimization. A thorough work-up may identify reversible or contributing causes. We identified several areas where treatment of ED could be optimized. These include; management of associated medical conditions, lifestyle improvements, PDE5 inhibitor prescription strategies, management of hypogonadism and the initiation of intracavernosal injection therapy (ICI). Conclusions: In our view, once a man presents for help to the clinician, use of the simple strategies identified in this review to optimize the tolerability, safety and effectiveness of the selected treatment should result in enhanced patient and partner satisfaction, with improved outcomes.

Characterization of Septal and Punctate Scarring in Peyronie's Disease.

OBJECTIVE: To characterize patients with isolated septal scarring (ISS) and punctate scarring (PS) in Peyronie's disease (PD) and to highlight the importance of duplex ultrasonography in the workup of patients with PD. MATERIALS AND METHODS: Data from all men undergoing duplex ultrasonography at London Health Sciences Center for PD or erectile dysfunction over a 3-year period were retrospectively reviewed. RESULTS: Our cohort included 722 patients with duplex ultrasound. ISS were demonstrated in 217 patients (30%), and PS in 197 (27%), with 72 (33%) and 148 (75%), respectively, having a normal physical examination. In both ISS and PS groups, more than half of patients also had associated erectile dysfunction. Predictive factors for ISS on multivariate analysis included trauma history (odds ratio [OR] 1.90, P = .04) and age (OR 1.02, P = .01). Patients with ISS were more likely to have dorsal curvature (OR 3.81, P <.01). CONCLUSION: Limited data exist in the literature regarding ISS and PS in PD. Our study illustrates that one-third of ISS and three-quarters of PS would have remained unrecognized without duplex ultrasonography, and it highlights its importance in the workup and subsequent management of these patients. Further studies are needed to better understand and to determine the at-risk patient and the associated clinical implications of ISS and PS, and to ultimately provide optimized and individualized management strategies.

Dual Role of Humic Substances As Electron Donor and Shuttle for Dissimilatory Iron Reduction.

Dissimilatory iron-reducing bacteria (DIRB) are known to use humic substances (HS) as electron shuttles for dissimilatory iron reduction (DIR) by transferring electrons to HS-quinone moieties, which in turn rapidly reduce Fe(III) oxides. However, the potential for HS to serve as a source of organic carbon (OC) that can donate electrons for DIR is unknown. We studied whether humic acids (HA) and humins (HM) recovered from peat soil by sodium pyrophosphate extraction could serve as both electron shuttles and electron donors for DIR by freshwater sediment microorganisms. Both HA and HM served as electron shuttles in cultures amended with glucose. However, only HA served as an electron donor for DIR. Metagenomes from HA-containing cultures had an overrepresentation of genes involved in polysaccharide and to a lesser extent aromatic compound degradation, suggesting complex OC metabolism. Genomic searches for the porin-cytochrome complex involved in DIR resulted in matches to Ignavibacterium/Melioribacter, DIRB capable of polymeric OC metabolism. These results indicate that such taxa may have played a role in both DIR and decomposition of complex OC. Our results suggest that decomposition of HS coupled to DIR and other anaerobic pathways could play an important role in soil and sediment OC metabolism.