Female urethroplasty with dorsal onlay buccal mucosal graft: a single institution experience.

PURPOSE: Female urethral stricture disease is frequently unrecognized or misdiagnosed, with controversy in the literature regarding the definition of strictures and approach to management. The purpose of this study is to report our institutional experience with female urethroplasty and add our experience to the growing body of research. METHODS: We performed a retrospective review of patients undergoing female urethroplasty with dorsal onlay BMG at the University of Colorado between March 2015 and December 2021 performed by two surgeons (BF and JO). The primary outcome measure was surgical success, defined as no stricture recurrence. The secondary outcome measure was the incidence of de novo urinary incontinence. RESULTS: 23 patients were included in our data analysis. The median duration of lower urinary tract symptoms prior to urethroplasty was 16 years. 87% had undergone previous dilations. At a median follow-up of 12.2 months (range 1-81 months), four patients required a secondary procedure for obstruction with an overall success rate of 83%. One patient developed de novo stress urinary incontinence and one patient developed urge urinary incontinence. Subgroup analysis was performed comparing the patients that developed stricture recurrence (N = 4) to those that did not (N = 19). Those with stricture recurrence had a longer duration of symptoms and more dilations prior to urethroplasty. CONCLUSION: Female urethroplasty with BMG is effective at treating female urethral stricture disease, with excellent outcomes at over a year of follow-up and minimal risk of stress incontinence postoperatively.

Nephrectomy After High-Grade Renal Trauma is Associated With Higher Mortality: Results From the Multi-Institutional Genitourinary Trauma Study (MiGUTS).

OBJECTIVE: To test the hypothesis that undergoing nephrectomy after high-grade renal trauma is associated with higher mortality rates. METHODS: We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS≤8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure <90 mmHg), and Glasgow Coma Scale (GCS). RESULTS: A total of 1181 high-grade renal trauma patients were included. Median age was 31 and trauma mechanism was blunt in 78%. Injuries were graded as III, IV, and V in 55%, 34%, and 11%, respectively. There were 96 (8%) mortalities and 129 (11%) nephrectomies. Mortality was higher in the nephrectomy group (21.7% vs 6.5%, P <.001). Those who died were older, had higher ISS, lower GCS, and higher rates of shock. After adjusting for patient and injury characteristics nephrectomy was still associated with higher risk of death (RR: 2.12, 95% CI: 1.26-2.55). CONCLUSION: Nephrectomy was associated with higher mortality in the acute trauma setting even when controlling for shock, overall injury severity, and head injury. These results may have implications in decision making in acute trauma management for patients not in extremis from renal hemorrhage.

External validation of a nomogram predicting risk of bleeding control interventions after high-grade renal trauma: The Multi-institutional Genito-Urinary Trauma Study.

BACKGROUND: Renal trauma grading has a limited ability to distinguish patients who will need intervention after high-grade renal trauma (HGRT). A nomogram incorporating both clinical and radiologic factors has been previously developed to predict bleeding control interventions after HGRT. We aimed to externally validate this nomogram using multicenter data from level 1 trauma centers. METHODS: We gathered data from seven level 1 trauma centers. Patients with available initial computed tomography (CT) scans were included. Each CT scan was reviewed by two radiologists blinded to the intervention data. Nomogram variables included trauma mechanism, hypotension/shock, concomitant injuries, vascular contrast extravasation (VCE), pararenal hematoma extension, and hematoma rim distance (HRD). Mixed-effect logistic regression was used to assess the associations between the predictors and bleeding intervention. The prediction accuracy of the nomogram was assessed using the area under the receiver operating characteristic curve and its 95% confidence interval (CI). RESULTS: Overall, 569 HGRT patients were included for external validation. Injury mechanism was blunt in 89%. Using initial CT scans, 14% had VCE and median HRD was 1.7 (0.9-2.6) cm. Overall, 12% underwent bleeding control interventions including 34 angioembolizations and 24 nephrectomies. In the multivariable analysis, presence of VCE was associated with a threefold increase in the odds of bleeding interventions (odds ratio, 3.06; 95% CI, 1.44-6.50). Every centimeter increase in HRD was associated with 66% increase in odds of bleeding interventions. External validation of the model provided excellent discrimination in predicting bleeding interventions with an area under the curve of 0.88 (95% CI, 0.84-0.92). CONCLUSION: Our results reinforce the importance of radiologic findings such as VCE and hematoma characteristics in predicting bleeding control interventions after renal trauma. The prediction accuracy of the proposed nomogram remains high using external data. These variables can help to better risk stratify high-grade renal injuries. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

The American Association for the Surgery of Trauma Renal Grading System-Should Segmental Kidney Infarction be Classified as a Grade IV Injury?

PURPOSE: In 2018 the American Association for the Surgery of Trauma revised renal injury grading. One change was inclusion of segmental kidney infarction under grade IV injuries. We aimed to assess how segmental kidney infarction will change the scope of grade IV injuries and compare bleeding control interventions in those with and without isolated segmental kidney infarction. METHODS: We used high grade renal trauma data from 7 level 1 trauma centers from 2013 to 2018 as part of the Multi-institutional Genito-Urinary Trauma Study. Initial computerized tomography scans were reviewed to regrade the injuries. Injuries were categorized as isolated segmental kidney infarction if segmental parenchymal infarction was the only reason for inclusion under grade IV injury. All other grade IV injuries (including combined injury patterns) were categorized as without isolated segmental kidney infarction. Bleeding interventions were compared between those with and without isolated segmental kidney infarction. RESULTS: From 550 patients with high grade renal trauma and available computerized tomography, 250 (45%) were grade IV according to the 2018 American Association for the Surgery of Trauma grading system. Of these, 121 (48%) had isolated segmental kidney infarction. The majority of patients with isolated segmental kidney infarction (88%) would have been assigned a lower grade using the original 1989 grading system. Rate of bleeding control interventions was lower in isolated segmental kidney infarction compared to other grade IV injuries (7% vs 21%, p=0.002). Downgrading all patients with isolated segmental kidney infarction to grade III did not change the grading system's associations with bleeding interventions. CONCLUSIONS: Approximately half of the 2018 American Association for the Surgery of Trauma grade IV injuries have isolated segmental kidney infarction. Including isolated segmental kidney infarction in grade IV injuries increases the heterogeneity of these injuries without increasing the grading system's ability to predict bleeding interventions. In future iterations of the American Association for the Surgery of Trauma renal trauma grading isolated segmental kidney infarction could be reclassified as grade III injury.

Identifying a Break in the Chain: An Analysis of Where Ureteroscope Damage Occurs in the Hospital Cycle.

OBJECTIVE: To assess the timing and variables associated with damage to flexible ureteroscopes (fURS) at our institution. Flexible ureteroscopy is an important modality in the treatment of benign and malignant conditions of the upper urinary tract. While the durability and versatility of fURS have improved considerably, repair costs remain high and time out of commission diminishes workflow. After purchasing new digital fURS, we studied how and when these instruments were being damaged. MATERIALS AND METHODS: Between September 1, 2017 and June 30, 2018, we performed leak testing on fURS both before and after use. We gathered intraoperative data related to the user, the surgical indication, and the associated tools used in all cases that employed a digital or fiber optic fURS. Categorical and continuous variables were analyzed to identify risk factors for intraoperative fURS damage. RESULTS: During the study period, complete data was gathered for 281 cases. Twenty-two fURS failed leak testing indicating an overall leak failure rate of 7.8%. Of these, 15 failed leak testing preoperatively indicating nonoperative damage occurring sometime during transport, handling, or sterile processing. The other 7 failures occurred during the procedures. No intraoperative variables were significantly associated with failures. CONCLUSION: Our institutional leak failure rate is 8% (22/281). The majority of these failures did not occur during surgery. Of the 7 that occurred during surgery, larger stone burden and higher wattage showed mild association. Ongoing evaluation will target minimizing fURS damage outside of the operating room.

Open Vesicocalicostomy for the Management of Transplant Ureteral Stricture.

A 59-year-old male developed a proximal stricture of his transplant ureter ten years after a living donor renal transplant. Endoscopic management was unsuccessful, and the patient was temporized with percutaneous nephrostomy tubes for months. Eventually, it became clear he would require surgical revision. Intraoperatively, complete fibrosis of the renal hilum, and intrarenal location of the pelvis precluded the planned pyelovesicostomy. A successful open vesicocalicostomy was performed, anastomosing a bladder flap to a lower pole calix. The patient remains recurrence free after 6 months of follow-up.

Alexithymia, emotional dysregulation, and recovery from alcoholism: therapeutic response to assessment of mood.

This study is a secondary analysis of a randomized controlled trial that tested the effects of a gratitude intervention on well-being in a sample of individuals in outpatient treatment for alcohol use disorder (AUD). Follow-up qualitative interviews unexpectedly revealed that participants found the Positive and Negative Affect Schedule (PANAS) to be helpful to their recovery in the ways that it asked them to identify and rate their emotions. Participant statements were purposively sampled and analyzed using grounded theory methods to produce a conceptual framework illustrating the process of mood identification and its sequelae. Evidence of existing alexithymia and emotional dysregulation, dominance of negative mood, and increasing ability to identify, accept, and regulate mood as part of recovery was found. Findings suggest that emotion regulation is a compelling topic for those in recovery from AUD, and may deserve a more prominent role in treatment.

Feasibility, Acceptability, and Impact of a Web-based Gratitude Exercise among Individuals in Outpatient Treatment for Alcohol Use Disorder.

This mixed-methods pilot study examined the feasibility, acceptability, and impact of a web-based gratitude exercise (the 'Three Good Things' exercise (TGT)) among 23 adults in outpatient treatment for alcohol use disorder (AUD). Participants were randomized to TGT or a placebo condition. The intervention was feasible with high rates of completion. Participants found TGT acceptable and welcomed the structure of daily emails; however, they found it difficult at times and discontinued TGT when the study ended. Participants associated TGT with gratitude, although there were no observed changes in grateful disposition over time. TGT had a significant effect on decreasing negative affect and increasing unactivated (e.g., feeling calm, at ease) positive affect, although there were no differences between groups at the 8 week follow up. Qualitative results converged on quantitative findings that TGT was convenient, feasible, and acceptable, and additionally suggested that TGT was beneficial for engendering positive cognitions and reinforcing recovery.