Characteristics of Participants in the American Urological Association Quality (AQUA) Registry and Early Impact of Participation on Quality of Care.

INTRODUCTION: The American Urological Association Quality Registry (AQUA) is an approved Qualified Clinical Data Repository that was created in 2013 to serve as a platform of quality assessment and improvement. Little is known about how such specialty specific platforms are adopted and used. We describe AQUA participants and report early impact on quality metrics. METHODS: We compared characteristics of practices and urologists participating in AQUA from 2014-2017 to those of the broader urologist workforce as reported in the 2017 American Urological Association Census, and examined pass rates of 4 measures reported to the Centers for Medicare and Medicaid Services after participation in AQUA. RESULTS: Participation increased during the first 4 years and included >125 practices and 1,148 urologists (9.2% of practicing U.S. urologists). Of AQUA participants 97.6% were in private practice, 1.9% were in academic practice and the rest (0.5%) were employed by private or public hospitals, compared to 59.1%, 25.5% and 11.2%, respectively, of urologists nationally. Among AQUA participants 95.9% lived in metropolitan areas, compared to 89.9% of urologists nationally. A total of 17 quality measures were reported to the Centers for Medicare and Medicaid Services through AQUA, of which 4 were urology specific and 13 were crosscutting. The average pass rate across the 4 select urological measures was 31.1% prior to AQUA dashboard access and 48.8% after access was gained, a 56.9% improvement (17.1% absolute difference). CONCLUSIONS: Early participants in AQUA were mostly community practitioners. Participation in AQUA seemed to facilitate quality score improvements, although whether this was due to improved measurement vs clinical care is unknown at this time.

Understanding the drivers of mortality in African savannah elephants.

Populations of African savannah elephants (Loxodonta africana) have been declining due to poaching, human-elephant conflict, and habitat loss. Understanding the causes of these declines could aid in stabilizing elephant populations. We used data from the Great Elephant Census, a 19-country aerial survey of savannah elephants conducted in 2014 and 2015, to examine effects of a suite of variables on elephant mortality. Independent variables included spatially explicit measures of natural processes and human presence as well as country-level socioeconomic measures. Our dependent variable was the carcass ratio, the ratio of dead elephants to live plus dead elephants, which is an index of recent elephant mortality. Carcass ratios are inversely proportional to population growth rates of elephants over the 4 yr prior to a survey. At the scale of survey strata (n = 275, median area = 1,222 km2 ), we found strong negative associations for carcass ratios with vegetation greenness at the time of the survey, overseas development aid to the country, and distance to the nearest international border. At the scale of ecosystems (n = 42, median area = 12,085 km2 ), carcass ratios increased with drought frequency and decreased with human density and overseas development aid to the country. Both stratum- and ecosystem-scale models explained well under one-half of the variance in carcass ratios. The differences in results between scales suggest that the drivers of mortality may be scale-specific and that the corresponding solutions may vary by scale as well.

Using species traits to predict detectability of animals on aerial surveys.

In animal surveys, detectability can vary widely across species. We hypothesized that detectability of animals should be a function of species traits such as mass, color, and mean herd size. We also hypothesized that models of detectability based on species traits can be used to predict detectability for new species not in the original data set, leading to substantial benefits for ecology and conservation. We tested these hypotheses with double-observer aerial surveys of 10 mammal species in northern Botswana. We combined all 10 species and modeled their detectability with species traits (mass, mean herd size, color) as predictors while controlling for observer effects, vegetation, and herd size. We found support for effects of mass and an interaction between herd size and mean herd size on detectability. This model accurately predicted the ratio of herds detected by two observers vs. one observer for 8 of 10 species. To test whether a model based on species traits could be applied to a new species, we serially deleted each species from the data set, fit a trait-based model to the remaining nine species, and used this model to predict detectability for the deleted species. The model was able to reproduce the species-trait model for seven species and accurately predicted the ratio of detections by one or two observers for a different set of seven species; the model was successful by both measures for five species. To our knowledge, this represents the first time that a mechanistic model for detectability of animals has been used to predict detectability for new species. Prediction failed for species with extreme values of traits, suggesting that predicting detectability is not possible near or beyond the boundaries of one's data set. The approach taken in this paper can potentially be used with a variety of taxa and may provide new opportunities to apply detectability corrections where they have not been possible before.

Bucket handle tears of the medial meniscus: meniscal intrusion rather than meniscal extrusion.

OBJECTIVE: To determine the frequency of medial meniscal extrusion (MME) versus "medial meniscal intrusion" in the setting of bucket handle tears. Images were evaluated for previously reported risk factors for MME, including: medial meniscal root tear, radial tear, degenerative joint disease and joint effusion. METHODS: Forty-one consecutive cases of bucket handle tear of the medial meniscus were reviewed by consensus by two musculoskeletal radiologists. Imaging was performed using a 1.5 GE Signa MR unit. Patient age, gender, medial meniscal root integrity, MME, medial meniscal intrusion, degenerative joint disease, effusion and anterior cruciate ligament (ACL) tear were recorded. RESULTS: Thirteen females and 27 males (age 12-62 years, median=30 years) were affected; one had bucket handle tear of each knee. Effusion was small in 13, moderate in 9 and large in 18. Degenerative joint disease was mild in three, moderate in two and severe in one. 26 ACL tears included three partial and three chronic. Medial meniscal root tear was complete in one case and partial thickness in two. None of the 40 cases with an intact or partially torn medial meniscal root demonstrated MME. MME of 3.1 mm was seen in the only full-thickness medial meniscal root tear, along with chronic ACL tear, moderate degenerative joint disease and large effusion. Medial meniscal intrusion of the central bucket handle fragment into the intercondylar notch was present in all 41 cases. CONCLUSION: Given an intact medial meniscal root in the setting of a "pure" bucket handle tear, there is no MME.

Bilateral testicular lymphoma treated with chemotherapy and radiation without orchiectomy: complete response relapsed at 52 months in the vitreous humor.

We report the first detailed case of testicular lymphoma managed with chemotherapy and radiation without orchiectomy. A 60-year-old man with Stage II extralymphatic bilateral testicular lymphoma refused orchiectomy, but underwent cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy and radiation. He remained disease free for 52 months, when a solitary central nervous system relapse to the vitreous humor was diagnosed. The optimal therapy for testicular lymphoma is unclear but often includes orchiectomy with adjuvant chemotherapy and radiation. Stage I testicular lymphoma can be cured by surgery alone; however, the relapse rates for all stages of testicular lymphoma are high despite systemic therapy. For Stage II disease and higher, chemotherapy/radiation is recommended; orchiectomy may not be mandatory.

Management of penile amputation injuries.

Penile amputation is an uncommon injury resulting from self-mutilation, felonious assault, or accidental trauma. Management requires resuscitation and stabilization of the patient with particular attention to underlying psychiatric illness. Amputated tissue can be preserved under hypothermic conditions in preparation for surgical replantation. Current replantation techniques rely on microsurgical approximation of the dorsal structures and cavernosal arteries with uniformly good results. Phallic replacement may be necessary when the amputated segment is lost. Microsurgical free forearm flap phalloplasty is the current mainstay of penile replacement surgery. Although urethral complications remain problematic, the results continue to be acceptable with regard to appearance and function. A unique subset of patients sustaining amputation injury is children. Both replantation and phallic construction have been successful in children and represent an alternative to gender reassignment.

Differential effects of sex hormones and phytoestrogens on peak and steady state contractions in isolated rabbit detrusor.

PURPOSE: Recent evidence suggests that sex steroids may produce rapid inhibition of voltage operated Ca2+ channels (VOCCs). Detrusor smooth muscle is highly dependent upon Ca2+ influx for receptor-activated contractions. Thus, we examined the relative effectiveness of a select group of sex steroids and dietary phytoestrogens to relax detrusor contracted with the muscarinic receptor agonist, bethanechol (BE) and the purinergic P2X receptor agonist, alpha,beta-methylene ATP (alpha,beta-MeATP). MATERIALS AND METHODS: Isolated strips of rabbit detrusor were secured to isometric force transducers in a tissue bath and length-adjusted until maximum contractions were achieved. Peak (P) contractile responses were recorded for alpha,beta-MeATP (P(ATP)) and BE (P(BE)) and steady-state (SS) responses were recorded for BE (SS(BE)) in the presence and absence of selected sex steroids and phytoestrogens (10 microM, unless indicated). RESULTS: The L-type VOCC inhibitor, nifedipine (1 to 10 microM), completely inhibited P(ATP) but reduced SS(BE) by approximately 50%, whereas the VOCC and non-VOCC inhibitor, SKF 96365, inhibited SS(BE) by approximately 95%, suggesting that P(ATP) was entirely dependent on L-type VOCCs, but (BE)-induced contractions depended also on activation of non-VOCCs. 17Beta-estradiol (estradiol) and progesterone inhibited P(ATP) by approximately 60% and 20%, respectively, and 32 microM estradiol and ethinyl estradiol inhibited SS(BE) by approximately 80 and 95%, respectively. Inhibition by estradiol was potentiated, rather than blocked, by the nuclear estrogen receptor antagonist, tamoxifen. Moreover, tamoxifen alone nearly completely relaxed SS(BE). The inactive metabolite of estradiol, 17alpha-estradiol, inhibited both P(ATP) and P(BE) by approximately 40%. Testosterone had no effect on P(ATP) and P(BE). The phytoestrogen and tyrosine kinase inhibitor, genistein, inhibited SS(BE) by 44%, whereas daidzein, a phytoestrogen without tyrosine kinase inhibitory activity, produced only a 7% inhibition. None of the phytoestrogens examined inhibited P(BE), whereas all inhibited P(ATP) by approximately 20 to 35%. A comparison of inhibition of (BE) and alpha,beta-MeATP-induced contractions by selected estrogen isomers showed some distinct differences. For example, estrone did not inhibit P(BE) or SS(BE), but inhibited P(ATP) by approximately 20%, whereas DES inhibited SS(BE) by nearly 90%, but P(ATP) by a lesser degree (approximately 70%). CONCLUSIONS: Our data support the hypothesis that 17beta-estradiol, ethinyl estradiol, DES, tamoxifen and genistein may relax detrusor contractions by inhibition of both VOCCs and non-VOCCs. Moreover, our data show that genistein, a dietary phytoestrogen with tyrosine kinase inhibitory activity, selectively reduced alpha,beta-MeATP-induced peak and BE-induced steady-state contractions, sparing the maximum response to BE. Lastly, the inactive isomer, 17alpha-estradiol, inhibited both BE- and alpha,beta-MeATP-induced contractions. These data suggest that certain dietary phytoestrogens (for example, genistein) or sex steroids, especially those with weak activity at the nuclear steroid site (for example, 17alpha-estradiol), or tamoxifen may prove therapeutically useful in treating overactive bladder caused by elevated muscarinic and purinergic receptor activation.

Conservative surgical therapy for penile and urethral carcinoma.

OBJECTIVES: Invasive penile and urethral tumors are traditionally treated with aggressive excision that requires involved organ and adjacent organ sacrifice. An alternative approach seeks to completely excise the tumor with adequate margins while preserving form and function of the organ. We present 6 patients who underwent such organ-sparing surgery. METHODS: Six selected cases (4 penile and 2 urethral) are presented with operative photographs and pertinent data. RESULTS: Three distal tumors of the penis were treated with excision limited to the glans with histopathologic findings of verrucous carcinoma, melanoma, and angiosarcoma. One patient with squamous cell carcinoma of the distal shaft refused partial penectomy and underwent a local wedge resection. A patient with locally advanced bulbourethral transitional cell carcinoma (TCC) refused cystourethrectomy and underwent an anterior urethrectomy and perineal urethrostomy. A 48-year-old woman with an adenocarcinoma contained in a very distal urethral diverticulum underwent simple diverticulectomy and excision of distal urethra. Postoperative voiding and sexual function were well preserved. Follow-up was 12 to 48 months. The patient with angiosarcoma died of lung metastases at 48 months with no local disease, and the patient with bulbourethral TCC developed pelvic disease at 12 months with no local recurrence and died of metastases at 25 months. CONCLUSIONS: Organ-sparing surgery is appropriate in selected patients on the basis of stage and location, high risk of distant failure, and patient disposition. Close follow-up is necessary. Comanagement with reconstructive and oncologic specialists optimizes results and outcomes.

[General principles in treatment of urethral strictures]. / Prinzipien der Behandlung von Harnröhrenstrikturen.

This manuscript outlines the important points in the evaluation and treatment of urethral stricture disease. The algorithms described within are not presented as strict guidelines but rather are intended to give a logical thought progression which incorporates the basic principles of urethral reconstruction. It is important to determine the therapeutic goal before applying these principles. There are basically two arms of consideration, the first is to attempt to cure the patient of urethral stricture disease and the second is to simply manage the patient's urethral stricture disease without intent of cure. Applying the current knowledge of anatomy with modern tissue transfer techniques will achieve a highly successful, single stage reconstruction in most patients. Although approaching urethral stricture disease with the intent to cure is preferred, management may not be unreasonable in certain cases. Some patients have entensive co-morbidities or may prefer a trial of conservative measures before definitive treatment is undertaken. If the goal established is urethral reconstruction, the gold standard is to perform a single stage procedure that is highly successful and durable. Excision of the urethral stricture with primary anastomosis (EPA) represents this gold standard. However, ist application is limited by stricture location or length. An accurate evaluation of the stricture location, length, and associated spongiofibrosis is mandatory in forming viable options for repair. By exploiting the advantages of differing techniques, the proper course of action can be chosen which generally will solve even the most complex problem in one stage. The reconstructive surgeon come to the operative suite armed with the full knowledge and understanding of the principals and techniques which will result in a favorable outcome. It is not uncommon for intra-operative findings to guide the decision for the best alternative for urethral reconstruction. We also offer some helpful hints regarding positioning, sutures, exposure, and retractors.

Proposal: trauma as the cause of the Peyronie's lesion.

PURPOSE: We define the cause of the occurrence of Peyronie's disease. MATERIALS AND METHODS: Clinical evaluation of a large number of patients with Peyronie's disease, while taking into account the pathological and biochemical findings of the penis in patients who have been treated by surgery, has led to an understanding of the relationship of the anatomical structure of the penis to its rigidity during erection, and how the effect of the stress imposed upon those structures during intercourse is modified by the loss of compliance resulting from aging of the collagen composing those structures. Peyronie's disease occurs most frequently in middle-aged men, less frequently in older men and infrequently in younger men who have more elastic tissues. During erection, when full tumescence has occurred and the elastic tissues of the penis have reached the limit of their compliance, the strands of the septum give vertical rigidity to the penis. Bending the erect penis out of column stresses the attachment of the septal strands to the tunica albuginea. RESULTS: Plaques of Peyronie's disease are found where the strands of the septum are attached in the dorsal or ventral aspect of the penis. The pathological scar in the tunica albuginea of the corpora cavernosa in Peyronie's disease is characterized by excessive collagen accumulation, fibrin deposition and disordered elastic fibers in the plaque. CONCLUSIONS: We suggest that Peyronie's disease results from repetitive microvascular injury, with fibrin deposition and trapping in the tissue space that is not adequately cleared during the normal remodeling and repair of the tear in the tunica. Fibroblast activation and proliferation, enhanced vessel permeability and generation of chemotactic factors for leukocytes are stimulated by fibrin deposited in the normal process of wound healing. However, in Peyronie's disease the lesion fails to resolve either due to an inability to clear the original stimulus or due to further deposition of fibrin subsequent to repeated trauma. Collagen is also trapped and pathological fibrosis ensues.

The role of colpocleisis with urethral lengthening in transsexual phalloplasty.

OBJECTIVE: Transsexual surgery is an unique area of rarely performed surgery. This study examines factors that have significance in the prevention of major morbidity in this unusual surgery. The role of the gynecologist in the psychologic, endocrine, and operative management is presented. STUDY DESIGN: Initial operations were complicated by fistulas at the urethra-to-phallus anastomosis site. After reviewing these complications, we modified our approach to include a two-stage procedure allowing for healing before microsurgery and sparing of the anterior vaginal wall during vaginal hysterectomy and colpocleisis. By sparing the anterior vaginal wall, we were able to better extend the urethra for later phallus attachment. RESULTS: Using the two-stage procedure at colpocleisis allowed a significant reduction in the fistula rate. (p = 0.0087) with the effective elimination-fistulas, the use of stiffeners during phalloplasty for better functional results is possible. CONCLUSION: Extending the urethra during colpocleisis allows for better healing and significantly decreased fistula formation. Proper blood supply for microvascular surgery and adequate tissue for the anastomosis site contribute to better results.

Repair of obliterative vesicourethral stricture after radical prostatectomy: a technique for preservation of continence.

We present the open surgical repair of complete obstruction of the bladder neck unresponsive to endoscopic management. By combining abdominal and perineal dissection, partial pubectomy, and omental wrapping, repeat anastomosis is possible without the need for bladder tubularization. Two patients have been repaired successfully. Although both men presented with indwelling suprapubic tubes and a defect of greater than 1.5 cm, they are now voiding normally at 18 and 7 months post-operatively without the need for pads, medication, or instrumentation. Complete obliteration of the bladder neck after radical prostatectomy can be functionally reconstructed. Postoperative continence will depend on the function of the membranous urethra. If incontinence occurs, this can be managed in a reconstructed open urethra.

Laser tissue welding in genitourinary reconstructive surgery: assessment of optimal suture materials.

OBJECTIVES: Laser tissue welding in genitourinary reconstructive surgery has been shown in animal models to decrease operative time, improve healing, and decrease postoperative fistula formation when compared with conventional suture controls. Although the absence of suture material is the ultimate goal, this has not been shown to be practical with current technology for larger repairs. Therefore, suture-assisted laser tissue welding will likely be performed. This study sought to determine the optimal suture to be used during laser welding. METHODS: The integrity of various organic and synthetic sutures exposed to laser irradiation were analyzed. Sutures studied included gut, clear Vicryl, clear polydioxanone suture (PDS), and violet PDS. Sutures were irradiated with a potassium titanyl phosphate (KTP)-532 laser or an 808-nm diode laser with and without the addition of a light-absorbing chromophore (fluorescein or indocyanine green, respectively). A remote temperature-sensing device obtained real-time surface temperatures during lasing. The average temperature, time, and total energy at break point were recorded. RESULTS: Overall, gut suture achieved significantly higher temperatures and withstood higher average energy delivery at break point with both the KTP-532 and the 808-nm diode lasers compared with all other groups (P < 0.05). Both chromophore-treated groups had higher average temperatures at break point combined with lower average energy. The break-point temperature for all groups other than gut occurred at 91 degrees C or less. The optimal temperature range for tissue welding appears to be between 60 degrees and 80 degrees C. CONCLUSIONS: Gut suture offers the greatest margin of error for KTP and 808-nm diode laser welding with or without the use of a chromophore.

Development and initial application of a real time thermal control system for laser tissue welding.

The ability to sense and control continuously surface temperatures of a tissue being exposed to laser radiation could standardize parameters and eliminate subjective interpretation of results during laser tissue repair. We describe the development and testing of a control system that enables the operator to maintain relatively specific tissue temperatures for the purpose of laser welding. After initial development, the infrared thermal control system combined with an argon laser was used to repair urethral defects in 45 adult male rats. Repairs were completed using various predetermined temperatures of 50, 60, 70, 80 or 90C. The integrity of each weld was quantitatively determined by measuring intraluminal bursting pressure immediately after repair. In all temperature groups bursting pressures were in excess of 85 mm. Hg. Those performed at 80C produced the strongest weld (analysis of variance p = 0.0001). However, welding temperatures above 70C sacrificed the integrity of the underlying urothelium producing obvious damage when viewed microscopically. We were able to demonstrate that temperature is an objective parameter of tissue welding that can be continuously assessed and controlled during the laser repair of tissue defects to produce effective, predictable welds.

Complex urethral reconstruction.

Modern tissue transfer techniques, often incorporating penile or scrotal skin islands based on a dartos fascia pedicle, have revolutionized urethral reconstruction. There are certain situations, however, that require a more creative and complex approach. The majority of these cases involve patients with panurethral stricture disease or those who have undergone multiple previous procedures for urethral stricture disease or hypospadias and their subsequent complications. In this article, the authors discuss the various aspects of these two conditions and outline several techniques for urethral reconstruction in these challenging patients.

Chromophore enhanced laser welding of canine ureters in vitro using a human protein solder: a preliminary step for laparoscopic tissue welding.

Laser welding of the genitourinary tract has the potential advantage of forming an immediate watertight seal. It may obviate the need for sutures, eliminate the inherent lithogenic reaction to suture, and potentially improve healing. In the current study we employed a KTP-532 laser in vitro to weld canine ureters. Ureters were transected over a stent and immediately repaired using the KTP-532 laser (power density 7.14 W/cm.2, spot size = 0.5 cm.) alone or in combination with different tissue solders. Solders consisted of 40% human albumin alone or with the addition of iron oxide or fluorescein as light absorbing dyes (chromophores). Following the repairs, intraluminal bursting strength and the total energy required to complete the repairs were measured. The KTP laser alone was not able to achieve a satisfactory repair. Successful ureteral repairs were achieved in all solder groups while maintaining ureteral continuity at supraphysiologic pressures.