Non-grafted Vaginal Depth Augmentation for Transgender Atresia, Our Experience and Survey of Related Procedures.

INTRODUCTION: Neovaginal atresia especially following male-to-female transgender vaginoplasty is a distressing concern. A pelvic space must be re-created. Traditionally, an epithelial or mucosal lining is employed to cover the space. However, in our series of 18 patients, a non-grafted approach has been equally efficacious, as previously described by others. AIM: To follow the outcome of male-to-female transsexuals undergoing secondary depth enhancement without use of graft or flap. METHODS: Patient selection included two operated on elsewhere, one of whom had a lower abdominal skin graft, and the remainder done here using an inverted penile skin flap supplemented by a scrotal graft extension as needed. The time lag from primary to revision surgery varied from 5 months to 23 years, average 3.7 years. The fascial plane of Denonvilliers was reopened and packed for 7 days to facilitate maintenance of a pelvic space. Patients are requested to perform serial self-dilations with a stent set indefinitely to maintain patency and procure additional depth. Immuno-histochemistry staining was performed to demonstrate estrogen receptor (ER) presence in male genital skin. Estrogen cream may be utilized to facilitate wound healing. Main outcome measures were post-operative depth results and Female Sexual Function Index (FSFI) scores. Several attempts were made to contact all patients for completion of a FSFI. Ten out of 18 responded. RESULTS: Following revision of the pelvic space, static depths increased two-fold on average, from 2.4 in. (6.2 cm) to 5.0 in. (12.7 cm). The FSFI domain scores (of desire, arousal, lubrication, orgasm, satisfaction, and pain) were all mid-range or above. Full scale FSFI scores (compilation score) averaged 23.4 (range limits 2-36). Histologic staining showed the presence of ER in genital skin of all genetic males tested regardless of estrogen usage and perceived gender. CONCLUSIONS: Given adequate development of the rectal-vesical space and preservation of that space with self-dilation, epithelialization will ensue providing sexual gratification for patient and partner (as per patient). LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The "Tri-Glide" Technique: A Case Report on a Novel Intraoperative Approach for Removal of Retained and Encrusted Ureteral Stents.

BACKGROUND: Retained ureteral stents can result in significant morbidity and can be surgically challenging to urologists. A multimodal approach is often necessary for removal, potentially including retrograde and antegrade procedures performed over multiple anesthetic sessions. We describe the novel "Tri-Glide" technique for treating retained stents, particularly those with stent shaft encrustation prohibiting safe removal. Case Presentation. Two patients with nephrolithiasis and retained, encrusted ureteral stents were managed with the "Tri-Glide" technique. Patient #1 was a 58-year-old man with a severely calcified ureteral stent, retained for 14 years. After undergoing simultaneous cystolitholapaxy and percutaneous nephrolithotomy to treat proximal and distal encrustations, the stent shaft remained trapped in the ureter due to heavy calcifications. Three hydrophilic guidewires were passed alongside the stent, allowing it to easily slide out of the ureter intact. Patient #2 was a 74-year-old man who after only 3-months of stent dwell time developed severe stent shaft encrustation preventing removal. After multiple maneuvers failed, the "Tri-Glide" technique was used to create a smooth track for stent to slide out intact with gentle traction. Both patients did well postoperatively with no complications. CONCLUSION: The "Tri-Glide" technique can aid in the management of complex encrusted stent extractions, especially when there is significant shaft encrustation.

The Single Wire Ureteral Access Sheath, Both Safe and Economical.

Introduction. Novel disposable products for ureteroscopy are often inherently more expensive than conventional ones. For example, the Cook Flexor© Parallel™ (Flexor) access sheath is designed for ease and efficiency of gaining upper tract access with a solitary wire. We analyze the cost combinations, efficiency, and safety of disposable products utilized for upper tract access, including the Flexor and standard ureteral access sheath. Methods. We performed a retrospective review from January 2014 to October 2014 of patients undergoing URS for nephrolithiasis, who were prestented for various reasons (e.g., infection). Common combinations most utilized at our institution include "Classic," "Flexor," and "Standard." Total costs per technique were calculated. Patient characteristics, operative parameters, and outcomes were compared among the groups. Results. The most commonly used technique involved a standard ureteral sheath and was the most expensive ($294). The second most utilized and least expensive combination involved the Flexor, saving up to $80 per case (27%). All access sheaths were placed successfully and without complications. There were no significant differences in operative time, blood loss, or complications. Conclusions. In prestented patients within this study, the Flexor combination was the most economical. Although the savings appear modest, long-term impact on costs can be substantial.

Reducing robotic prostatectomy costs by minimizing instrumentation.

INTRODUCTION AND OBJECTIVE: Since the introduction of robotic surgery for radical prostatectomy, the cost-benefit of this technology has been under scrutiny. While robotic surgery professes to offer multiple advantages, including reduced blood loss, reduced length of stay, and expedient recovery, the associated costs tend to be significantly higher, secondary to the fixed cost of the robot as well as the variable costs associated with instrumentation. This study provides a simple framework for the careful consideration of costs during the selection of equipment and materials. MATERIALS AND METHODS: Two experienced robotic surgeons at our institution as well as several at other institutions were queried about their preferred instrument usage for robot-assisted prostatectomy. Costs of instruments and materials were obtained and clustered by type and price. A minimal set of instruments was identified and compared against alternative instrumentation. A retrospective review of 125 patients who underwent robotically assisted laparoscopic prostatectomy for prostate cancer at our institution was performed to compare estimated blood loss (EBL), operative times, and intraoperative complications for both surgeons. Our surgeons now conceptualize instrument costs as proportional changes to the cost of the baseline minimal combination. RESULTS: Robotic costs at our institution were reduced by eliminating an energy source like the Ligasure or vessel sealer, exploiting instrument versatility, and utilizing inexpensive tools such as Hem-o-lok clips. Such modifications reduced surgeon 1's cost of instrumentation to ∼40% less compared with surgeon 2 and up to 32% less than instrumentation used by surgeons at other institutions. Surgeon 1's combination may not be optimal for all robotic surgeons; however, it establishes a minimally viable toolbox for our institution through a rudimentary cost analysis. A similar analysis may aid others in better conceptualizing long-term costs not as nominal, often unwieldy prices, but as percent changes in spending. With regard to intraoperative outcomes, the use of a minimally viable toolbox did not result in increased EBL, operative time, or intraoperative complications. CONCLUSION: Simple changes to surgeon preference and creative utilization of instruments can eliminate 40% of costs incurred on robotic instruments alone. Moreover, EBL, operative times, and intraoperative complications are not compromised as a result of cost reduction. Our process of identifying such improvements is straightforward and may be replicated by other robotic surgeons. Further prospective multicenter trials should be initiated to assess other methods of cost reduction.

Urology Patients and the Internet: Socioeconomic Status and Language Skills Significantly Impact Use.

INTRODUCTION: Patient Internet use and resources are likely multifactorial. We assess how socioeconomic factors and language skills affect Internet use by patients. METHODS: We prospectively surveyed 116 patients with a bilingual questionnaire before they underwent urological surgery from July to September 2013. We obtained institutional review board approval for this study. Patients were surveyed for demographic data, English abilities, Internet use, anxiety level and understanding of the surgery. RESULTS: Patients with low English abilities were significantly more likely to have lower incomes and education (p <0.05). In addition, patients with low English abilities were significantly more likely neither to have Internet access nor to have used it to research their surgery. On multivariate analysis those with low confidence in English were 2.8 times more likely not to have used the Internet to research their surgery when controlling for age. Increased age remained statistically associated with a lower likelihood of using the Internet even when controlling for all demographic data. Lastly, patients with low confidence in English were significantly less likely to report increased anxiety before surgery (OR 0.147) when controlling for all demographic data including ethnicity. CONCLUSIONS: In our community those patients with low confidence in their English abilities are less likely to have access to, and use, the Internet before undergoing surgery. Older patients also use the Internet less often. Urologists should be aware of this potential language and age gap. Those with low English skills should likely be provided with additional counseling.

Estudio de la maduración ósea por sexo y raza / Study of bone maturation by race and sex

La "edad ósea" es el indicador de madurez biológica que más comúnmente se ha utilizado, pues permite al pediatra un enfoque clínico de mayor precisión. En el presente trabajo, se evaluaron 5.000 radiografías de mano y muñeca izquierdas, tomadas del 10

de niños y adolescentes que fueron medidos en el Estudio Nacional de Crecimiento y Desarrollo Físico 1972-1974. Todas las radiografías fueron evaluadas por el método TWII. El estudio se efectuó por sexo y raza, desde el mes de nacido hasta los 19,9 años de edad. Se realizaron comparaciones intersexo e inter-raza a todas las edades. Se obtuvieron los patrones con las puntuaciones cubanas de la maduración ósea separadamente para cada sexo, pues las diferencias entre ambos sexos son estadísticamente significativas a todas las edades, no resultó lo mismo en la comparación inter-raza. Las niñas poseen un mayor ritmo de maduración ósea desde el nacimiento hasta la adultez en relación con los varones (AU)

Estado de nutrición y algunas características del ambiente familiar de niños de 2 a 9 años de edad / Nutritional status and some characteristics of familial environment of children aged 2-9 years

Se estudió la posible relación entre el crecimiento y desarrollo físico como indicador del estado de nutrición, y el nivel de escolaridad de los padres y el ingreso monetario per cápita de la familia como caracterizadores del ambiente familiar. Se analizaron los datos de 12 580 individuos entre 2,50 y 9,49 años de edad, tomados de la Investigación Nacional de Crecimiento y Desarrollo. El estado de nutrición fue clasificado según los valores de referencia nacionales de peso para la talla. Se encontró relación de las categorias inferiores del estado de nutrición con los niveles más bajos de ingreso monetario per cápita de la familia, así como con el nivel inferior de escolaridad de los padres

¿Cómo lograr una mayor aproximación de la distribución del peso corporal a la distribución normal? / How to achieve a closer approximation of body weight distribution to normal distribution

Se presentan los resultados de un estudio de 15 497 indiviuos entre 2,50 y 9,49 años de edad decimal, tomados de la investigación nacional de crecimiento y desarrollo. Como el peso es una variable continua y no sigue una distribuciòn normal, se realizaron 2 transformaciones logarítmicas, cuyos modelos se aplicaron mediante una regresión paso a paso a algunas variables independientes. Se evidenció que el modelo ln (peso - a) es el que ofrece una mejor aproximación a la distribuciòn normal

El peso del niño y su relación con el nivel de escolaridad de los padres y el ingreso monetario percápita de la familia / Child-weight and its relation to parents`s school education level and percapita family income

El peso es una dimensión tan lábil a los cambios del ambiete que puede servir como indicador, en cierto sentido, de algunos de los factores que caracterizan hasta cierto punto al modo de vida de la población, como son el nivel de escolaridad de los padres y el ingreso monetario percápita de la familia. Para tener una noción de la conducta de estas variables relacionadas entre sí, en este estudio se aplica el método de la regresión paso a paso, siempre conscientes de que quedará un porcentaje de variables que influyen y que no están controladas. Del análisis de los resultados se obtuvo que la variable independiente más relacionada con el peso es la talla del propio individuo para todas las edades estudiadas y en ambos sexos le sigue, de modo general, la escolaridad de la madre

El peso del niño y su relación con el nivel de escolaridad de los padres y el ingreso monetario percápita de la familia / Child-weight and its relation to parents`s school education level and percapita family income

El peso es una dimensión tan lábil a los cambios del ambiete que puede servir como indicador, en cierto sentido, de algunos de los factores que caracterizan hasta cierto punto al modo de vida de la población, como son el nivel de escolaridad de los padres y el ingreso monetario percápita de la familia. Para tener una noción de la conducta de estas variables relacionadas entre sí, en este estudio se aplica el método de la regresión paso a paso, siempre conscientes de que quedará un porcentaje de variables que influyen y que no están controladas. Del análisis de los resultados se obtuvo que la variable independiente más relacionada con el peso es la talla del propio individuo para todas las edades estudiadas y en ambos sexos le sigue, de modo general, la escolaridad de la madre

Estado de nutrición y algunas características del ambiente familiar de niños de 2 a 9 años de edad / Nutritional status and some characteristics of familial environment of children aged 2-9 years

Se estudió la posible relación entre el crecimiento y desarrollo físico como indicador del estado de nutrición, y el nivel de escolaridad de los padres y el ingreso monetario per cápita de la familia como caracterizadores del ambiente familiar. Se analizaron los datos de 12 580 individuos entre 2,50 y 9,49 años de edad, tomados de la Investigación Nacional de Crecimiento y Desarrollo. El estado de nutrición fue clasificado según los valores de referencia nacionales de peso para la talla. Se encontró relación de las categorias inferiores del estado de nutrición con los niveles más bajos de ingreso monetario per cápita de la familia, así como con el nivel inferior de escolaridad de los padres

¿Cómo lograr una mayor aproximación de la distribución del peso corporal a la distribución normal? / How to achieve a closer approximation of body weight distribution to normal distribution

Se presentan los resultados de un estudio de 15 497 indiviuos entre 2,50 y 9,49 años de edad decimal, tomados de la investigación nacional de crecimiento y desarrollo. Como el peso es una variable continua y no sigue una distribuciòn normal, se realizaron 2 transformaciones logarítmicas, cuyos modelos se aplicaron mediante una regresión paso a paso a algunas variables independientes. Se evidenció que el modelo ln (peso - a) es el que ofrece una mejor aproximación a la distribuciòn normal

Estudio de la maduración ósea por sexo y raza / Study of bone maturation by race and sex

La "edad ósea" es el indicador de madurez biológica que más comúnmente se ha utilizado, pues permite al pediatra un enfoque clínico de mayor precisión. En el presente trabajo, se evaluaron 5.000 radiografías de mano y muñeca izquierdas, tomadas del 10% de niños y adolescentes que fueron medidos en el Estudio Nacional de Crecimiento y Desarrollo Físico 1972-1974. Todas las radiografías fueron evaluadas por el método TWII. El estudio se efectuó por sexo y raza, desde el mes de nacido hasta los 19,9 años de edad. Se realizaron comparaciones intersexo e inter-raza a todas las edades. Se obtuvieron los patrones con las puntuaciones cubanas de la maduración ósea separadamente para cada sexo, pues las diferencias entre ambos sexos son estadísticamente significativas a todas las edades, no resultó lo mismo en la comparación inter-raza. Las niñas poseen un mayor ritmo de maduración ósea desde el nacimiento hasta la adultez en relación con los varones