"I think my vagina is still there?": Women's perspectives on sexual function and dysfunction following radical cystectomy for bladder cancer, a qualitative study.

BACKGROUND: Women's sexual health after radical cystectomy is an important but poorly understood aspect of bladder cancer survivorship. Dedicated investigation is needed to elucidate patient perceptions on sexual function and dysfunction in this setting. AIMS: In this study we sought to qualitatively examine women's perceptions and experiences of sexual health following radical cystectomy for bladder cancer. METHODS: We conducted one-on-one qualitative telephone interviews with 40 women who underwent radical cystectomy in the past 6 months to 5 years and signed a research consent form to be contacted for future studies. We examined women's experiences of engaging in sexual activity after surgery and their attitudes toward sex and body image. We audio recorded, transcribed, and coded the interviews using ATLAS.ti software and applied grounded theory methods for analysis. OUTCOMES: For data that emerged during the qualitative interviews that was related to lack of knowledge about how physical and psychological sexual health would be affected after surgery, we reviewed and discussed transcripts that enabled coding of the data into emerging topic areas. RESULTS: Our analysis yielded 4 main themes. (1) Women reported receiving little to no information from providers about female sexual dysfunction prior to or after radical cystectomy. Women wished they had been provided more information about female sexual dysfunction from their clinicians, including strategies for postoperative self-pleasure and nonintercourse methods of sexual pleasure with partners. (2) Women shared that they were not sexually active following surgery due to physical and mental barriers. (3) When women did try to engage in sex, they described feeling disappointed that it did not feel the same as prior to surgery. (4) Some women found that physical therapy helped them to physically and mentally recover their strength to engage in sexual activity again. CLINICAL IMPLICATIONS: Clinicians must directly address sexual health concerns with patients who undergo radical cystectomy. STRENGTHS AND LIMITATIONS: This study has several key strengths. Investigation into women's sexual function and dysfunction addresses a gap in understanding of this component of women's health-related quality of life after radical cystectomy, which represents an unmet need. The large number of interviews conducted as well as the in-depth information obtained through one-on-one interviews are additional strengths. This study also has limitations, including possible shortcomings of telephone interviews compared with in-person interviews. However, telephone interviews were beneficial because the interviews took place during the COVID-19 pandemic and spared patients from extra visits or from having to travel long distances to the respective medical centers. Other possible limitations were that patients may have been reluctant to share all of their experiences and that patients who underwent urostomies, also termed ileal conduits, were overrepresented in this study compared with women who underwent continent urine diversions, which allow greater control over urine output. CONCLUSION: Broadening the understanding of sexual health beyond sexual intercourse to encompass sexuality and self-pleasure can provide clinicians, patients, and their families with more effective preparation and strategies to care for an essential aspect of their wellbeing.

Safety and feasibility of urological procedures in Jehovah's Witness patients.

OBJECTIVES: To describe the safety and feasibility of urological transfusion-free surgeries in Jehovah's Witness patients. METHODS: An institutional review board-approved, retrospective review of Jehovah's Witness patients who underwent urological transfusion-free surgeries between 2003 and 2019 was carried out. Surgeries were stratified into low, intermediate and high risk based on complexity, invasiveness and bleeding potential. Patient demographics, perioperative data and clinical outcomes are reported. RESULTS: A total of 161 Jehovah's Witness patients (median age 63.4 years) underwent 171 transfusion-free surgeries, including 57 (33.3%) in low-, 82 (47.9%) in intermediate- and 32 (18.8%) in high-risk categories. The mean estimated blood loss increased with risk category at 48 mL (range 10-50 mL), 150 mL (range 50-200 mL) and 388 mL (range 137-500 mL), respectively (P < 0.001). Implementing blood augmentation and conservation techniques increased with each risk category (3.5% vs 29% vs 69%, respectively; P < 0.001). Average length of stay increased concordantly at 1.6 days (range 0-12 days), 2.9 days (range 1-13 days) and 5.6 days (range 2-12 days), respectively (P ≤ 0.001). However, there was no increase in complication rates and readmission rates attributed to bleeding among the risk categories at 30 days (P = 0.9 and 0.4, respectively) and 90 days (P = 0.7 and 0.7, respectively). CONCLUSIONS: Transfusion free urological surgery can be safely carried out on Jehovah's Witness patients using contemporary perioperative optimization. Additionally, these techniques can be expanded for use in the general patient population to avoid short- and long-term consequences of perioperative blood transfusion.

Factors Associated With Patient-Reported Penile Length Loss After Radical Cystoprostatectomy in Male Patients With Bladder Cancer.

BACKGROUND: The perception of penile length loss is common in male patients undergoing radical prostatectomy; however, this has not been described after radical cystoprostatectomy (RC). AIM: To evaluate perceptions of penile length loss in male patients after RC and contributing factors. METHODS: Patients completed an institutional review board-approved questionnaire comprised the International Index of Erectile Function (IIEF-5) and supplemental questions including perceived changes in penile length after RC. Multivariable analysis was performed to determine associations between the perception of penile length loss and the amount of length lost with patient and surgery-specific factors. OUTCOMES: The rate of patient-reported penile length loss and factors contributing to this perception was the outcome of this study. RESULTS: From October 2017 to January 2019, 151 patients completed the questionnaire. The median age at cystectomy was 66.1 years (interquartile range [IQR]: 59.4-73.3), and the median duration of follow-up was 28.3 months (IQR: 13-74.1). Preoperative IIEF-5 was available in 55 patients with a median score of 14 (IQR: 3-20). The median IIEF-5 score at time of survey completion was 3 (IQR: 1-18). The majority of patients (55.1%) reported a perceived loss of penile length, 20.4% reported no loss, and 24.5% were unsure. Of those who quantified their loss in penile length, 54.6% reported losses of an inch or more. Neurovascular preservation was not found to protect against penile length loss but did correlate with a reduction in the amount reported lost (P = .008). Multivariable logistic regression analysis identified increasing IIEF-5 score at time of survey completion to protect against a perceived loss in penile length (odds ratio: 0.924, 95% confidence interval: 0.878-0.973, P = .0025), whereas increasing body mass index was associated with a loss in perceived penile length (odds ratio: 1.198, 95% confidence interval: 10.53-1.383, P = .0060). CLINICAL IMPLICATIONS: The perception of penile length loss is a commonly held belief in patients after RC, and many patients will perceive losses that exceed 1 inch (2.54 cm). STRENGTHS AND LIMITATIONS: This study is the first series to describe the perception of penile length loss after RC. It is strengthened by the study population's size, heterogeneity, and patient-reported results. It is limited by lack of objective measurements of stretched penile length. CONCLUSIONS: RC can result in significant sexual dysfunction including the perceived loss of penile length. Loh-Doyle JC, Han J, Ghodoussipour S. Factors Associated With Patient-Reported Penile Length Loss After Radical Cystoprostatectomy in Male Patients With Bladder Cancer. J Sex Med 2020;17:957-963.

B-lymphocyte-mediated delayed cognitive impairment following stroke.

Each year, 10 million people worldwide survive the neurologic injury associated with a stroke. Importantly, stroke survivors have more than twice the risk of subsequently developing dementia compared with people who have never had a stroke. The link between stroke and the later development of dementia is not understood. There are reports of oligoclonal bands in the CSF of stroke patients, suggesting that in some people a B-lymphocyte response to stroke may occur in the CNS. Therefore, we tested the hypothesis that a B-lymphocyte response to stroke could contribute to the onset of dementia. We discovered that, in mouse models, activated B-lymphocytes infiltrate infarcted tissue in the weeks after stroke. B-lymphocytes undergo isotype switching, and IgM, IgG, and IgA antibodies are found in the neuropil adjacent to the lesion. Concurrently, mice develop delayed deficits in LTP and cognition. Genetic deficiency, and the pharmacologic ablation of B-lymphocytes using an anti-CD20 antibody, prevents the appearance of delayed cognitive deficits. Furthermore, immunostaining of human postmortem tissue revealed that a B-lymphocyte response to stroke also occurs in the brain of some people with stroke and dementia. These data suggest that some stroke patients may develop a B-lymphocyte response to stroke that contributes to dementia, and is potentially treatable with FDA-approved drugs that target B cells.

Is Hydronephrosis on Ultrasound Predictive of Ureterolithiasis in Patients with Renal Colic?

PURPOSE: Renal ultrasound accurately identifies hydronephrosis but it is less sensitive than computerized tomography for the detection of ureterolithiasis. We investigated whether the presence of hydronephrosis on ultrasound was associated with a ureteral stone in patients who underwent both ultrasound and computerized tomography during the evaluation of acute renal colic. MATERIALS AND METHODS: We retrospectively reviewed the records of patients from 3 institutions who were evaluated for acute renal colic by both ultrasound and computerized tomography between 2012 and 2015. Patients were included in analysis if ultrasound and computerized tomography were performed on the same day. The presence of ureterolithiasis, stone location and hydronephrosis was reviewed and compared between imaging modalities. RESULTS: Ureteral stones were present in 85 of 144 patients. Ultrasound identified hydronephrosis in 89.8% of patients and a ureteral stone in 25.9%. Computerized tomography identified hydronephrosis in 91.8% of patients and a ureteral stone in 98.8%. In 75.0% of cases the presence or absence of hydronephrosis on ultrasound correctly predicted the presence or absence of a ureteral stone on computerized tomography. Hydronephrosis on ultrasound had a positive predictive value of 0.77 for the presence of a ureteral stone and a negative predictive value of 0.71 for the absence of a ureteral stone. CONCLUSIONS: Hydronephrosis on ultrasound did not accurately predict the presence or absence of a ureteral stone on computerized tomography in 25.0% of the patients in this study. Ultrasound is an important tool for evaluating hydronephrosis associated with renal colic but patients may benefit from other studies to confirm the presence or absence of ureteral stones.

Astrocytic transforming growth factor-beta signaling reduces subacute neuroinflammation after stroke in mice.

Astrocytes limit inflammation after CNS injury, at least partially by physically containing it within an astrocytic scar at the injury border. We report here that astrocytic transforming growth factor-beta (TGFß) signaling is a second, distinct mechanism that astrocytes utilize to limit neuroinflammation. TGFßs are anti-inflammatory and neuroprotective cytokines that are upregulated subacutely after stroke, during a clinically accessible time window. We have previously demonstrated that TGFßs signal to astrocytes, neurons and microglia in the stroke border days after stroke. To investigate whether TGFß affects astrocyte immunoregulatory functions, we engineered "Ast-Tbr2DN" mice where TGFß signaling is inhibited specifically in astrocytes. Despite having a similar infarct size to wildtype controls, Ast-Tbr2DN mice exhibited significantly more neuroinflammation during the subacute period after distal middle cerebral occlusion (dMCAO) stroke. The peri-infarct cortex of Ast-Tbr2DN mice contained over 60% more activated CD11b(+) monocytic cells and twice as much immunostaining for the activated microglia and macrophage marker CD68 than controls. Astrocytic scarring was not altered in Ast-Tbr2DN mice. However, Ast-Tbr2DN mice were unable to upregulate TGF-ß1 and its activator thrombospondin-1 2 days after dMCAO. As a result, the normal upregulation of peri-infarct TGFß signaling was blunted in Ast-Tbr2DN mice. In this setting of lower TGFß signaling and excessive neuroinflammation, we observed worse motor outcomes and late infarct expansion after photothrombotic motor cortex stroke. Taken together, these data demonstrate that TGFß signaling is a molecular mechanism by which astrocytes limit neuroinflammation, activate TGFß in the peri-infarct cortex and preserve brain function during the subacute period after stroke.

Human umbilical cord allograft associated with higher pediatric urethrocutaneous fistula repair success rates.

BACKGROUND: Urethrocutaneous fistula (UCF) formation is a known complication following hypospadias repair, affecting between 5 and 70% of cases. Moreover, approximately 30% of patients experience refistulization after UCF repair. The use of extracellular matrices, such as AmnioCord, a dehydrated human umbilical cord allograft manufactured by MiMedx®, may mitigate high rates of refistulization. OBJECTIVE: To determine whether the use of AmnioCord during UCF repair is associated with reduced incidence of subsequent UCFs among pediatric patients. DESIGN, SETTING, AND PARTICIPANTS: Electronic medical records were retrospectively reviewed among 60 patients who underwent at least one UCF repair at a pediatric hospital in a large urban setting in the U.S. between January 2012-June 2018. Patients were followed through January 2024. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Adjusted generalized estimating equation regression models were used to assess the association between AmnioCord use and rates of refistulization, while controlling for confounding variables. RESULTS: The number of fistula presentations per patient ranged from one to four; 53.3% had one fistula, 30.0% had two, and 16.6% had three or more. Overall fistula repair success rate was 56.8% but significantly differed by AmnioCord use in adjusted modelling; 69.4% of cases that received AmnioCord were successfully repaired, compared to 47.2% of cases that did not receive AmnioCord. In adjusted models, patients who received AmnioCord had 2.66 times greater odds of surgical success than patients who did not receive AmnioCord (95% CI:1.13-6.24; p = 0.02). CONCLUSIONS: This study demonstrates a positive association between AmnioCord use and successful UCF closure among pediatric patients.

Delayed administration of a small molecule tropomyosin-related kinase B ligand promotes recovery after hypoxic-ischemic stroke.

BACKGROUND AND PURPOSE: Stroke is the leading cause of long-term disability in the United States, yet no drugs are available that are proven to improve recovery. Brain-derived neurotrophic factor stimulates neurogenesis and plasticity, processes that are implicated in stroke recovery. It binds to both the tropomyosin-related kinase B and p75 neurotrophin receptors. However, brain-derived neurotrophic factor is not a feasible therapeutic agent, and no small molecule exists that can reproduce its binding to both receptors. We tested the hypothesis that a small molecule (LM22A-4) that selectively targets tropomyosin-related kinase B would promote neurogenesis and functional recovery after stroke. METHODS: Four-month-old mice were trained on motor tasks before stroke. After stroke, functional test results were used to randomize mice into 2 equally, and severely, impaired groups. Beginning 3 days after stroke, mice received LM22A-4 or saline vehicle daily for 10 weeks. RESULTS: LM22A-4 treatment significantly improved limb swing speed and accelerated the return to normal gait accuracy after stroke. LM22A-4 treatment also doubled both the number of new mature neurons and immature neurons adjacent to the stroke. Drug-induced differences were not observed in angiogenesis, dendritic arborization, axonal sprouting, glial scar formation, or neuroinflammation. CONCLUSIONS: A small molecule agonist of tropomyosin-related kinase B improves functional recovery from stroke and increases neurogenesis when administered beginning 3 days after stroke. These findings provide proof-of-concept that targeting of tropomyosin-related kinase B alone is capable of promoting one or more mechanisms relevant to stroke recovery. LM22A-4 or its derivatives might therefore serve as "pro-recovery" therapeutic agents for stroke.

Missed anterior sacral meningomyelocele presenting with obstructive uropathy.

A 2-month-old full-term female presented with a large anterior sacral meningomyelocele resulting in transient obstructive uropathy with bilateral hydronephrosis and acute kidney injury. After initial bladder decompression and surgical resection of the meningomyelocele, there was spontaneous resolution of bladder function confirmed with urodynamics. Anterior spinal meningomyelocele (ASM) is a rare neural tube defect that may present with urinary dysfunction secondary to compression of the bladder and sacral nerve roots or congenital defects to the bladder nervous supply. Obstructive uropathy due to ASM may spontaneously resolve after surgical resection.

Patient Reported Sexual Function Outcomes in Male Patients Following Open Radical Cystoprostatectomy and Urinary Diversion.

OBJECTIVE: To report sexual health outcomes in male patients undergoing open radical cystoprostatectomy using a validated questionnaire. MATERIALS AND METHODS: Beginning in 2017, male patients were asked to complete a validated questionnaire during scheduled post-cystectomy clinic visits that assessed sexual function using the 5 item International Index of Erectile Function (IIEF-5) and supplemental questions which evaluated libido, orgasm, partner interest, and adequacy of pre-operative counselling. Baseline data and functional outcomes were compared and multivariable analysis performed. RESULTS: A total of 134 patients who met inclusion criteria completed the questionnaire. Pre-operative IIEF-5 was available in 78 patients with a median score of 16 (IQR:5-23). In those patients, median age at cystectomy was 68.9 years (IQR:60.2-72.4) and median duration of follow-up was 17.3 months (IQR:6.3-28.7). Median IIEF-5 score at time of survey completion was 1 (IQR:1-11). Increasing age, shorter follow-up duration, insufficient counselling, and absence of partner interest were predictive of lower scores. Younger age, pre-operative erectile function, and neurovascular preservation were predictive of a higher IIEF-5 score on univariate and multivariate analysis. Median libido score was 2 "low" (IQR:1-3) and ability to orgasm was reported by 34 (43.6%) patients. Neurovascular preservation (OR:3.03 95% CI:1.10-8.26, P = .03) and sufficient preoperative counselling (OR:3.078 95% CI:1.17-8.098, P = .02) were associated with preserved ability to orgasm. Libido was influenced by partner interest (OR 11.7, 95% CI:3.793-6.14, P <.0001). CONCLUSION: Sexual dysfunction after radical cystoprostatectomy is prevalent with many contributing factors. As such, establishing appropriate expectations and goals during preoperative counseling, performing neurovascular preservation when appropriate, and readily identifying and treating dysfunction in follow-up may improve sexual recovery.

Development and validation of an objective scoring tool to evaluate surgical dissection: Dissection Assessment for Robotic Technique (DART).

Purpose: Evaluation of surgical competency has important implications for training new surgeons, accreditation, and improving patient outcomes. A method to specifically evaluate dissection performance does not yet exist. This project aimed to design a tool to assess surgical dissection quality. Methods: Delphi method was used to validate structure and content of the dissection evaluation. A multi-institutional and multi-disciplinary panel of 14 expert surgeons systematically evaluated each element of the dissection tool. Ten blinded reviewers evaluated 46 de-identified videos of pelvic lymph node and seminal vesicle dissections during the robot-assisted radical prostatectomy. Inter-rater variability was calculated using prevalence-adjusted and bias-adjusted kappa. The area under the curve from receiver operating characteristic curve was used to assess discrimination power for overall DART scores as well as domains in discriminating trainees (≤100 robotic cases) from experts (>100). Results: Four rounds of Delphi method achieved language and content validity in 27/28 elements. Use of 3- or 5-point scale remained contested; thus, both scales were evaluated during validation. The 3-point scale showed improved kappa for each domain. Experts demonstrated significantly greater total scores on both scales (3-point, p< 0.001; 5-point, p< 0.001). The ability to distinguish experience was equivalent for total score on both scales (3-point AUC= 0.92, CI 0.82-1.00, 5-point AUC= 0.92, CI 0.83-1.00). Conclusions: We present the development and validation of Dissection Assessment for Robotic Technique (DART), an objective and reproducible 3-point surgical assessment to evaluate tissue dissection. DART can effectively differentiate levels of surgeon experience and can be used in multiple surgical steps.

Refractory Lymphatic Ascites After Radical Prostatectomy.

Lymphatic ascites after pelvic lymphadenectomy is a rare complication and is rarely reported after urologic surgery. We report a case of delayed and refractory lymphatic ascites following robotic-assisted laparoscopic radical prostatectomy.

Corona Mortis Artery Pseudoaneurysm Causing Delayed Intermittent Hemoperitoneum After Robotic Radical Prostatectomy.

Pseudoaneurysms are rare in urology and typically have a delayed presention with intermittent episodes of bleeding. We report a patient who presented with delayed and recurent hemoperitoneum following robotic assisted laparoscopic salvage radical prostatectomy and was found to have a pseudoaneurysm in the corona mortis artery.

Delayed Presentation of Urethro-Cavernosal Fistula After Urotrauma.

OBJECTIVE: To define clinical features and surgical management of urethro-cavernosal fistulas (UCF). METHODS: A literature search was performed using PubMed to identify publications with the key word urethro-cavernosal fistula. RESULTS: We herein describe surgical techniques and long-term outcomes for UCF repair. CONCLUSION: UCFs is a rare urological condition with only 9 cases reported to date. UCFs can be diagnosed with careful history, physical examination, and retrograde urethrography. Surgical management includes basic tenets of fistula repair, including adequate mobilization, tension-free but watertight approximation, multilayered closure with nonoverlapping suture lines, and maximal bladder drainage.

Ultrasonography Significantly Overestimates Stone Size When Compared to Low-dose, Noncontrast Computed Tomography.

OBJECTIVE: To evaluate the differences between low-dose noncontrast computed tomography (NCCT) and renal ultrasound (US) in the identification and measurement of urinary calculi. MATERIALS AND METHODS: A retrospective review was conducted at 3 institutions of patients evaluated for flank pain with both renal US and NCCT, within 1 day of one another, from 2012 to 2015. Stone presence and size were compared between imaging modalities. Stone size was determined by largest measured diameter. Stones were grouped into size categories (≤5 mm, 5.1-10 mm, and >10 mm) based on NCCT and compared with US. Statistical analysis was performed using 2-sided t tests. RESULTS: One hundred fifty-five patients received both a renal US and NCCT within 1 day. In 79 patients (51.0%), both US and NCCT identified a stone for size comparison. Fifty-eight patients (37.4%) had a stone visualized on NCCT but not on US, and 2 patients (1.3%) had a stone documented on US but not seen on NCCT. The average NCCT size of the stones missed on US was 4.5 mm. When comparing the average largest stone diameter for US (9.1 mm) vs NCCT (6.9 mm), US overestimated stone size by 2.2 mm (P < .001). US overestimated stone size by 84.6% for stones ≤5 mm, 27.1% for stones 5.1-10 mm, and 3.0% for stones >10 mm. CONCLUSION: US significantly overestimated stone size and this was most pronounced for small (≤5 mm) stones. The potential for systematic overestimation of stone size with standard US techniques should be taken into consideration when evaluating endourologic treatment options.

Negative influence of changing biopsy practice patterns on the predictive value of prostate-specific antigen for cancer detection on prostate biopsy.

BACKGROUND: A correlation between prostate specific antigen (PSA) level and positive prostate biopsy rate was established in an era when biopsy practice patterns were different from what they are today. We evaluated if changes in biopsy practice patterns have affected the ability of PSA to predict cancer detection on prostate biopsy in the current era. METHODS: Of 3634 prostate biopsies performed from 1993-2005, 1607 met criteria for analysis. Biopsy data were divided into 3 time-cohorts (1993-1997, 1998-2001, and 2002-2005) to assess for practice patterns shifts and correlation between PSA and biopsy results. RESULTS: Significant changes in biopsy practice patterns included an increase in biopsy cores and more frequent use of PSA 2.5-3.99 ng/mL as a biopsy indication. In men with normal DRE, a moderate correlation between PSA and positive biopsy rate did exist from 1993-1997, but was subsequently lost. On multivariate analysis, PSA was not a significant predictor of biopsy result in men with normal DRE. CONCLUSIONS: Early in the PSA era, the predictive power of PSA depended on multiple factors: high prevalence of disease, higher prevalence of high-grade disease, and low likelihood of prostate cancer diagnosis in men with low PSA. Now, beyond the culling effect of increased biopsy incidence and with shifted biopsy practice patterns, the correlation between PSA and biopsy result is lost in men with normal DRE. Diagnosing a higher proportion of tumors in men with a PSA between 2.0-4.0 ng/mL has negatively influenced the predictive value of PSA for cancer detection.