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Objective: To evaluate potential associations between patient risk factors and incontinence related patient-reported outcome measures (PROMs) preandpost artificial urinary sphincter (AUS) implantation. We hypothesize patient risk factors, including prior radiation and diabetes will have a negative association with post AUS PROMs.Methods: A review of prospectively collected preandpostoperative Incontinence Symptom Index [ISI] and Incontinence Impact Questionnaire-7 (IIQ-7)s from multiple institutions in the Trauma and Urologic Reconstruction Network of Surgeons was performed. Changes in preandpost AUS ISI and IIQ-7 scores were compared for the entire cohort then stratified by patients with prior AUS, obesity, diabetes, prior radiation, and mixed urinary incontinence.Results: A total of 145 patients, 67.2 (SD 10.9) years had complete preandpost AUS questionnaires (median follow up 186 days, IQR 136-362). Post AUS ISI and IIQ-7 scores improved significantly for the group at large. Prior radiation was associated with less improvement in total IIQ-7 scores, -25.5 (31.9) vs -39 (33.0), P = .03. Obesity was associated with a greater reduction in incontinence severity -13.6 (SD 9.1) vs -9.2 (SD 8.9), P<0.01, urge -5.2(SD 4.2) vs -2.5(SD 4.5), P <.01, and total ISI score -29.7(SD19.7) vs -21.2 (SD 19.9), P = .02. Prior AUS, diabetes, and mixed incontinence were not associated with post AUS PROMs outcome.Conclusion: Overall, patients reported a significant reduction in incontinence severity, bother, impact, and distress following AUS placement. Prior radiation was associated with less improvement in total IIQ-7 scores. In contrast, obesity demonstrated a greater reduction in ISI severity and urge scores compared to non-obese patients. [ABSTRACT FROM AUTHOR]

Purpose: To analyze outcomes of posterior urethroplasty following pelvic fracture urethral injuries (PFUI) and to determine risk factors for surgical complexity and success. Methods: Patients who underwent posterior urethroplasty following PFUI were identified in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) database. Demographics, injury patterns, management strategies, and prior interventions were evaluated. Risk factors for surgical failure and the impact of ancillary urethral lengthening maneuvers (corporal splitting, pubectomy and supracrural rerouting) were evaluated. Results: Of the 436 posterior urethroplasties identified, 122 were following PFUI. 83 (68%) patients were acutely managed with suprapubic tubes, while 39 (32%) underwent early endoscopic realignment. 16 (13%) patients underwent pelvic artery embolization in the acute setting. 116 cases (95%) were completed via a perineal approach, while 6 (5%) were performed via an abdominoperineal approach. The need for one or more ancillary maneuvers to gain urethral length occurred in 4 (36%) patients. Of these, 44 (36%) received corporal splitting, 16 (13%) partial or complete pubectomy, and 2 (2%) supracrural rerouting. Younger patients, those with longer distraction defects, and those with a history of angioembolization were more likely to require ancillary maneuvers. 111 patients (91%) did not require repeat intervention during follow-up. Angioembolization (p = 0.03) and longer distraction defects (p = 0.01) were associated with failure. Conclusions: Posterior urethroplasty provides excellent success rates for patients following PFUI. Pelvic angioembolization and increased defect length are associated with increased surgical complexity and risk of failure. Surgeons should be prepared to implement ancillary maneuvers when indicated to achieve a tension-free anastomosis. [ABSTRACT FROM AUTHOR]

Objective: To examine the rate of urethral trauma and pubic symphysis diastasis in saddle horn injury, which occurs when horseback riders are bucked into the air and land with their perineum striking the rigid saddle horn, compared to pelvic fracture from other mechanisms.Methods: A retrospective review was performed of male patients presenting to our level-1 trauma center with pelvic ring fractures between January 1, 2001 and December 30, 2016. Demographics, injury severity score, mechanism of injury (saddle horn vs other), pubic symphysis diastasis, and lower genitourinary (GU) injuries (bladder and urethra) were identified in the trauma registry. Chart review confirmed accuracy of lower GU trauma.Results: A total of 1195 males presented with pelvic ring fractures, average age 43 years (SD 19 years). Of these, 87 of 1195 (7%) presented with lower GU injuries. Saddle horn injuries had a higher rate of lower GU injuries, 12/60 (20%) versus 75 of 1135 (7%) [P = .001]. In those with lower GU injuries, 47 of 87 (54%) had urethral injury. The rate of urethral injury was significantly higher in the saddle horn cohort, 10 of 12 (83%) versus 37 of 75 (49%) [P = .03]. Furthermore, rate of pubic symphysis diastasis was higher amongst saddle horn injuries, 12 of 12 (100%) versus other mechanisms 39 of 75 (52%) [P = .001].Conclusion: We found that urethral injury and pubic symphysis diastasis were higher in patients with saddle horn injury compared to other mechanisms of pelvic ring disruption. Clinicians should be aware of these associations when treating pelvic fracture following equestrian injuries. [ABSTRACT FROM AUTHOR]

Objective: To assess the efficacy of exchanging the pressure regulating balloon (PRB) to 71-80 cm H2O in patients with persistent or recurrent stress urinary incontinence (SUI) following artificial urinary sphincter (AUS) placement.Methods: Patients with SUI following AUS placement who underwent PRB replacement between 2011 and 2017 in the absence of urethral cuff malfunction, atrophy, stricture, or erosion were reviewed. Primary outcomes included changes in pad per day (PPD), Incontinence Symptom Index score, and Incontinence Quality of Life (I-QOL). Secondary outcomes included rates of device erosion and all-cause explant or revision. Differences were compared between patients with and without erosion, explant, or revision. Kaplan Meier device survival analysis was performed.Results: Twenty two patients (67 ± 9 years, body mass index of 30 ± 5 kg/m2) with a median follow up of 22.4 months (IQR 9.3, 47.3) were included. Incontinence etiology included radical prostatectomy in 60% of patients. After PRB exchange, the average number of PPD decreased from 4.0 ± 3.0 to 1.0 ± 1.6 PPD (P = .01), as did Incontinence Symptom Index scores (21.6 ± 8.5 vs 16.3 ± 8.1, P <.001) and Incontinence Quality of Life (15.2 ± 6.8 vs 7.2 ± 3.4, P = .01). Three patients with prior radiation (14%) experienced cuff erosion. The explantation/revision rate was 45%(10/22) at 33.5(IQR 8.9,48) months. Kaplan-Meier analysis demonstrated 68%(15/22) and 41%(9/22) retained their device for 12 and 24 months, respectively.Conclusion: PRB exchange can transiently alleviate persistent or recurrent post-AUS SUI in the absence of mechanical failure or urethral pathology. Caution is warranted in patients with prior radiation as this was a risk factor for urethral erosion. Although many patients may require device revision within 2 years, it can be a temporizing solution that avoids urethral manipulation and periprocedural device deactivation. [ABSTRACT FROM AUTHOR]

Natale C, McLellan DM, Yousif A et al: Review of intralesional collagenase Clostridium histolyticum injection therapy and related combination therapies in the treatment of Peyronie's disease (an update). A randomized, double-blinded study of 375 women with moderate or severe cellulite demonstrated that patients treated with up to 3 treatment sessions with 0.84 mg CCH were more Figure 3. AUANEWS April 2021 33 Xiaflex/Collagensase Applications and Use t Continued from page 32 CCH was investigated using H&E stain, MT stain, and Western blot analysis (fig. 3). Both the low and high dose treatment groups revealed decreased type I and III collagen expression compared to the control group, with the high dose CCH treatment group showing greater decreases in collagen expression. [Extracted from the article]

Study Design: Retrospective analysis of patients undergoing elective lumbar fusion operations, comparing rates of repeat spine surgery based on method of ascertainment.Objective: We report the accuracy of a claims-based approach for reporting repeat surgery compared with medical records abstraction as the "gold standard."Summary Of Background Data: Previous studies have reported the validity of a claims-based algorithm for grouping patients by surgical indication and classifying operative features, but their accuracy in measuring surgical quality indicators has not been widely examined.Methods: We identified a subset of patients undergoing elective lumbar fusion operations at a single institution from 1996 to 2011, excluding those with spinal fracture, spinal cord injury, or cancer. From the medical record we abstracted the incidence of repeat spine operation or rehospitalization at 1 year. We cross-classified each event record with its corresponding value derived from claims. The sensitivity and specificity of the claims-based approach were calculated for reoperation within 30, 90, and 365 days, and all-cause hospital readmission within 30 days.Results: Medical records linked to claims data were obtained for 520 patients undergoing elective lumbar fusion. Reoperation rates based on chart review were 1.0%, 1.3%, 3.6%, compared with 0.8%, 1.7%, and 3.8% based on the final claims methods at 30, 90, and 365 days, respectively. The claims-based algorithm had sensitivities of 80.0%, 100%, and 94.1% and specificities of 100%, 99.6%, 99.2% for repeat surgery within 30, 90, and 365 days, respectively. The sensitivity for all-cause readmission was 50%.Conclusion: Health care quality improvement efforts often rely on administrative data to report surgical safety. We found that claims-based ascertainment of safety at a single institution was very accurate. However, accuracy depended on careful attention to the timing of outcomes, as well as the definitions and coding of repeat surgery, including how orthopedic device removal codes are classified.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Objective: To investigate the incidence of systemic inflammatory response syndrome (SIRS) following percutaneous nephrolithotomy (PCNL) and evaluate any association with unplanned 90-day readmission.Methods: We retrospectively reviewed consecutive patients undergoing PCNL in 2 dedicated endourologic practices between 2009 and 2013. We collected patient demographics, perioperative culture data, and operative characteristics. SIRS was defined as having 2 or more of the following: maximum white blood cell count >12,000 or <4000, temperature >38 or <34°C, heart rate >90, and respiratory rate >20 within the first 24 hours following PCNL. Proportions between groups were compared to identify significant associations.Results: We identified 389 patients undergoing PCNL and 43% (167 of 389) met SIRS criteria, more commonly in patients with multiple PCNL accesses (OR 2.3; CI: 1.1-4.8, P = .025). Readmission was required in 8% (31 of 389), most commonly for infection (n = 21). Although possession of a struvite stone was associated with unplanned readmission (16% vs 4%, P < .01), SIRS in the absence of fever within 48 hours postoperative was not associated with readmission (29.4% vs 25.8%, P = .837).Conclusion: Nearly half of the patients undergoing PCNL met the criteria for SIRS within the first postoperative day. There was no association between SIRS and unplanned readmission in the postoperative PCNL patient. Despite discharge during the first postoperative day, patients with SIRS (without fever or struvite stones) had no increased risk for unplanned return. Our findings suggest that the development of SIRS immediately following PCNL does not preclude safe discharge on the first postoperative day. [ABSTRACT FROM AUTHOR]

Objective:This study sought to evaluate factors associated with unplanned hospital return (UR) following transurethral resection of bladder tumor (TURBT), the largest source of readmission among ambulatory urological procedures. Materials and methods:A retrospective review of TURBTs at a single academic institution between April 2011 and August 2014 was performed. Demographics, comorbidities, length of stay, tumor size and multiple other factors were recorded. UR was recorded within 30 days of surgery. Bivariate and multivariable analyses were performed to determine factors associated with UR. Results:Among 708 patients undergoing TURBT, 23.9% were female with a mean age of 70 years. The rate of UR was 10.9%. The most common cause of UR was gross hematuria, accounting for 70%. On bivariate analysis, Foley catheter placement in the operating room, non-aspirin anticoagulation and index length of stay longer than 24 h were associated with hematuria-related UR (p < 0.05). Preoperative antibiotics, female gender and aspirin therapy were associated with lower rates of hematuria-related UR (p < 0.05), while tumor size, distance of residence to the hospital, and Foley on hospital discharge (rather than from the operating room) had no association (p > 0.05). On multivariable analysis, only Foley placement in the operating room remained associated with higher rates of hematuria-related UR, while preoperative antibiotics, female gender and aspirin therapy remained associated with a lower likelihood of this event. Conclusions:UR following TURBT is common and typically results from gross hematuria. Patients with postoperative Foley catheterization in the operating room may require additional counseling or supervision before discharge, and should be considered for discharge with a Foley rather than having a prompt voiding trial. [ABSTRACT FROM PUBLISHER]

To examine the changes in stone composition from 1990 to 2010. A retrospective review was performed of all renal and ureteral stones submitted from the state of Massachusetts to a single laboratory (Laboratory for Stone Research, Newton, MA) for the years 1990 and 2010. Stone composition was determined by infrared spectroscopy and/or polarizing microscopy. A total of 11,099 stones were evaluated (56.7 % from 1990, 43.3 % from 2010). From 1990 to 2010, the percentage of stones from females (i.e., female/male ratio) increased significantly (29.8 % in 1990 to 39.1 % in 2010, p < 0.001). Among women, from 1990 to 2010, there was a significant increase in stones which were >50 % uric acid (7.6-10.2 %, p < 0.005) and a significant decrease in struvite stones (7.8-3.0 %, p < 0.001). Among women with calcium stones, the % apatite per stone decreased significantly (20.0 vs. 11.7 %, p < 0.001). Among men, there were no changes in stones which were majority uric acid (11.7-10.8 %, p = 0.2). Among men with calcium stones, the % apatite per stone increased significantly (9.8 vs. 12.5 %, p < 0.001). Males also demonstrated a significant increase in both cystine (0.1-0.6 %, p < 0.001) and struvite stones (2.8-3.7 %, p = 0.02). The epidemiology of stone disease continues to evolve and appears to vary according to gender. While some of these findings may be related to population changes in body mass index and obesity, the etiology of others remains unclear. [ABSTRACT FROM AUTHOR]

Study Design. Subgroup analysis of the lumbar spinal stenosis (LSS) without degenerative spondylolisthesis diagnostic cohort of the Spine Patient Outcomes Research Trial multicenter randomized clinical trial with a concurrent observational cohort. Objective. To determine if sedimentation sign on magnetic resonance image can help with LSS treatment decisions. Summary of Background Data. LSS is one of the most common reasons for surgery in the US elderly, but there is a dearth of reliable diagnostic tools that give a clear indication for surgery. Recent studies have suggested that positive sedimentation sign on magnetic resonance image may be a possible prognostic indicator. Methods. All patients with LSS in both the randomized and observational cohorts had imaging-confirmed stenosis, were surgical candidates, and had neurogenic claudication for at least 12 weeks prior to enrollment. Patients were categorized as "mild," "moderate," or "severe" according to stenosis severity. Of the 654 patients with LSS enrolled in Spine Patient Outcomes Research Trial, complete T2-weighted axial and sagittal digitized images of 115 patients were available for retrospective review. An independent orthopedic spine surgeon evaluated these deidentified Digital Imaging and Communications in Medicine files for the sedimentation sign. Results. Sixty-six percent (76/115) of patients were found to have a positive sedimentation sign. Those with a positive sedimentation sign were more likely to have stenosis at L2-L3 (33% vs. 10% P = 0.016) or L3-L4 76% vs. 51%, P = 0.012), and to have severe (72% vs. 33%, P < 0.0001) central stenosis (93% vs. 67% P < 0.001) at 2 or more concurrent levels (57% vs. 18%, P = 0.01). In multivariate models, the surgical treatment effect was significantly larger in the positive sedimentation sign group for Oswestry Disability Index (-16 vs. -7; P = 0.02). Conclusion. A positive sedimentation sign was associated with a small but significantly greater surgical treatment effect for Oswestry Disability Index in patients with symptomatic LSS, after adjusting for other demographic and imaging features. These findings suggest that positive sedimentation sign may potentially be a useful adjunct to help guide an informed treatment choice regarding surgery for LSS. [ABSTRACT FROM AUTHOR]

Study Design. A retrospective cohort design. Objective. To determine whether baseline magnetic resonance imaging findings, including central/foraminal stenosis, Modic change, disc morphology, facet arthropathy, disc degeneration, nerve root impingement, and thecal sac compression, are associated with differential surgical treatment effect. Summary of Background Data. Intervertebral disc herniation remains the most common source of lumbar radiculopathy treated either with discectomy or nonoperative intervention. Although magnetic resonance imaging remains the reliable "gold standard" for diagnosis, uncertainty surrounds the relationship between magnetic resonance imaging findings and treatment outcomes. Methods. Three hundred seven "complete" images from patients enrolled in a previous trial were de-identified and evaluated by 1 of 4 independent readers. Findings were compared with outcome measures including the Oswestry Disability Index. Differences in surgery and nonoperative treatment outcomes were evaluated between image characteristic subgroups and TE determined by the difference in Oswestry Disability Index scores. Results. The cohort comprised 40% females with an average age of 41.5 (±11.6) years, 61% of whom underwent discectomy for intervertebral disc herniation. Patients undergoing surgery with Modic type I endplate changes had worse outcomes (-26.4 vs. -39.7 for none and -39.2 for type 2, P = 0.002) and smaller treatment effect (-3.5 vs. -19.3 for none and -15.7 for type 2, P = 0.003). Those with compression of ≥1/3 showed the greatest improvement within the surgical group (-41.9 for ≥1/3 vs. -31.6 for none and -38.1 for <1/3, P = 0.007) and the highest TE (-23 compared with -11.7 for none and -15.2 for <1/3, P = 0.015). Furthermore, patients with minimal nerve root impingement demonstrated worse surgical outcomes (-26.5 vs. -41.1 for "displaced" and -38.9 for "compressed," P = 0.016). Conclusion. Among patients with intervertebral disc herniation, those with thecal sac compression of 1/3 or more had greater surgical treatment effect than those with small disc herniations and Modic type I changes. In addition, patients with nerve root "compression" and "displacement" benefit more from surgery than those with minimal nerve root impingement. [ABSTRACT FROM AUTHOR]

Discussion: Internal fistulization of the colon to other organs, such as the urinary bladder, vagina, or small bowel is a relatively common complication associated with inflammatory diseases such as diverticulitis, Crohn disease, as well as neoplasia such as colorectal cancer or lymphoma. However, fistulization of the colon to the spleen is an exceedingly rare condition described by few in the literature. [ABSTRACT FROM AUTHOR]

Objective: To describe the infrapubic approach to penile prosthesis insertion in transmen after phalloplasty.Materials and Methods: After verifying phalloplasty vascular pedicle anatomy and reliable micturition, patients may be considered for implant surgery. Specific modifications of the infrapubic approach to penile prosthesis insertion as well as individualization of commercially available implants are performed intraoperatively to help reduce the risk of postoperative complications.Results: In our single surgeon series (MLC) using the infrapubic approach with these specific implants after phalloplasty, 17/107 (16%) patients from October 2017 to November 2020 required revision surgery after mean follow-up of 79.8 weeks.Conclusion: Our infrapubic prosthesis insertion after phalloplasty technique with modifications to commercially available implants may help reduce the risk of postoperative complications. [ABSTRACT FROM AUTHOR]

Objective: To describe the risks of urinary diversion performed to address adverse effects of gynecologic radiation, with the hypothesis that high grade complications would be more common in sarcopenic women and in those undergoing continent diversion (vs noncontinent) or concomitant cystectomy (vs bladder-sparing diversion).Methods: A retrospective review was performed of patient records of women who underwent urinary diversion for urinary adverse effects of gynecologic radiotherapy during the period of 2008-2018 from 3 tertiary centers. Skeletal muscle index was calculated to assess for sarcopenia based on preoperative computed tomography scans. Outcomes include high-grade postoperative complications within 90 days of surgery, 30-day readmission rate, and long-term (>90 days) outcomes.Results: Among 34 women who met the inclusion criteria, the majority were white/Caucasian (73.5%). Twenty-six of 34 (76.5%) underwent noncontinent diversion. Seventy nine percent (27/34) (79.4%) of women experienced complications within 90 days; 9 of 34 (26.5%) experienced high-grade (Clavien grade ≥3) complications. Thirty-two percent (11/34) were readmitted within 30 days. Rates of high-grade complications were not significantly impacted by diversion type (P = .49), concurrent cystectomy (P = .70), or sarcopenia (P = 1.0).Conclusions: Urinary diversion for late adverse effects of gynecologic radiotherapy is associated with high peri-operative risk, even in skilled hands. In this series, neither sarcopenia, nor continent diversion, nor cystectomy were associated with increased complications. Patients and surgeons should consider risks and benefits when deciding to proceed with urinary diversion, however further study is needed to elucidate significant preoperative markers which may predispose patients to significant complications. [ABSTRACT FROM AUTHOR]

Purpose: To assess the functional Queryoutcome of patients with cystoscopic recurrence of stricture post-urethroplasty and to evaluate the role of cystoscopy as initial screening tool to predict future failure. Methods: Cases with cystoscopy data after anterior urethroplasty in a multi-institutional database were retrospectively studied. Based on cystoscopic evaluation, performed within 3-months post-urethroplasty, patients were categorized as small-caliber (SC) stricture recurrence: stricture unable to be passed by standard cystoscope, large-caliber (LC) stricture accommodating a cystoscope, and no recurrence. We assessed the cumulative probability of intervention and the quality of life scores in association with cystoscopic recurrence 1-year post-urethroplasty. Patients with history of hypospadias, perineal urethrostomy, urethral fistula, and meatal pathology were excluded. Results: From a total of 2630 men in our cohort, 1054 patients met the inclusion criteria: normal (n = 740), LC recurrence (n = 178), and SC recurrence (n = 136) based on the first cystoscopic evaluation performed at median 111 days postoperatively. Median follow-up was 350 days (IQR 121–617) after urethroplasty. Cystoscopic recurrence was significantly associated with secondary interventions (2.7%, 6.2%, 33.8% in normal, LC, and SC groups, respectively). Quality of life variables were not statistically significantly different among the three study groups. Conclusions: Many patients with cystoscopic recurrence do not need an intervention after initial urethroplasty. Despite good negative predictive value, cystoscopy alone may be a poor screening test for stricture recurrence defined by patient symptoms and need for secondary interventions. [ABSTRACT FROM AUTHOR]

Background: Decision aids help patients consider the benefits and drawbacks of care options but rarely include cost information. We assessed the impact of a conversation‐based decision aid containing information about low‐risk prostate cancer management options and their relative costs. Methods: We conducted a stepped‐wedge cluster randomised trial in outpatient urology practices within a US‐based academic medical center. We randomised five clinicians to four intervention sequences and enroled patients newly diagnosed with low‐risk prostate cancer. Primary patient‐reported outcomes collected postvisit included the frequency of cost conversations and referrals to address costs. Other patient‐reported outcomes included: decisional conflict postvisit and at 3 months, decision regret at 3 months, shared decision‐making postvisit, financial toxicity postvisit and at 3 months. Clinicians reported their attitudes about shared decision‐making pre‐ and poststudy, and the intervention's feasibility and acceptability. We used hierarchical regression analysis to assess patient outcomes. The clinician was included as a random effect; fixed effects included education, employment, telehealth versus in‐person visit, visit date, and enrolment period. Results: Between April 2020 and March 2022, we screened 513 patients, contacted 217 eligible patients, and enroled 117/217 (54%) (51 in usual care, 66 in the intervention group). In adjusted analyses, the intervention was not associated with cost conversations (β =.82, p =.27), referrals to cost‐related resources (β = −0.36, p =.81), shared decision‐making (β = −0.79, p =.32), decisional conflict postvisit (β = −0.34, p=.70), or at follow‐up (β = −2.19, p =.16), decision regret at follow‐up (β = −9.76, p =.11), or financial toxicity postvisit (β = −1.32, p =.63) or at follow‐up (β = −2.41, p =.23). Most clinicians and patients had positive attitudes about the intervention and shared decision‐making. In exploratory unadjusted analyses, patients in the intervention group experienced more transient indecision (p <.02) suggesting increased deliberation between visit and follow‐up. Discussion: Despite enthusiasm from clinicians, the intervention was not significantly associated with hypothesised outcomes, though we were unable to robustly test outcomes due to recruitment challenges. Recruitment at the start of the COVID‐19 pandemic impacted eligibility, sample size/power, study procedures, and increased telehealth visits and financial worry, independent of the intervention. Future work should explore ways to support shared decision‐making, cost conversations, and choice deliberation with a larger sample. Such work could involve additional members of the care team, and consider the detail, quality, and timing of addressing these issues. Patient or Public Contribution: Patients and clinicians were engaged as stakeholder advisors meeting monthly throughout the duration of the project to advise on the study design, measures selected, data interpretation, and dissemination of study findings. [ABSTRACT FROM AUTHOR]

To study the prevalence and management of shattered kidney and to evaluate if the new description of "loss of identifiable renal anatomy" in the 2018 American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) would improve the ability to predict bleeding control interventions. We used high-grade renal trauma data from 21 Level-1 trauma centers from 2013 to 2018. Initial CT scans were reviewed to identify shattered kidneys, defined as a kidney having ≥3 parenchymal fragments displaced by blood or fluid on cross-sectional imaging. We further categorized patients with shattered kidney in two models based on loss of identifiable renal parenchymal anatomy and presence or absence of vascular contrast extravasation (VCE). Bleeding interventions were compared between the groups. From 861 high-grade renal trauma patients, 41 (4.8%) had shattered kidney injury. 25 (61%) underwent a bleeding control intervention including 18 (43.9%) nephrectomies and 11 (26.8%) angioembolizations. 18 (41%) had shattered kidney with "loss of identifiable parenchymal renal anatomy" per 2018 AAST OIS (model-1). 28 (68.3%) had concurrent VCE (model-2). Model-2 had a statistically significant improvement in area under the curve over model-1 in predicting bleeding interventions (0.75 vs 0.72; P =.01). Shattered kidney is associated with high rates of active bleeding, urinary extravasation, and interventions including nephrectomy. The definition of shattered kidney is vague and subjective and our definition might be simpler and more reproducible. Loss of identifiable renal anatomy per the 2018 AAST OIS did not provide better distinction for bleeding control interventions over presence of VCE. [ABSTRACT FROM AUTHOR]

To describe our surgical technique and outcomes of glans augmentation with autologous adipodermal or acellular dermal matrix (ADM) interposition grafts for fat atrophy of the neophallus following penile implant insertion. We retrospectively reviewed the outcomes of glans augmentation in phalloplasty patients presenting with fat atrophy following penile prosthesis insertion. Glans augmentation is performed by making a small posterior coronal incision to preserve the shaft-to-glans dermal blood supply. A plane is made between the glans skin and the capsule of the distal penile implant cylinder. An adipodermal graft or ADM sheet graft is then sized to the glans dissection space and inserted, covering the implant capsule and filling the glans. The graft harvest site and posterior coronal incisions are then closed. The primary postoperative outcome was the recurrence of implant glans skin impingement or erosion. From October 2017 through January 2023, 15 patients underwent glans augmentation after penile prosthesis insertion. The mean follow-up was 20 months. Adipodermal grafts were placed in 12 (80%) patients and ADM grafts in 3 (20%) patients. Two patients developed complications requiring surgical revision and 3 patients are considering a secondary glans augmentation, for a potential surgical revision rate of 33% (5/15). There were no wound infections, implant infections, or erosions. Glans augmentation with adipodermal or ADM graft interposition between the glans skin and implant capsule improves the neophallus appearance and may help prevent future implant erosion in phalloplasty patients who develop fat atrophy after penile implant insertion. [ABSTRACT FROM AUTHOR]

Background: Gender-affirming surgical procedures, such as metoidioplasty and phalloplasty for those assigned female at birth, are complex and multistaged and involve risks. Individuals considering these procedures experience greater uncertainty or decisional conflict, compounded by difficulty finding trustworthy information. Aim: (1) To explore the factors contributing to decisional uncertainty and the needs of individuals considering metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) and (2) to inform development of a patient-centered decision aid. Methods: This cross-sectional study was based on mixed methods. Adult transgender men and nonbinary individuals assigned female at birth at various stages of MaPGAS decision making were recruited from 2 study sites in the United States to participate in semistructured interviews and an online gender health survey, which included measures of gender congruence, decisional conflict, urinary health, and quality of life. Trained qualitative researchers conducted all interviews with questions to explore constructs from the Ottawa decision support framework. Outcomes: Outcomes included goals and priorities for MaPGAS, expectations, knowledge, and decisional needs, as well as variations in decisional conflict by surgical preference, surgical status, and sociodemographic variables. Results: We interviewed 26 participants and collected survey data from 39 (24 interviewees, 92%) at various stages of MaPGAS decision making. In surveys and interviews, affirmation of gender identity, standing to urinate, sensation, and the ability to "pass" as male emerged as highly important factors for deciding to undergo MaPGAS. A third of survey respondents reported decisional conflict. Triangulation of data from all sources revealed that conflict emerged most when trying to balance the strong desire to resolve gender dysphoria through surgical transition against the risks and unknowns in urinary and sexual function, appearance, and preservation of sensation post-MaPGAS. Insurance coverage, age, access to surgeons, and health concerns further influenced surgery preferences and timing. Clinical Implications: The findings add to the understanding of decisional needs and priorities of those considering MaPGAS while revealing new complexities among knowledge, personal factors, and decisional uncertainty. Strengths and Limitations: This mixed methods study was codeveloped by members of the transgender and nonbinary community and yielded important guidance for providers and individuals considering MaPGAS. The results provide rich qualitative insights for MaPGAS decision making in US contexts. Limitations include low diversity and sample size; both are being addressed in work underway. Conclusions: This study increases understanding of the factors important to MaPGAS decision making, and results are being used to guide development of a patient-centered surgical decision aid and informed survey revision for national distribution. [ABSTRACT FROM AUTHOR]

Purpose: To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management. Methods: We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery). Results: Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35 years (Interquartile range (IQR) 25–50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found. Conclusion: Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group. [ABSTRACT FROM AUTHOR]

Around the world, musical engagement frequently involves movement. Most adults easily clap or sway to a wide range of tempos, even without formal musical training. The link between movement and music emerges early--young infants move more rhythmically to music than speech, but do not reliably align their movements to the beat. Laboratory work encouraging specific motor patterns (e.g., drumming, tapping) demonstrates that toddlers and young children's movements are affected by music in a rudimentary way, such that they move faster to faster rhythms (tempo flexibility). In the present study, we developed and implemented a novel home recording method to investigate how musical familiarity and tempo affect children's naturalistic free-dance movements. Caregivers made home recordings of their children's responses to an experimenter-created playlist (N = 83, age range = 1.25 to 3.91 years, Mage = 2.39 years, SD = .74 years; 41 girls, 42 boys; 75% of household incomes > $90 000 CAD). Children listened to 1-min excerpts of their favorite music and unfamiliar, genre-matched music, each played at 90, 120, and 150 bpm (pitch constant; order randomized). Children moved faster to faster music and demonstrated tempo flexibility for both favorite and unfamiliar music. Favorite music encouraged more smiling across tempo conditions than unfamiliar music, as well as more dancing in the slowest tempo condition. Results demonstrate that young children's self-selected movements are affected by musical tempo and familiarity. We also demonstrate the usefulness of a naturalistic home recording method for assessing early auditory-motor integration. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: The impact of onabotulinum toxin type A (BoNT-A) on bladder afferent nerve pathways and chemosensory functions is an active area of investigation. There may be a role for BoNT-A in disorders of the ureter; however, no histologic studies have assessed the effects of BoNT-A on ureteral tissue. Our objective was to develop an animal model of ureteral inflammation and determine the impact of ureteral BoNT-A instillation on known mechanisms of inflammation. Methods: The safety and feasibility of a novel animal model of ureteral inflammation was assessed. Through open cystotomy, the effect of ureteral BoNT-A instillation on inflammation was determined through H&E, masson's trichrome, Ki-67 stain, and prostaglandin E (PGE) synthase expression, a known marker of pain and inflammation in ureteral tissue. Urothelial microstructure was assessed using electron microscopy and standard histologic techniques. Results: All experiments were carried to completion, and no systemic signs of botulinum toxicity were seen. BoNT-A exposure was associated with a decrease in PGE synthase expression in a dose-dependent fashion. BoNT-A exposure was not found to impact collagen deposition or cell proliferation. Disruption of tight junctions between urothelial cells was observed under conditions of inflammation. Conclusion: We describe the feasibility of a novel in vivo model of ureteral inflammation and report the first histologic study of the effects of BoNT-A on the ureter. Preliminary findings show that BoNT-A attenuates ureteral PGE synthase expression under conditions of inflammation. The application of BoNT-A may provide anti-inflammatory and analgesic effects in the context of ureteral disorders. [ABSTRACT FROM AUTHOR]

Objective: To find clinical or radiographic factors that are associated with angioembolization failure after high-grade renal trauma.Material and Methods: Patients were selected from the Multi-institutional Genito-Urinary Trauma Study. Included were patients who initially received renal angioembolization after high-grade renal trauma (AAST grades III-V). This cohort was dichotomized into successful or failed angioembolization. Angioembolization was considered a failure if angioembolization was followed by repeat angiography and/or an exploratory laparotomy.Results: A total of 67 patients underwent management initially with angioembolization, with failure in 18 (27%) patients. Those with failed angioembolization had a larger proportion ofgrade IV (72% vs 53%) and grade V (22% vs 12%) renal injuries. A total of 53 patients underwent renal angioembolization and had initial radiographic data for review, with failure in 13 cases. The failed renal angioembolization group had larger perirenal hematoma sizes on the initial trauma scan.Conclusion: Angioembolization after high-grade renal trauma failed in 27% of patients. Failed angioembolization was associated with higher injury grade and a larger perirenal hematoma. Likely these characteristics are associated with high-grade renal trauma that may be less amenable to successful treatment after a single renal angioembolization. [ABSTRACT FROM AUTHOR]