Search

Space use by mammals can differ among age-classes, sexes, or seasons, and these processes are recognized as adaptive behavioral strategies. Semi-fossorial ground squirrels, in particular, have shown age- and sex-specific patterns in their aboveground movement behaviors. We studied space use of Mohave ground squirrels (Xerospermophilus mohavensis) at the Freeman Gulch study site in the central region of their range in the Mojave Desert, California. We documented the timing of their full annual cycle, investigated correlates of size of home ranges of adults and distance of long-distance movements by juveniles, and evaluated whether juvenile body masses and movements were related to interannual climatic variation. Adult males emerged from burrows and entered hibernation sooner than did adult females. Home ranges were larger for males (x¯ ± SD = 0.50 ± 0.40 km2) than females (0.05 ± 0.03 km2), especially during the mating season. Maximum distances moved by juveniles did not differ significantly between males (1.6 ± 2.3 km) and females (1.0 ± 1.8 km), and both sexes were equally likely to travel long distances from natal sites. The longest-distance movement we documented was 7.7 km by a juvenile male. Juveniles born in a year of low vegetation productivity gained significantly less mass (97 ± 7 g) and traveled shorter distances than those born in a year of higher vegetation productivity (177 ± 20 g). Our findings were similar to those documented in the Coso Range study site in the northern region of the geographic range of the species, indicating that movement patterns are similar range-wide. Mohave ground squirrels responded strongly to climate variation, and global climate change will likely result in a northward shift in suitable habitats. Informed conservation planning, therefore, will be essential for this rare, declining species.

Background Urinary fistula (UF) is a global health problem but less common in well-resourced countries. Over the past decade there has been a trend toward managing UF in dedicated centres. Most of the evidence for surgical treatment is from individual case series, with few publications that involve high numbers. We describe the repair of recurrent and complex UF cases and outcomes in a tertiary referral setting. Objective To describe UF aetiology, repair techniques, and outcomes. Design, setting, and participants This is a retrospective study of a series of patients undergoing UF repair at a specialist unit. Outcome measurements and statistical analysis We describe the aetiology, cure rate, complications, and postoperative urinary incontinence rates for the series of UF cases. Results and limitations A consecutive series of 98 patients was identified, all of whom were tertiary referrals. Of these, 31 (31.6%) had at least one prior attempt at repair at another centre. The median age was 48 yr (interquartile range [IQR] 40–60.25). The median time from occurrence to repair was 12 mo (IQR 6–12). UF occurred most commonly following hysterectomy (48.0%), Caesarean section (9.2%), other gynaecological surgery (7.1%), and anti-incontinence surgery (7.1%). Complex fistulae (eg, repeat cases, radiation, ureteric involvement) comprised 41 of the cases (41.8%). Most patients with vesicovaginal fistula underwent repair via a transabdominal approach (70.4%). Tissue interposition was used in 96 cases (98%). There were no Clavien-Dindo grade >3 complications. Two patients (2%) had a persistent UF postoperatively. Two patients (2%) developed recurrence more than 2 yr after their initial repair, and both were successfully repaired at our centre. Twelve patients (12.3%) developed de novo overactive bladder, 22 (22.5%) developed stress urinary incontinence (13 had subsequent incontinence surgery), and two (2%) developed bladder pain (both had a subsequent cystectomy). Conclusions Despite a high rate of recurrent and complex UF, successful lasting closure was achieved in 96% of our cases. A minority of patients developed other problems such as de novo overactive bladder and stress urinary incontinence that may require further treatment. Patient summary Urinary fistula is an abnormal opening or connection in the urinary tract and is less common in well-resourced countries. As a consequence, management of this condition is more frequently undertaken at specialist units. Even patients with a complex fistula and those who have had multiple attempts at repair can experience a cure. Urinary leakage is a common complication after the operation but can be successfully managed with surgery., Take Home Message Despite a high number of complex and recurrent cases, we achieved a success rate in excess of 95% in the surgical management of genitourinary fistula. It is important that such cases are managed by teams of surgeons who are comfortable in undertaking both vaginal and abdominal approaches to repair.

Objective:Transvaginal excision of urethral diverticulum (UD) is the gold standard treatment for symptomatic women with UD. Complete UD excision can be challenging due to poor access to the surgical field, especially with proximal, circumferential and recurrent UD. Prone patient positioning has been suggested as an effective way of improving surgical access and vision compared to the traditional supine positioning. However, direct comparison of the two positions is yet to be performed. This study aimed to compare patients who underwent UD excision in prone and supine positions.Materials and Methods:Prospectively recorded data of 79 women undergoing urethral diverticulectomy between 2004 and 2017 in a single referral centre were reviewed. Patients were operated either in supine or prone positions based on the surgeon’s preference. Data collected included patient demographics, UD characteristics on magnetic resonance imaging, intraoperative details and postoperative outcomes. Operative time was calculated from the electronic theatre records starting from the entry of the patient into the operating room to their exit.Results:The mean patient age was 42.38 (±15.24) years. More than half of the patients had a recurrent UD at presentation (51.89%). The mean size of the diverticulum was 25.06 (±1.2) mm, and the mean operative time was 146.18 (±6.0) min. UD excision was undertaken in prone position in 50 (63.3%) and supine position in 29 (36.7%) patients. Patients in the prone position group were older and had relatively larger and proximal UD. In the multivariable analysis, it was found that a proximally located UD was the main indicator for undergoing surgery in the prone position.Conclusion:Despite longer operative times, prone patient positioning appears to be the preferred option for patients with larger and proximal UD, presumably because it offers better access to the surgical field.

Background Female urethral diverticula (UD) are an uncommon and often overlooked aetiology in women presenting with lower urinary tract symptoms, urethral pain, and recurrent urinary tract infection. With increasing awareness, appropriate imaging is more commonly undertaken with consideration given to surgical management. Objective The video presented demonstrates the technique for excising large and/or complex UD using a modified prone jack-knife position—a position that offers excellent surgical access and allows the surgeon to operate in a more ergonomic position. Design, setting, and participants A retrospective review of the data on patients undergoing excision of UD at a tertiary referral unit was performed. Surgical procedure Urethral and suprapubic catheters (±insertion of ureteric stents) were placed in supine position. UD excised in the modified prone jack-knife position (±placement of a Martius flap). Measurements Subjective cure rate, recurrence rate, rates of postoperative urinary incontinence, need for secondary incontinence procedure, and postoperative complications were measured. Results and limitations A total of 121 patients were operated on in the study period. The mean follow-up time was 10 mo (range 3–40). The most frequent presenting symptoms included a vaginal mass (n = 76, 63%), followed by dysuria (n = 72, 60%) and pelvic pain (n = 71, 59%). An identifiable aetiological factor was present in 45 patients, including traumatic vaginal delivery (18, 15%), prior periurethral surgery (17, 14%), and urethral dilatation (10, 8%). All patients underwent postvoiding magnetic resonance imaging (MRI) to confirm the diagnosis and plan surgery. UD ranged in maximum diameter from 8 to 48 mm, with a mean of 43 mm (standard deviation 9.24). The most common anatomical location was midurethral (55, 46%), followed by distal (36, 30%), proximal (25, 21%), and full length (5, 4%). Most UDs were single in configuration (74%), followed by multiloculated (15%), saddle shaped (7%), and circumferential (5%). On preoperative videourodynamics, 17 (14%) had stress urinary incontinence. UD excision was undertaken in the modified prone jack-knife position in all cases. A Martius flap was utilised in 36 (30%). The median postoperative postvoiding residual was 26 ml (interquartile range 0–40). In total, 88 (73%) patients were continent postoperatively and 16 (13%) experienced de novo stress urinary incontinence. Of the 37 with pre-existing stress incontinence symptoms, 20 (54%) were continent after operation. A total of 14 patients had subsequent autologous fascial sling at 6 mo. In total, five symptomatic recurrences occurred (4%); of these patients, three elected to undergo surgical excision, all of whom had symptom resolution and were continent after operation. A total of 11 patients (9%) experienced a Clavien-Dindo grade I–II complication within 90 d after operation. Five patients complained of dyspareunia, which resolved by 6 mo. Conclusions The modified prone jack-knife position facilitates excellent access for excision of both simple and complex UDs. This positioning of the patient is not widely recognised amongst urologists. Using this approach, there were low rates of symptomatic recurrence and de novo stress incontinence at medium-term follow-up. Associated urinary incontinence resolves in over half of patients following UD excision; hence, we advocate deferring any incontinence procedure until after the results of surgery are established. Patient summary Surgical removal of urethral outpouching (diverticula) in women is challenging due to its potential to damage the nearby sphincter muscle, which controls continence, or the urethra tube. Placement of patients on their front, rather than on their back, provides excellent access for the surgical removal of urethral diverticula. With this approach, we achieved excellent rates of cure and low rates of urinary incontinence at an average follow-up of 10 mo.

Two tortoise species native to the American southwest have experienced significant habitat loss from development and are vulnerable to ongoing threats associated with continued development. Mojave desert tortoises Gopherus agassizii are listed as threatened under the US Endangered Species Act, and Sonoran desert tortoises G. morafkai are protected in Arizona (USA) and Mexico. Substantial habitat for both species occurs on multiple-use public lands, where development associated with traditional and renewable energy production, recreation, and other activities is likely to continue. Our goal was to quantify development to inform and evaluate actions implemented to protect and manage desert tortoise habitat. We quantified a landscape-level index of development across the Mojave and Sonoran desert tortoise ranges using models of potential habitat for each species (152485 total observations). We used 13 years of Mojave desert tortoise monitoring data (4732 observations) to inform the levels and spatial scales at which tortoises may be affected by development. Most (66-70%) desert tortoise habitat has some development within 1 km. Development levels on desert tortoise habitat are lower inside versus outside areas protected by actions at national, state, and local levels, suggesting that protection efforts may be having the desired effects and providing a needed baseline for future effectiveness evaluations. Of the relatively undeveloped desert tortoise habitat, 43% (74030 km2) occurs outside of existing protections. These lands are managed by multiple federal, state, and local entities and private landowners, and may provide opportunities for future land acquisition or protection, including as mitigation for energy development on public lands.

The Akikiki (Oreomystis bairdi) and Akekee (Loxops caeruleirostris) are two honeycreepers endemic to Kauai, Hawaii, that were listed as federally endangered in 2010. Both species are rare, little‐studied, and occur in a remote, roadless area. We analyzed high‐resolution airborne lidar data to identify forest structure and topography metrics associated with Akikiki and Akekee nest locations (88 for Akikiki and 22 for Akekee) and occurrences (3706 for Akikiki and 1581 for Akekee) from 2012 to 2017 on the Alakai Plateau to predict their distribution in unsurveyed areas. Akikiki and Akekee nested in areas with similar forest structure at 10 m resolution, but different maximum tree heights. Akikiki and Akekee foraged in areas with significantly different forest structure (maximum tree height, mean canopy height, relative heights) and topography (slope) based on occurrences. Elevation was consistently one of the most important metrics for predicting both species nest locations and occurrences across scales (10, 100, 250 m) and it appears that both species are at the upper limits of their elevational range. We estimate that the area of suitable nesting habitat for Akikiki is 17.59 km2 while the area of suitable nesting habitat for Akekee is 11.10 km2 at 10 m resolution. The Akikiki has a potential range of 38 km2 while the Akekee has a range of 58 km2 at 100 m resolution. We produce predictive nest and occurrence maps at 10 m and 100 m resolutions to spatially target conservation actions. Results suggest that if avian malaria cannot be controlled and both species populations do not stabilize over the coming years, translocation may be needed to insure their viability.

Penile paraffinoma is a rare cause of penile mass that can occur following injection of liquid paraffin, performed illicitly for penile augmentation. Over the past 2 yr, we have observed an increasing number of cases presenting with the complications of penile paraffinoma; three patients of central European origin have required inpatient treatment at our institution and posed a significant management dilemma. This mini-review aims to review the literature on the aetiopathogenesis, clinical features, diagnosis, and management of penile paraffinoma. A systematic search of PubMed and Scopus was performed with 10 case series and 26 case reports identified between 1956 and 2017. A total of 124 cases, with a mean age of 36.29 yr, were identified. The majority originated in Korea, and the most common injected material was liquid paraffin (80.6%). Patients presented with pain/swelling, ulceration/fistulae, and penile deformity. The majority required surgical excision of paraffinoma followed by reconstruction with a variety of procedures including split skin grafting, scrotal skin flap reconstruction, and prepuce grafting. Mean duration of follow-up was 15.8 mo. Penile paraffinoma remains a rare presentation; however, it can present management difficulties. We have had an increase in cases, with three patients presenting with complications following injection of paraffin in our unit in the past 2 yr. Definitive management includes surgical excision and reconstruction as required with early involvement of plastic surgeons. There may be a role for conservative management; however, long-term outcomes are unclear. There may be a need for targeted preventative measures through public health agencies in communities where the practice is more prevalent. PATIENT SUMMARY: Penile paraffinoma can occur following injection of liquid paraffin or similar substances, generally used by non-healthcare personnel for the purpose of penile augmentations, and can cause significant pain, ulceration, and penile deformity. Definitive management includes surgical excision with reconstruction as required. Prevention of its use through awareness and education may be required in communities where the practice is more common.

The ability to infer paleo-distributions with limited knowledge of absence makes species distribution modeling (SDM) a useful tool for exploring paleobiogeographic questions. Spatial sampling bias is a known issue when modeling extant species. Here we quantify the spatial sampling bias in a North American packrat midden archive and explore its impact on estimating paleo-distributions. We test whether (1) spatial sampling bias inherent in this macrofossil record can influence estimates of paleo-distributions, (2) this bias can alter the ability to measure shifts in distributions and climatic niche breadth from the Northgrippian subdivision of the Holocene (8.3 ka – 4.2 ka) to present day (1950–2000 yr), and (3) bias correction methods can improve estimates of paleo-distributions and analyses of range shifts and niche breadth. We estimate spatial sampling bias for the mid-Holocene period with a three-stage statistical model, each representing a hypothesized source of bias: fossil site availability, preservation and accessibility. This approach enables the use of SDM to evaluate three separate paleo-distributions calibrated on the packrat midden archive: those without bias correction (σ-naive), those created with a standard method (σ-standard), and those created with a novel alternative (σ-modeled) incorporating the three-stage model of bias. We find that paleo-distributions modeled for the mid-Holocene without bias correction (σ-naive) provided poor estimates of hindcast paleo-distributions, and that the σ-modeled correction method improved paleo-distributions for our six species with, on average, 50% higher overlap to hindcast distributions than σ-naive paleo-distributions (σ-standard results fell between σ-naive and σ-modeled).

Context Bladder pain syndrome/interstitial cystitis (BPS/IC) is a poorly understood chronic debilitating condition. Surgery is reserved for severe refractory cases; however, there is no consensus on patient selection or optimal approach. Objective To evaluate the evidence relating to the safety and efficacy of surgical interventions for treating BPS/IC. Evidence acquisition PubMed and Scopus databases were searched for original studies, using keywords “cystectomy”, “interstitial cystitis”, and “bladder pain syndrome”. Articles were reviewed and screened by three independent reviewers. Evidence synthesis A total of 450 patients were identified from 20 eligible studies: mean age was 54.5 yr and 90.2% were female. The median duration of symptoms preoperatively was 60 mo (range 9–84), with a mean follow-up of 45.5 mo. A total of 448 patients underwent surgery: subtotal cystectomy with cystoplasty (48.6%), cystectomy and orthotopic neobladder (21.9%), cystectomy and ileal conduit (11.2%), and urinary diversion only (18.3%). Symptomatic improvement occurred in 77.2%, with higher rates in the total cystectomy and orthotopic neobladder group. Thirty-one patients (6.9%) required secondary total cystectomy and/or ileal conduit diversion; 48.4% subsequently improved. Seventeen studies reported 102 complications overall (26.5%). Overall mortality was 1.3%. Conclusions Overall surgical intervention is associated with a 23% risk of failure to improve symptoms. Higher rates of improvement were reported in patients with total cystectomy. Interpretation should be guarded given the small patient number, multiple centres, and variable outcome measurements. There is a need for prospective randomised studies to answer questions regarding patient selection and optimal surgical approach. Patient summary In this review, we looked at the outcomes of surgery for treatment-refractory bladder pain syndrome/interstitial cystitis. We found overall symptom improvement in 77.2% of patients with a complication rate of 26.5%. However, there remains a need for further studies of higher quality to identify patients who will have symptom improvement and the best surgical option.

Lower urinary tract symptoms (LUTS) in women produce significant bother. Common conditions causing LUTS in women include urinary tract infections, overactive bladder, and stress incontinence. Urethral diverticulae and female urethral strictures are rare pathologies. They can cause symptoms, which can mimic commoner conditions, leading to delay in diagnosis and unnecessary delay in treatment. In this article, we discuss in detail the definition, symptoms, epidemiology, pathogenesis, diagnosis, and treatment option for these two conditions. Further understanding of these conditions will aid in the proper diagnosis and prevent delay in management. Keywords: Urethral diverticula, Female urethral stricture, Lower urinary tract symptoms, Urethral diverticulae, Female urethral stricture, Reconstruction

Objective To describe the surgical approach and outcomes in the treatment of adult patients with complications of childhood hypospadias surgery, as such patients present a significant reconstructive challenge due to the combination of anatomical and cosmetic deformity, which often results in major functional and psychosexual sequelae. Patients and methods We analysed prospectively collected data on 79 adults with complications of childhood hypospadias surgery, who were operated on between 2004 and 2016. Of the 79 patients, 48 underwent a two-stage urethroplasty using a buccal mucosa graft, and 31 underwent a one-stage distal urethroplasty. Results Patients were followed up using flexible cystoscopy (every 6-9 months). The mean (range) follow-up was 48 (12-96) months. Of the 48 patients who underwent a two-stage repair, eight (16%) needed a revision of the first-stage graft. In total, nine of the 48 patients (16%) developed fistula requiring closure after the second stage; all but one was closed successfully on the first attempt, whilst one required two attempts before closure. Only two of the 48 patients that underwent a two-stage procedure required a re-do urethroplasty within 3 years. Of the 31 patients who underwent a one-stage repair, six (19%) needed fistula closure, all of which were successful. No patient required a further urethroplasty during follow-up. Conclusions Despite the significant surgical challenges found in this patient group, excellent long-term functional outcomes can be achieved. As expected there is a need for additional intervention, either for revision of the first stage or to close fistulae and less commonly for further reconstruction for stricture recurrence.

Spatial demographic models can help guide monitoring and management activities targeting at-risk species, even in cases where baseline data are lacking. Here, we provide an example of how site-specific changes in land use and anthropogenic stressors can be incorporated into a spatial demographic model to investigate effects on population dynamics of Golden Eagles (Aquila chrysaetos). Our study focused on a population of Golden Eagles exposed to risks associated with rapid increases in renewable energy development in southern California, U.S.A. We developed a spatially explicit, individual-based simulation model that integrated empirical data on demography of Golden Eagles with spatial data on the arrangement of nesting habitats, prey resources, and planned renewable energy development sites. Our model permitted simulated eagles of different stage-classes to disperse, establish home ranges, acquire prey resources, prospect for breeding sites, and reproduce. The distribution of nesting habitats, prey resources, and threats within each individual's home range influenced movement, reproduction, and survival. We used our model to explore potential effects of alternative disturbance scenarios, and proposed conservation strategies, on the future distribution and abundance of Golden Eagles in the study region. Results from our simulations suggest that probable increases in mortality associated with renewable energy infrastructure (e.g., collisions with wind turbines and vehicles, electrocution on power poles) could have negative consequences for population trajectories, but that site-specific conservation actions could reduce the magnitude of negative effects. Our study demonstrates the use of a flexible and expandable modeling framework to incorporate spatially dependent processes when determining relative effects of proposed management options to Golden Eagles and their habitats.

Daytime and nighttime thermal infrared observations acquired by the ASTER and MODIS instruments onboard the NASA Terra spacecraft have produced a dataset that can be used to map thermophysical properties across large regions, which have implications on surface processes, thermal environments and habitat suitability for desert species. ASTER scenes acquired between 2004 and 2012 are combined using new mosaicking and data-fusion techniques to produce a map of daytime and nighttime land surface temperature with coverage exclusive of the effects of clouds and weather. These data are combined with Landsat 7 visible imagery to generate a consistent map of apparent thermal inertia (ATI), which is related to the presence of exposed bedrock, rocks, fine-grained sediments and water on the surface. The resulting datasets are compared to known geomorphic units and surface types to generate an interpreted mechanical composition map of the entire Mojave Desert at 100 m per pixel that is most sensitive to large clast size distinctions in grain size distribution.

Predicting changes in species distributions under a changing climate is becoming widespread with the use of species distribution models (SDMs). The resulting predictions of future potential habitat can be cast in light of planned land use changes, such as urban expansion and energy development to identify areas with potential conflict. However, SDMs rarely incorporate an understanding of dispersal capacity, and therefore assume unlimited dispersal in potential range shifts under uncertain climate futures. We use SDMs to predict future distributions of the Mojave ground squirrel, Xerospermophilus mohavensis Merriam, and incorporate partial dispersal models informed by field data on juvenile dispersal to assess projected impact of climate change and energy development on future distributions of X. mohavensis. Our models predict loss of extant habitat, but also concurrent gains of new habitat under two scenarios of future climate change. Under the B1 emissions scenario- a storyline describing a convergent world with emphasis on curbing greenhouse gas emissions- our models predicted losses of up to 64% of extant habitat by 2080, while under the increased greenhouse gas emissions of the A2 scenario, we suggest losses of 56%. New potential habitat may become available to X. mohavensis, thereby offsetting as much as 6330 km2 (50%) of the current habitat lost. Habitat lost due to planned energy development was marginal compared to habitat lost from changing climates, but disproportionately affected current habitat. Future areas of overlap in potential habitat between the two climate change scenarios are identified and discussed in context of proposed energy development.

Conservation planning and biodiversity management require information on landscape connectivity across a range of spatial scales from individual home ranges to large regions. Reduction in landscape connectivity due changes in land use or development is expected to act synergistically with alterations to habitat mosaic configuration arising from climate change. We illustrate a multiscale connectivity framework to aid habitat conservation prioritization in the context of changing land use and climate. Our approach, which builds upon the strengths of multiple landscape connectivity methods, including graph theory, circuit theory, and least-cost path analysis, is here applied to the conservation planning requirements of the Mohave ground squirrel. The distribution of this threatened Californian species, as for numerous other desert species, overlaps with the proposed placement of several utility-scale renewable energy developments in the American southwest. Our approach uses information derived at three spatial scales to forecast potential changes in habitat connectivity under various scenarios of energy development and climate change. By disentangling the potential effects of habitat loss and fragmentation across multiple scales, we identify priority conservation areas for both core habitat and critical corridor or stepping stone habitats. This approach is a first step toward applying graph theory to analyze habitat connectivity for species with continuously distributed habitat and should be applicable across a broad range of taxa.

Background Botulinum neurotoxin (BotN) is used to treat detrusor overactivity (DO) refractory to medical treatment. Catheterised patients with symptoms of bladder spasm and catheter bypass leakage are challenging to manage and the efficacy of BotN is not established. Objective To review our experience using intravesical BotN to treat refractory bladder pain and catheter bypass leakage in patients with long-term indwelling catheters. Design, setting, and participants We carried out a review of data prospectively collected for patients with indwelling urethral or suprapubic catheters receiving BotN for the treatment of bladder spasms and catheter bypass leakage in a UK tertiary centre. An unvalidated structured questionnaire was used to ascertain quality of life (QoL) outcomes. Outcome measurements and statistical analysis Qualitative data were collected for patient-reported symptoms and QoL. Paired Student t tests were applied for statistical analysis. Results and limitations Of the 54 catheterised patients who received BotN, 14 (26%) were male and 40 (74%) were female. The mean follow-up was 38 mo. Of the patients, 34 (63%) had a neurological aetiology and 94% had experienced failure of medical therapy before BotN administration. The BotN starting dose was 100 or 200 U and 17 patients (31%) required dose escalation. All 34 neurogenic and six non-neurogenic patients started on 200 U. After treatment, 63% of patients managed their catheter with intermittent drainage and 37% managed on free drainage; 51 patients (94%) reported that their symptoms were controlled and 38% reported being treated for a urinary tract infection following BotN. Patients reported a mean improvement in QoL of 7.7/10 following BotN, while 83% reported a significant reduction in urine leakage (p = 0.0001). Conclusions Outpatient intravesical BotN is safe and efficacious for patients with long-term catheters suffering from bladder pain and catheter bypass leakage. Patient summary Outpatient administration of intravesical botulinum toxin is a safe and effective treatment for patients with a long-term indwelling catheter with bothersome urine storage symptoms. Attention should be paid to urine microbiology results before treatment to ensure appropriate prophylactic antibiotic treatment to reduce the incidence of urinary tract infections.

Background Surgery for stress urinary incontinence (SUI) has been dominated recently by synthetic midurethral tapes. Increasing recognition of serious complications associated with nonabsorbable polypropylene mesh has led to resurgence in interest in alternative approaches, such as the autologous fascial sling (AFS). Despite being an efficacious and durable option in women with recurrent and complex SUI, there has been a reluctance to consider AFS in women with primary SUI due to a perception that it is only appropriate for treating patients with intrinsic sphincter deficiency (ISD) and is associated with high rates of urinary retention and de novo storage symptoms. Objective The video presented demonstrates the technique for a loosely applied midurethral AFS. In contrast to AFS applied at the bladder neck, this technical modification in patients who demonstrate primary SUI without ISD avoids high rates of de novo storage symptoms and urinary retention. Design, setting, and participants A retrospective review of data on patients undergoing AFS at a tertiary referral unit. Surgical procedure AFS placement in a "loose" fashion using a short length of fascia suspended on a suture bilaterally at the midurethral level rather than at the bladder neck and only using more tension in patients with ISD. Measurements Subjective cure rate, rates of postoperative storage symptoms, and urinary retention necessitating intermittent self-catheterisation (ISC). Results and limitations A total of 106 patients underwent AFS; the mean follow-up period was 9 mo. The mean age was 52.6 (range 24–83) yr. In total, 46.2% had primary SUI, whilst all of the remaining 53.8% had undergone prior surgical intervention. Overall subjective cure occurred in 79.2% of patients; a further 15.1% described significant subjective improvement in symptoms, whilst 5.7% reported no change in symptoms. In those with primary SUI, rates of subjective cure, improvement, and nonresolution of symptoms were 87.8%, 12.2%, and 0%, respectively. In individuals with prior surgical intervention, rates of subjective cure, improvement, and nonresolution of symptoms were 72.0%, 17.5%, and 10.5%, respectively. De novo storage symptoms occurred in 8.2% of those with primary SUI compared with 14.0% of those with prior surgical intervention. Only 2.0% patients with primary SUI needed to perform ISC beyond 2 wk compared with 10.5% of those after prior surgery. Conclusions A midurethral AFS appears to be effective and safe both in women with primary SUI who want to avoid the placement of permanent material and its attendant risks, and in more complex cases where this is less appropriate. Patient summary A graft taken from the covering of the abdominal muscle or the outer aspect of the thigh is an alternative to a synthetic vaginal mesh in women who have stress urinary incontinence requiring surgical treatment. Placing the graft loosely at the midpoint of the urethral tube, rather than at the bladder neck, reduces the risk of postoperative voiding difficulty and overactive bladder symptoms. Long-term data have suggested an outcome at least as good as a synthetic nonabsorbable tape without the potential for sling erosion into adjacent structures, as it avoids the use of nonabsorbable material.

Pelvic fracture urethral injuries comprise one of the most challenging reconstructive procedures in urology. The obliterated or stenosed urethra can usually be effectively repaired by an end-to-end anastomosis (bulbomembranous anastomosis). To achieve this, a progression of surgical steps can be used to make a tension-free anastomosis. Before undertaking surgery it is important to comprehensively assess the patient to define their anatomical defects, in particular the site of the stenosis, the length of the distraction injury and the integrity of the bladder neck, and thus guide preoperative decision-making. Contemporary reports suggest that most pelvic fracture urethral distraction defects (PFUDD) can be adequately managed by a perineal approach. Nevertheless it is essential that all surgeons treating these injuries are familiar with the whole spectrum of operative steps that are necessary to repair PFUDD.

Urological disease is highly prevalent and affects both males and females in all age groups. The disorders affecting the urinary tract are diverse encompassing neoplastic, inflammatory, neurogenic, infective as well functional disease. Urological emergencies represent a significant proportion of surgical admissions, therefore the ability to properly assess patients is essential. History-taking and clinical examination form the basis of the urological assessment, which is further aided by bedside tests such as urinalysis as well as basic laboratory investigations including urine microscopy/culture and blood tests. Thereafter imaging with radiography, ultrasound or computed tomography scanning is often undertaken in the acute situation to confirm the cause of haematuria or loin pain. MRI scanning is mainly used to image the pelvic organs and stage bladder or prostatic malignancy. Nuclear medicine is useful in detecting metastases from urological malignancy as well estimating the split renal function and assessing renal obstruction. Direct inspection of the urinary tract is possible through endoscopic techniques, essential for determining the cause of haematuria. Urodynamic studies are undertaken to assess the underlying pathophysiological abnormality causing urinary symptoms and to plan subsequent treatment. We review the basis of history-taking and examination in urology as well as describing the common investigations undertaken.

Genetic diversity within species provides the raw material for adaptation and evolution. Just as regions of high species diversity are conservation targets, identifying regions containing high genetic diversity and divergence within and among populations may be important to protect future evolutionary potential. When multiple co-distributed species show spatial overlap in high genetic diversity and divergence, these regions can be considered evolutionary hotspots. We mapped spatial population genetic structure for 17 animal species across the Mojave Desert, USA. We analyzed these in concurrence and located 10 regions of high genetic diversity, divergence or both among species. These were mainly concentrated along the western and southern boundaries where ecotones between mountain, grassland and desert habitat are prevalent, and along the Colorado River. We evaluated the extent to which these hotspots overlapped protected lands and utility-scale renewable energy development projects of the Bureau of Land Management. While 30–40% of the total hotspot area was categorized as protected, between 3–7% overlapped with proposed renewable energy project footprints, and up to 17% overlapped with project footprints combined with transmission corridors. Overlap of evolutionary hotspots with renewable energy development mainly occurred in 6 of the 10 identified hotspots. Resulting GIS-based maps can be incorporated into ongoing landscape planning efforts and highlight specific regions where further investigation of impacts to population persistence and genetic connectivity may be warranted.

Mohave ground squirrels Xerosper- mophilus mohavensis Merriam are small ground- dwelling rodents that have a highly restricted range in the northwest Mojave Desert, California, USA. Their small natural range is further reduced by habitat loss from agriculture, urban develop- ment, military training and recreational activities. Development of wind and solar resources for re - newable energy has the potential to further re - duce existing habitat. We used maximum entropy habitat models with observation data to describe current potential habitat in the context of future renewable energy development in the region. While 16% of historic habitat has been impacted by, or lost to, urbanization at present, an additional 10% may be affected by renewable energy devel- opment in the near future. Our models show that X. moha vensis habitat suitability is higher in areas slated for renewable energy development than in surrounding areas. We provide habitat maps that can be used to develop sampling designs, evaluate conservation corridors and inform development planning in the region.

Aim We explored lineage diversification within desert-dwelling fauna. Our goals were (1) to determine whether phylogenetic lineages and population expansions were consistent with younger Pleistocene climate fluctuation hypotheses or much older events predicted by pre-Pleistocene vicariance hypotheses, (2) to assess concordance in spatial patterns of genetic divergence and diversity among species and (3) to identify regional evolutionary hotspots of divergence and diversity and assess their conservation status. Location Mojave, Colorado, and Sonoran Deserts, USA. Methods We analysed previously published gene sequence data for twelve species. We used Bayesian gene tree methods to estimate lineages and divergence times. Within each lineage, we tested for population expansion and age of expansion using coalescent approaches. We mapped interpopulation genetic divergence and intra-population genetic diversity in a GIS to identify hotspots of highest genetic divergence and diversity and to assess whether protected lands overlapped with evolutionary hotspots. Results In seven of the 12 species, lineage divergence substantially predated the Pleistocene. Historical population expansion was found in eight species, but expansion events postdated the Last Glacial Maximum (LGM) in only four. For all species assessed, six hotspots of high genetic divergence and diversity were concentrated in the Colorado Desert, along the Colorado River and in the Mojave/Sonoran ecotone. At least some proportion of the land within each recovered hotspot was categorized as protected, yet four of the six also overlapped with major areas of human development. Main conclusions Most of the species studied here diversified into distinct Mojave and Sonoran lineages prior to the LGM – supporting older diversification hypotheses. Several evolutionary hotspots were recovered but are not strategically paired with areas of protected land. Long-term preservation of species-level biodiversity would entail selecting areas for protection in Mojave and Sonoran Deserts to retain divergent genetic diversity and ensure connectedness across environmental gradients.

The inability to generate a voiding contraction sufficient to allow efficient bladder emptying within a reasonable time frame is a common problem seen in urological practice. Typically, the symptoms that arise are voiding symptoms, such as weak and slow urinary flow. These symptoms can cause considerable bother to patients and impact upon quality of life. The urodynamic finding of inadequate detrusor contraction has been termed detrusor underactivity (DUA). Although a definition is available for this entity, there are no widely accepted diagnostic criteria. Drawing parallels to detrusor overactivity and the overactive bladder, the symptoms arising from DUA have been referred to as the “underactive bladder” (UAB), while attempts to crystallize the definition of UAB are now ongoing. In this article, we review the contemporary literature pertaining to the epidemiology and etiopathogenesis of DUA as well as discuss the definitional aspects that are currently under consideration.

Assessing the recovery of the federally listed Mojave population of desert tortoises Gopherus agassizii requires detecting subtle changes in population size over a period of many years. The methods that have been employed by the US Fish and Wildlife Service to estimate population density of desert tortoises are inadequate for detecting modest trends in population density, partly due to a hidden variance in a parameter (g0) that corrects for the proportion of tortoises that are inactive and thus unavailable for sampling when population density is being assessed. We used small dataloggers to record the activity of tortoises throughout their active season, and derived daily esti- mates of g0, which we compared with the 2004 estimate published by the US Fish and Wildlife Ser- vice. Due to the substantial variation in animal activity that we found within and among days during the active season, we used a daily method to estimate density. We found that this method, while pro- viding a more accurate assessment of g0, translates into estimates of density with coefficients of vari- ation that are 4" larger than previously reported due to the variation in g0 and n (number of animals encountered). This discrepancy could adversely influence managers' perceptions of population recovery for desert tortoises, and could undermine any ability to monitor the efficacy of recovery actions for populations.

Background There are several techniques for characterising and localising an anterior urethral stricture, such as preoperative retrograde urethrography, ultrasonography, and endoscopy. However, these techniques have some limitations. The final determinant is intraoperative assessment, as this yields the most information and defines what surgical procedure is undertaken. Objective We present our intraoperative approach for localising and operating on a urethral stricture, with assessment of outcomes. Design, setting, and participants A retrospective review of urethral strictures operated was carried out. All patients had a bulbar or bulbomembranous urethroplasty. All patients were referred to a tertiary centre and operated on by two urethral reconstructive surgeons. Surgical procedure Intraoperative identification of the stricture was performed by cystoscopy. The location of the stricture is demonstrated externally on the urethra by external transillumination of the urethra and comparison with the endoscopic picture. This is combined with accurate placement of a suture through the urethra, at the distal extremity of the stricture, verified precisely by endoscopy. Outcome measures and statistical analysis Clinical data were collected in a dedicated database. Intraoperative details and postoperative follow-up data for each patient were recorded and analysed. A descriptive data analysis was performed. Results and limitations A representative group of 35 male patients who had surgery for bulbar stricture was randomly selected from January 2010 to December 2013. Mean follow-up was 13.8 mo (range 2–43 mo). Mean age was 46.5 yr (range 17–70 yr). Three patients had undergone previous urethroplasty and 26 patients had previous urethrotomy or dilatation. All patients had preoperative retrograde urethrography and most (85.7%) had endoscopic assessment. The majority of patients (48.6%) had a stricture length of >2–7cm and 45.7% of patients required a buccal mucosa graft. There were no intraoperative complications. Postoperatively, two patients had a urinary tract infection. All patients were assessed postoperatively via flexible cystoscopy. Only one patient required subsequent optical urethrotomy for recurrence. Conclusions Our intraoperative strategy for anterior urethral stricture assessment provides a clear stepwise approach, regardless of the type of urethroplasty eventually chosen (anastomotic disconnected or Heineke-Mikulicz) or augmentation (dorsal, ventral, or augmented roof strip). It is useful in all cases by allowing precise localisation of the incision in the urethra, whether the stricture is simple or complex. Patient summary We studied the treatment of bulbar urethral strictures with different types of urethroplasty, using a specific technique to identify and characterise the length of the stricture. This technique is effective, precise, and applicable to all patients undergoing urethroplasty for bulbar urethral stricture.

Introduction To assess the feasibility of converting from 300IU to 200IU OnabotulinumtoxinA in patients diagnosed with either idiopathic detrusor overactivity (IDO) or neurogenic detrusor overactivity (NDO). Material and methods Retrospective case-notes review of patients who were converted from 300IU to 200IU OnabotulinumtoxinA. Subjective patient reported improvements at interview and bladder diary reported parameters of urgency, urgency incontinence, frequency and nocturia. Results Forty-four patients had received 300IU OnabotulinumtoxinA and were switched to 200IU after July 2008, 28 for IDO and 16 for NDO. Thirty-seven patients reported ongoing improvement with 200IU OnabotulinumtoxinA, six patients had worsening in their symptoms since down-titrating to 200IU and one patient did not attend follow-up. Improvement in urgency and urgency incontinence episodes per day were 82% and 72%, respectively, in patients who received 200IU. Of the 44 patients, 39 continued to receive 200IU, four requested up-titration to 300IU (due to decreased effect) and one did not attend after the 1st treatment. After converting from 300IU to 200IU, additional three patients were started on CISC for de novo voiding difficulty. Conclusions Seventy-nine percent of patients were satisfied with their symptoms after switching from 300IU to 200IU OnabotulinumtoxinA. Only 9% of patients (all with NDO) reverted back to receiving 300IU. This study showed similar efficacy and longevity in the majority of patients (90%) using 200IU in both NDO and IDO.

Background Urethral diverticula (UDs) affect between 1% and 6% of adult women. A total of 1.4% of women with stress urinary incontinence (SUI) have a UD. Clinically significant diverticula are rare and can be challenging to manage. Objective To review results of surgery on UDs in a single surgical centre. Design, setting, and participants We retrospectively evaluated a group of 89 patients with symptomatic UDs referred for surgical intervention to one teaching hospital. Data were from two surgeons over an 8-yr period between October 2004 and November 2012. Follow-up period ranged from 3 mo to 20 mo, and all patients were physically reviewed postoperatively in an outpatient setting. Intervention The surgical technique involved placing the patient prone, ureteric catheterisation, dissection and removal of the diverticulum, and layered closure. Where a large defect was present following excision, a Martius flap was interposed. Outcome measurements and statistical analysis Outcome data collected included symptomatic cure, continence, de novo SUI, early versus late complications, and recurrence. Results and limitations Early complications included one urinary tract infection and one Martius graft infection, both requiring intravenous antibiotics. Overall, 72% of patients were dry and cured postoperatively; 13 patients had de novo SUI following surgery. Those with bothersome SUI went on to have an autologous sling at 6 mo. All were dry; three (23%) required clean intermittent self-catheterisation. Three patients had a recurrent residual diverticulum (3.4%) following surgery. One chose conservative management. The other two had a redo diverticulectomy performed via a dorsal approach. They have recovered well and are dry. Two (2.2%) diverticula revealed unexpected abnormal pathology. The first was a leiomyoma; the second was a squamous cell carcinoma requiring further surgery. Conclusions The recommended preoperative imaging is postvoid sagittal magnetic resonance imaging and appropriate use of urodynamic assessment at baseline. The 72% dry rate (including a number with preoperative incontinence) is comparable with the literature as is the development of de novo SUI in 15% of patients. There is a small risk of unexpected tumours (2%). Patient summary A urethral diverticulum should be excluded as a diagnosis in anyone troubled by symptoms of a swelling of the urethra often associated with discomfort, pain on intercourse, urinary dribbling after passing urine, and/or recurrent urinary infections. In these circumstances patients should seek advice from their doctors and consider referral for a specialist assessment. If the diagnosis is made and the problem is symptomatic, surgery is likely to resolve the problem but should be carried out in a specialist centre with expertise in the management of this condition.

2405-4569/# 2016 Published by Elsevier B.V. on behalf of European Associ A 43-yr-old woman underwent a total abdominal hysterectomy for benign disease. The procedure appeared to be straightforward, although heavy bleeding around the left ovarian vascular pedicle was encountered. This needed additional sutures for control. Postoperatively the patient developed left loin pain and was found to have new-onset left-sided hydronephrosis on an abdominal ultrasound scan. A percutaneous nephrostomy was inserted into the left kidney and renal pelvis, and 2 d later this was followed by percutaneous antegrade ureteric stenting. The patient then developed continuous urinary leakage per vagina despite a period of catheterisation. A vesicovaginal fistula was diagnosed and she was referred to our specialist centre for repair. We performed a cystogram (Fig. 1) and upper tract imaging via a computed tomography urogram. We then performed an examination under anaesthesia, including cystoscopy with bilateral retrograde studies (Fig. 2).

Introduction Whilst buccal mucosa is the most versatile tissue for urethral replacement, the quest continues for an ideal tissue replacement for the urethra when substantial tissue transfer is needed. Previously we described the development of autologous tissue-engineered buccal mucosa (TEBM). Here we report clinical outcomes of the first human series of its use in substitution urethroplasty. Methodology Five patients with urethral stricture secondary to lichen sclerosus (LS) awaiting substantial substitution urethroplasty elected to undergo urethroplasty using TEBM, with full ethics committee support. Buccal mucosa biopsies (0.5cm) were obtained from each patient. Keratinocytes and fibroblasts were isolated and cultured, seeded onto sterilised donor de-epidermised dermis, and maintained at air–liquid interface for 7–10 d to obtain full-thickness grafts. These grafts were used for urethroplasty in a one-stage ( n =2) or a two-stage procedure ( n =3). Follow-up was performed at 2 and 6 wk, at 3, 6, 9, and 12 mo, and every 6 mo thereafter. Results Follow-up ranged from 32 to 37 mo (mean, 33.6). The initial graft take was 100%, as assessed by visual inspection. Subsequently, one patient had complete excision of the grafted urethra and one required partial graft excision, for fibrosis and hyperproliferation of tissue, respectively. Three patients have a patent urethra with the TEBM graft in situ, although all three required some form of instrumentation. Conclusions Whilst TEBM may in the future offer a clinically useful autologous urethral replacement tissue, in this group of patients with LS urethral strictures, it was not without complications, namely fibrosis and contraction in two of five patients.

Predicting wildfires that affect broad landscapes is important for allocating suppression resources and guiding land management. Wildfire prediction in the south-western United States is of specific concern because of the increasing prevalence and severe effects of fire on desert shrublands and the current lack of accurate fire prediction tools. We developed a fire risk model to predict fire occurrence in a north-eastern Mojave Desert landscape. First we developed a spatial model using remote sensing data to predict fuel loads based on field estimates of fuels. We then modelled fire risk (interactions of fuel characteristics and environmental conditions conducive to wildfire) using satellite imagery, our model of fuel loads, and spatial data on ignition potential (lightning strikes and distance to roads), topography (elevation and aspect) and climate (maximum and minimum temperatures). The risk model was developed during a fire year at our study landscape and validated at a nearby landscape; model performance was accurate and similar at both sites. This study demonstrates that remote sensing techniques used in combination with field surveys can accurately predict wildfire risk in the Mojave Desert and may be applicable to other arid and semiarid lands where wildfires are prevalent.

Spatially explicit decision support systems are assuming an increasing role in natural resource and conservation management. In order for these systems to be successful, however, they must address real-world management problems with input from both the scientific and management communities. The National Training Center at Fort Irwin, California, has expanded its training area, encroaching U.S. Fish and Wildlife Service critical habitat set aside for the Mojave desert tortoise (Gopherus agassizii), a federally threatened species. Of all the mitigation measures proposed to offset expansion, the most challenging to implement was the selection of areas most feasible for tortoise translocation. We developed an objective, open, scientifically defensible spatially explicit decision support system to evaluate translocation potential within the Western Mojave Recovery Unit for tortoise populations under imminent threat from military expansion. Using up to a total of 10 biological, anthropogenic, and/or logistical criteria, seven alternative translocation scenarios were developed. The final translocation model was a consensus model between the seven scenarios. Within the final model, six potential translocation areas were identified.