A Multi-Institutional Experience Utilizing Boari Flap in Robotic Urinary Reconstruction.

Objectives: There is presently scarce literature describing the outcomes of patients undergoing robotic ureteral reconstruction (RUR) using the Boari flap (BF) technique. Herein, we report our prospective, multi-institutional experience using BF in patients undergoing robotic urinary reconstruction. Patients and Methods: We reviewed our prospective, multicenter database for all patients undergoing RUR between September 2013 and September 2021 in which a BF was utilized. Preoperative, perioperative, and follow-up data were collected and analyzed. Major complications were defined as a Clavien-Dindo classification grade >2. Surgical failure was defined as recurrent symptoms, obstruction on imaging, or the need for additional surgical interventions. Results: We identified 50 patients who underwent RUR using a BF. Four (8%) underwent the Single Port approach. Twenty-four patients (48%) were active or former tobacco users. Thirty-four patients (68%) had previously undergone abdominal surgery, 17 (34%) had prior ureteral stricture interventions, and 9 (18%) had prior abdominopelvic radiation. The most common stricture etiology was malignancy (34.4%). The median follow-up was 15.0 months with a 90% (45/50) success rate. The five documented cases of failure occurred at a median of 1.8 months following the procedure. Conclusion: In the largest prospective, multi-institutional study of patients undergoing RUR with BF in the literature to date, we demonstrate a low rate of complications and a high rate of surgical success in three tertiary academic medical centers. All observed failures occurred within 2 months of surgical intervention.

Overactive bladder phenotypes: development and preliminary data.

INTRODUCTION: The purpose of this study is to develop overactive bladder (OAB) phenotypes that can be used to develop diagnostic and treatment pathways and offer clues to the underlying etiologies of patients with OAB. MATERIALS AND METHODS: This is a retrospective, multicenter study of patients with lower urinary tract symptoms (LUTS). Evaluation included a 24-hour bladder diary (24HBD), the lower urinary tract symptoms score (LUTSS) questionnaire, uroflowmetry (Q), and post-void residual urine (PVR) measurement. Patients completed the 24HBD and LUTSS on a smartphone application or paper. Those with an OAB symptom sub-score (OABSS) ≥ 8 were included. An expert panel developed a phenotype classification system based on variables considered to be important for treatment. RESULTS: The following variables were selected for inclusion in the phenotype modeling: 24-hour voided volume (24HV), maximum voided volume (MVV), Qmax and PVR. Subjects were divided into three phenotypes based on the 24HV: polyuria (24HV > 2.5 L), normal (24 HV 1-2.5 L), and oliguria (24HV < 1 L). Each phenotype was subdivided based on MVV, Qmax & PVR, resulting in 18 sub-types. Five hundred thirty-three patients, 348 men and 185 women, completed the LUTSS and 24HBD. OAB was present in 399 (75%) - 261 men and 138 women. The prevalence of the primary phenotypes was polyuria (25%), normal (63%), and oliguria (11%). CONCLUSIONS: Classification of OAB variants into phenotypes based on 24HV, MVV, Qmax, and PVR provides the substrate for further research into the diagnosis, etiology, treatment outcomes and development of granular diagnostic and treatment algorithms.

Clinical Outcomes of COVID-19 Patients with Pre-existing, Compromised Immune Systems: A Review of Case Reports.

In the ongoing COVID-19 pandemic, all COVID-19 patients are naïve patients as it is the first-time humans have been exposed to the SARS-CoV-2 virus. As with exposure to many viruses, individuals with pre-existing, compromised immune systems may be at increased risk of developing severe symptoms and/or dying because of (SARS-CoV-2) infection. To learn more about such individuals, we conducted a search and review of published reports on the clinical characteristics and outcomes of COVID-19 patients with pre-existing, compromised immune systems. Here we present our review of patients who possess pre-existing primary antibody deficiency (PAD) and those who are organ transplant recipients on maintenance immunosuppressants. Our review indicates different clinical outcomes for the patients with pre-existing PAD, depending on the underlying causes. For organ transplant recipients, drug-induced immune suppression alone does not appear to enhance COVID-19 mortality risk - rather, advanced age, comorbidities, and the development of secondary complications appears required.

Surgery for Stress Urinary Incontinence: Autologous Fascial Sling.

This article describes the operative technique of autologous fascial pubovaginal sling (AFPVS) surgery, examines the senior author's outcomes with AFPVS, compares these outcomes with those of other large studies and meta-analyses, and compares the safety and efficacy of AFPVS with those of the synthetic midurethral sling (SMUS). Recently, the SMUS has become the treatment of choice for most surgeons. The efficacy of the SMUS remains unchallenged and comparable with that of AFPVS, but SMUS are associated with more severe complications. In the author's opinion, the AFPVS should remain the gold standard for treating SUI.

An extra pair of eyes: do patients want a chaperone when having an anogenital examination?

BACKGROUND: Anogenital examinations can be embarrassing for patients and can leave clinicians open to accusations of professional misconduct. Little is known about the attitudes of patients in Australia towards the use of chaperones. METHODS: In 2006, we surveyed 480 patients attending two sexual health clinics in northern Sydney. Our aim was to determine their attitudes towards the use of chaperones for anogenital examinations. RESULTS: Of the 480, 58% were male and 42% female. Most women (64%) preferred a female examining clinician, whereas most men (68%) had no preference for gender of the examining clinician (P < 0.0001). While 32% of women wanted a chaperone if being examined by a male, 29% did not. Only 4% of women wanted a chaperone when being examined by a female. Only 1% of men wanted a chaperone irrespective of the sex of the examining clinician. Independent predictors of women wanting a chaperone with a male clinician were preference for a female clinician (OR 6.59, 2.48-17.5; P < 0.001) and preference for a female chaperone (OR 4.02, 1.44-11.2; P = 0.008). The majority of participants felt that they should be involved in the decision to have a chaperone. CONCLUSIONS: Although a substantial minority of women want a chaperone when being examined by a male, a similar proportion do not want a chaperone. If a woman requests a female clinician, she should be offered a chaperone if there is only a male examiner available. Further study is required to determine why some women want a chaperone and how to distinguish them from other women.

Pelvic inflammatory disease.

BACKGROUND: Pelvic inflammatory disease (PID) is a treatable condition with serious long term sequelae. The recognition and diagnosis of PID can be challenging due to the wide spectrum of disease and clinical presentation. OBJECTIVE: This article discusses the presentation, aetiology, diagnosis, management, and prevention of PID. DISCUSSION: A high index of suspicion and a low threshold for treatment for women at risk of PID may help decrease the burden of serious associated morbidity. Screening for chlamydia in young sexually active women may reduce the incidence of PID.

Men who have sex with men--a management approach for GPs.

BACKGROUND: At least one in 20 Australian men report sexual contact with another man in their lifetime. Men who have sex with other men have higher rates of sexually transmitted infections, and are more likely to experience mental health problems and use recreational drugs and alcohol. OBJECTIVE: This article describes the health problems and sexual behaviour of men who have sex with men and provides an outline and an approach to discussing sexuality in general practice. DISCUSSION: Sexuality can be difficult to discuss in general practice. A nonjudgmental approach to men who have sex with men may facilitate early identification of the relevant health issues.

Herpes simplex virus serology in an asymptomatic patient.

BACKGROUND: Genital herpes is one of the most common sexually transmitted infections. While genital herpes can present with self limiting genital lesions, most people with genital herpes simplex virus (HSV) infection are asymptomatic or have unrecognised infection. Use of type specific serology for HSV antibodies can identify these individuals. OBJECTIVE: This article discusses the role and use of HSV serology in asymptomatic patients, including pre- and post-test counselling and interpreting results. DISCUSSION: The indications for HSV serology in an asymptomatic patient are limited. Patients tested for HSV antibodies require careful assessment and counselling. Identifying asymptomatic genital herpes should ideally only be done in cases where there may be clinical benefit. Limitations of type specific HSV serology need to be considered when interpreting the results in low risk patients.

Syphilis treatment: old and new.

Syphilis has challenged scientists and clinicians since its first appearance in the late 1400s and debate continues to surround the best practice in management. Difficulties in defining the goals of successful treatment have contributed to problems in determining recommendations for the ideal management. Treatment regimens currently in use were developed before randomised controlled trials became standard. This, combined with national differences in disease definition, staging and varying interpretations of the studies, as well as the emergence of complicating comorbid conditions, such as HIV, has resulted in a lack of consensus for treatment. This paper will discuss the history and current treatment of syphilis focusing on dilemmas faced by clinicians today, including the emergence of a resistant strain. Despite the difference between current national guidelines, penicillin G largely remains the treatment of choice. Close follow up, monitoring and ensuring adequate compliance remain the most important aspects in the treatment of syphilis.

Contraception and sexually transmitted infections.

BACKGROUND: Many women seek contraceptive advice from general practitioners. These consultations provide an opportunity to discuss the prevention of sexually transmitted infections (STIs) including human immunodeficiency virus (HIV). OBJECTIVE: This article discusses the effect of various contraceptive methods on the transmission of STIs and HIV. It also highlights issues relevant to achieving both contraception and STI/HIV prevention, with a focus on younger women. DISCUSSION: There is no ideal method to achieve protection against both pregnancy and STIs/HIV. Counselling about risks of STIs/HIV, providing the option of being tested for bacterial STIs, hepatitis B and HIV at the start of new relationships and promoting condom use for casual sex and concurrent sexual relationships is to be encouraged.

Cervical screening and human papillomavirus.

BACKGROUND: Cervical screening in Australia has been successful in reducing the incidence and mortality of cervical cancer. Human papilloma virus (HPV) is a common sexually transmitted infection and an integral agent in the development of cervical cancer. OBJECTIVE: This article discusses cervical screening, HPV infection and counselling women with low grade abnormalities on cervical cytology. DISCUSSION: For most women, detectable HPV infection is transient and subclinical. While HPV is a precursor to cervical cancer, this is a rare outcome of HPV infection. Minor abnormalities on cervical cytology reflecting acute HPV infection are common. Women with low grade Pap test abnormalities require reassurance and education about the prevalence and natural history of HPV.

Recurrent vulvovaginal candidiasis.

BACKGROUND: Recurrent vulvovaginal candidiasis affects up to 5% of premenopausal women. It is often associated with significant morbidity and may be difficult to manage. OBJECTIVE: This article discusses the pathogenesis investigations and management of recurrent vulvovaginal candidiasis. DISCUSSION: Recurrent vulvovaginal candidiasis may be misdiagnosed as presenting signs and symptoms are not specific. Examination and microbial testing are required to confirm the diagnosis. Some women appear to have an abnormal host response to the presence of candida species in the vagina, making them susceptible to recurrent episodes of symptomatic infection. Women with recurrent vulvovaginal candidiasis generally respond to a course of suppressive treatment, but many relapse after ceasing therapy.

STIs in pregnancy. An update for GPs.

BACKGROUND: Pregnancy and sexually transmitted infections (STIs) are both consequences of unprotected vaginal sex. In addition to causing maternal morbidity in their own right, many STIs including human immunodeficiency virus (HIV) can be transmitted to the neonate. Antenatal screening during pregnancy provides an opportunity to minimise or eliminate the antepartum, intrapartum and postpartum consequences of most STIs. OBJECTIVE: This article discusses the diagnosis, management and treatments available for STIs in pregnancy to minimise morbidity and mortality for both mother and child. DISCUSSION: HIV testing in antenatal care should be added to routine syphilis and hepatitis B serology, as effective HIV interventions can significantly reduce the risk of mother-child transmission. Consideration should be given to testing in women less than 25 years of age for chlamydia and those women at increased sexual risk. Male partners should not be forgotten and contact tracing, treatment and follow up offered. Due to the very small risk associated with genital warts and genital herpes, normalisation, information and reassurance are appropriate for the majority of women affected.

The sexually transmitted infection 'check up'.

BACKGROUND: Many sexually transmitted infections (STIs) and blood borne viruses (BBV) such as HIV are asymptomatic. Early detection is important for minimising associated risks. With appropriate treatment and management (including contact tracing) it is possible to substantially reduce morbidity as well as transmission to sexual partners and the neonate. OBJECTIVE: This paper outlines which tests should be administered to otherwise 'well' individuals. It also examines the questions of when, why and how to respond to requests for an STI 'screen' or 'check up'. DISCUSSION: Testing and screening for asymptomatic STIs and BBV are important, especially in situations where proven interventions can decrease morbidity and transmission. Screening for STIs also provides the opportunity in a one-on-one consultation for health promotion. Sexually transmitted infection testing can also initiate a conversation about 'safer sex' and may help address other concerns patients may have.

Pelvic inflammatory disease.

BACKGROUND: Pelvic inflammatory disease (PID) is a treatable condition with serious long term sequelae. Due to the wide spectrum of disease and clinical presentation, diagnosis can often be challenging. OBJECTIVE: This article discusses the diagnosis, management and treatment of PID in the general practice setting. DISCUSSION: Prompt and effective treatment is essential in cases of PID. A high index of suspicion for symptomatic women at risk may help decrease the burden of serious associated morbidity.