Multidisciplinary management of sexual and gender minorities with bladder cancer.

Bladder cancer, a common urologic malignancy, has poor morbidity and mortality in sexual and gender minority (SGM) individuals, stemming from higher risk, poor access to care and lack of quality cancer care. To begin addressing this disparity, this review offers key considerations for evaluation, diagnosis and treatment of SGM individuals with bladder cancer. In addition to thorough medical and surgical history, initial evaluation should include discussion of patient goals for sexual function and organ preservation, as well as an evaluation of sexual function. Prior gender affirming surgery and patient specific sexual function goals will impact diagnosis and treatment approaches, including surgical and radiation therapy. Throughout care for SGM individuals with bladder cancer, it is critical to acknowledge the systemic discrimination that may be experienced by these individuals and approach conversations with sensitivity and humility and incorporate mental and social support as appropriate.

Legal Outcomes of Litigation After Iatrogenic Genitourinary Trauma.

OBJECTIVE: To evaluate plaintiff and defendant characteristics associated with iatrogenic genitourinary (GU) trauma litigation and outcomes of closed claims. METHODS: LexisNexis was queried in April 2023 using terms related to GU organs and injury, and manually reviewed for iatrogenic cases. Case details including defendant, organ involvement, and legal outcome were obtained. Multinomial regression analysis was performed to identify factors associated with outcome. RESULTS: Four hundred ten cases involving 611 defendants were identified, with the ureter the most commonly affected organ (202/410, 49.3%). Most cases involved adult plaintiffs (380, 92.7%) and resulted in favor of the defense (227, 55.4%). Injuries resulted most frequently from gynecologic surgeries (179, 43.7%). Defendants were most commonly obstetricians/gynecologists (243/611, 39.8%) and urologists (168, 27.5%). Penile (OR 6.3 [95% CI 2.5-16.1]) and urethral (OR 4.8 [2.0-11.7]) injuries were associated with greater odds of a plaintiff verdict relative to ureter injury. A plaintiff verdict was also more likely when defendants were academic hospitals compared to individual practitioners (OR 4.3 [1.9-9.9]). In cases ruling in favor of the plaintiff, indemnity payments were larger when the defendants were comprised of individual practitioners compared to a hospital or medical group (median $549,613 vs $250,000, P <.001). CONCLUSION: Urologists may be involved in medical malpractice lawsuits for iatrogenic injury even when they are uninvolved in the index procedure. Most cases that reach litigation result in defense verdicts regardless of the GU organ injured. Defendant characteristics associated with plaintiff verdicts are more nuanced, and providers should be aware of potential downstream effects of litigation.

Are cisnormative surveys adequate to assess sexual well-being in trans men post-genital gender-affirming surgery?

INTRODUCTION: For transmasculine spectrum individuals, there is a lack of validated surveys to assess sexual well-being (SWB) post-genital gender-affirming surgery. Currently, either providers are designing their own SWB surveys or surveys designed for cisgender men are being used. OBJECTIVE: This study investigated the applicability of SWB surveys validated for cisgender men to transmasculine spectrum individuals post-genital gender-affirming surgery (TMSX). Recognizing the paucity of validated tools for assessing SWB in transmasculine individuals post-genital gender-affirming surgery (TMSX), we evaluated current surveys for their inclusiveness and relevance to this population. METHODS: Our methodology involved analyzing surveys validated in English-speaking North American cisgender men. We conducted a systematic review, yielding 31 surveys, out of which 12 met our inclusion criteria. These were then assessed against the 10 domains of holistic SWB as identified by Özer et al. Each survey was scored based on its reflection of these domains, thus generating an SWB score. Additionally, we performed a thematic analysis to identify areas needing modification for better applicability to TMSX. RESULTS: Our findings indicate an average SWB score of 5.17 out of 10 across the surveys. The surveys predominantly addressed sexual function, with a marked underrepresentation of domains like quality of life, sexuality, and sexual pleasure. This underscores the tendency of these surveys to focus more on the biological mechanisms of sex, rather than on a nuanced biopsychosocial understanding. Thematic analysis revealed significant gaps, such as the irrelevance of questions about erections and ejaculations for TMSX, and the need for greater emphasis on psychosocial factors. CONCLUSION: Given these gaps and the inadequacy of most cisnormative surveys, we recommend the creation of a novel, validated SWB survey specifically for TMSX. This should be developed in collaboration with a multidisciplinary panel and TMSX community advisory board, ensuring a tool that truly reflects the unique SWB needs of this population.

Rates of Urinary Tract Infection in Transgender Women Postvaginoplasty vs Cisgender Women: A Retrospective Cohort Study in a Large US Health Network.

OBJECTIVE: To describe urinary tract infection (UTI) risk 3-month postvaginoplasty (VP) in transgender women (TW) compared to cis women (CW). METHODS: Using TriNetX (TriNetX, Inc, Cambridge, MA), we built cohorts of 2041 TW and 48,374,745 CW. Outcomes were ≥1 instance of UTI or Cystitis, and assessed from 3-6, 3-12, 3-36months, and 3months-10years post-VP. TW and CW were age-cohorted (18-39, 40-59, 60-74) and compared at each time interval. Kaplan-Meier was used to account for loss to follow-up, along with hazard ratios and log-rank tests to determine significance (P <.05). RESULTS: For all time intervals and age ranges, TW had a significantly (P <.0001-P = .0088) higher probability of developing a UTI compared to CW. The largest difference was ages 40-59 ten-year post-VP. In this analysis, CW and TW had a 12.96% and 29.34% cumulative outcome incidence, respectively. Cox proportional hazard analysis demonstrated increased hazard for TW compared to CW. Hazard ratios between CW and TW ranged from 1.363 (ages 18-39 at 10years, 95%CI: 1.119,1.660) to 3.522 (ages 60-74 at 12months, 95%CI: 1.951,6.360). CONCLUSION: We found a significantly higher probability of TW developing UTIs compared to age-cohorted CW. Contributing factors may include difficulties with neovaginal perineal hygiene, lack of commensal bacteria and vaginal mucosa, larger urethral meatus, high rates of meatal stenosis, and nonnative bacteria introduced through dilators and douching. These findings may help improve quality of postoperative care in TW.

Urethral Outcomes of the Labia Minora Ring Flap for Metoidioplasty and Phalloplasty.

OBJECTIVE: To determine urethral outcomes of single-stage metoidioplasty and radial forearm free flap (RFFF) phalloplasty using the labia minora ring flap for urethral lengthening (UL). METHODS: A retrospective review was performed of patients undergoing single-stage metoidioplasty and RFFF phalloplasty utilizing the labia minora ring flap technique. The ring flap consists of endodermal labia minora tissue ventral to the clitoris and surrounding the vaginal introitus. During metoidioplasty, the ring flap accounts for the entirety of UL. During RFFF phalloplasty, the ring flap becomes the pars fixa (PF) urethra. The primary outcomes measured were rates of fistula, stricture, and surgical revision. RESULTS: Between November 2017 and August 2023, 311 patients underwent metoidioplasty or RFFF phalloplasty (mean follow-up 37 months). Of the 69 metoidioplasties, urethrocutaneous fistulas developed in 11 patients (16%); strictures occurred in 4 (6%). Of the 242 phalloplasty patients, there were 71 fistulas (29%), 56 of which resolved spontaneously. Strictures developed in 44 patients (18%). Twenty-five patients (10%) developed both a stricture and fistula. Surgical repair was required in 8/69 (12%) metoidioplasty patients and in 46/242 (19%) RFFF phalloplasty patients for an overall revision rate of 17%. CONCLUSION: UL during metoidioplasty or RFFF phalloplasty can be accomplished in a single stage using the labia minora ring flap with comparable surgical revision rates to previously described techniques. This approach can also be applied to other phalloplasty techniques. Many fistulas of the PF urethra resolve spontaneously. Higher urethral revision rates were seen in phalloplasty compared to metoidioplasty.

Data-Independent Acquisition Peptidomics.

In recent years, data-independent acquisition (DIA) has emerged as a powerful analysis method in biological mass spectrometry (MS). Compared to the previously predominant data-dependent acquisition (DDA), it offers a way to achieve greater reproducibility, sensitivity, and dynamic range in MS measurements. To make DIA accessible to non-expert users, a multifunctional, automated high-throughput pipeline DIAproteomics was implemented in the computational workflow framework "Nextflow" ( https://nextflow.io ). This allows high-throughput processing of proteomics and peptidomics DIA datasets on diverse computing infrastructures. This chapter provides a short summary and usage protocol guide for the most important modes of operation of this pipeline regarding the analysis of peptidomics datasets using the command line. In brief, DIAproteomics is a wrapper around the OpenSwathWorkflow and relies on either existing or ad-hoc generated spectral libraries from matching DDA runs. The OpenSwathWorkflow extracts chromatograms from the DIA runs and performs chromatographic peak-picking. Further downstream of the pipeline, these peaks are scored, aligned, and statistically evaluated for qualitative and quantitative differences across conditions depending on the user's interest. DIAproteomics is open-source and available under a permissive license. We encourage the scientific community to use or modify the pipeline to meet their specific requirements.

PROPOSED REVISION OF THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA RENAL TRAUMA ORGAN INJURY SCALE: SECONDARY ANALYSIS OF THE MULTI-INSTITUTIONAL GENITOURINARY TRAUMA STUDY.

BACKGROUND: This study updates the American Association for Surgery of Trauma (AAST) Organ Injury Scale (OIS) for renal trauma using evidence-based criteria for bleeding control intervention. METHODS: This was a secondary analysis of a multi-center retrospective study including patients with high grade renal trauma from 7 Level-1 trauma centers from 2013-2018. All eligible patients were assigned new renal trauma grades based on revised criteria. The primary outcome used to measure injury severity was intervention for renal bleeding. Secondary outcomes included intervention for urinary extravasation, units of packed red blood cells (PRBCs) transfused within 24 hours, and mortality. To test the revised grading system, we performed mixed effect logistic regression adjusted for multiple baseline demographic and trauma covariates. We determined the area under the receiver-operator curve (AUC) to assess accuracy of predicting bleeding interventions from the revised grading system and compared this to 2018 AAST organ injury scale. RESULTS: based on the 2018 OIS grading system, we included 549 patients with AAST Grade III-V injuries and CT scans (III: 52% (n = 284), IV: 45% (n = 249), and V: 3% (n = 16)). Among these patients, 89% experienced blunt injury (n = 491) and 12% (n = 64) underwent intervention for bleeding. After applying the revised grading criteria, 60% (n = 329) of patients were downgraded and 4% (n = 23) were upgraded; 2.8% (n = 7) downgraded from grade V to IV, and 69.5% (n = 173) downgraded from IV to III. The revised renal trauma grading system demonstrated improved predictive ability for bleeding interventions (2018 AUC = 0.805, revised AUC = 0.883; p = 0.001) and number of units of PRBCs transfused. When we removed urinary injury from the revised system, there was no difference in its predictive ability for renal hemorrhage intervention. CONCLUSIONS: A revised renal trauma grading system better delineates the need for hemostatic interventions than the current AAST OIS renal trauma grading system. LEVEL OF EVIDENCE: II.

Incidence of prostate cancer in transgender women in the US: a large database analysis.

The risk of prostate cancer among transgender women undergoing medical and surgical gender-affirming interventions remains unclear, though up to a fivefold decreased risk has been reported in comparison to cisgender men. In this study, we conducted a comparative analysis of the risk of prostate cancer among transgender women (TW) using data from TriNetX, a large database, versus SEER. Our findings indicate that, overall, transgender women exhibited a 2.56-fold lower risk of prostate cancer compared to cisgender men. Specifically, among TW on hormone therapy between ages 50-64, we observed a 2.06-fold decrease in risk. Contrary to the previous perception of prostate cancer being rare in transgender women, our study suggests that it may not be as uncommon as previously believed.

Genomic Risk Factors for Urethral Stricture: A Systematic Review and Gene Network Analysis.

OBJECTIVE: To identify genes that may play a role in urethral stricture and summarize the results of studies that have documented variations in gene expression among individuals with urethral stricture compared to healthy individuals. METHODS: A systematic search was conducted in Cochrane, Ovid, Web of Science, and PubMed, limiting the results to articles published between January 1, 2000 and January 30, 2023. Only studies comparing the difference in gene expression between individuals with urethral stricture and healthy individuals utilizing molecular techniques to measure gene expression in blood, urine, or tissue samples were included in this systematic review. Gene network and pathway analyses were performed using Cytoscape software, with input data obtained from our systematic review of differentially expressed genes in urethral stricture. RESULTS: Four studies met our criteria for inclusion. The studies used molecular biology methods to quantify gene expression data from specimens. The analysis revealed gene expressions of CXCR3 and NOS2 were downregulated in urethral tissue samples, while TGFB1, UPK3A, and CTGF were upregulated in plasma, urine and urethral tissue samples, respectively, in patients with urethral stricture compared to healthy controls. The analysis demonstrated that the most significant pathways were associated with phosphoinositide 3-kinase (PI3 kinase) and transforming growth factor beta 1/suppressor of mothers against decapentaplegic (TGF-ß1/SMAD) signaling pathways. CONCLUSION: This systematic review identified gene expression variations in several candidate genes and identified underlying biological pathways associated with urethral stricture. These findings could inform further research and potentially shift treatment and prevention strategies for urethral stricture.

Utility of gastroscopy in the left lateral semi-recumbent position: A blood-free coup!

Background and study aims The utility of esophagogastroduodenoscopy (EGD) in the left lateral semi-recumbent position in the setting of acute upper gastrointestinal bleeding (UGIB) with a persistent fundal pool of blood for adequate visualization and effective endotherapy has not been studied. This study aimed to evaluate the feasibility, efficacy, and safety of this position in such settings. Patients and methods A prospective study of patients presenting with acute UGIB with an uncleared fundal pool of blood was conducted. All underwent EGD in the left lateral decubitus and secondary left lateral semi-recumbent positions. Outcomes in secondary position in terms of adequate visualization of the fundus, identification of new or additional sources of bleeding, and effectiveness of endotherapy were studied. Results We screened 860 patients and included 44 patients (5.11%) with a persistent fundal pool of blood. Endoscopy in the primary position revealed the source of bleeding in 37 of 44 patients (84%). The source of the bleeding was not identified in seven of 44 patients (16%). Endoscopy in the secondary position showed clearance of fundal pool in all 44 patients (100%). A new source of bleeding was identified in all seven patients (100%) and an additional source could be identified in another five patients (13.6%). Endotherapy was performed in the secondary position for all 44 patients with 100% technical success and 94% clinical success. Conclusions These data show that endotherapy in the left lateral semi-recumbent position is feasible, safe, and effective. It should be done when endoscopy in the left lateral decubitus position reveals a pool of blood in the fundus and there is inadequate visualization of the fundus.

Effectiveness and safety of Shankhaprakshalana-a yogic technique-in bowel preparation for colonoscopy: A retrospective study.

INTRODUCTION: Shankhaprakshalana (SP) is a yogic method aiming to cleanse the bowel. It involves the use of warm saline water and a combination of five asanas. This study was designed to assess the effectiveness and safety of bowel preparation by SP. METHODS: This is a retrospective observational study of prospectively collected data. Patients planned for colonoscopy were screened and enrolled to undergo bowel preparation by SP on the day of the colonoscopy. Patients having comorbid conditions, poor performance status, suspected or previously diagnosed intestinal stricture and past history of major abdominal surgery and those unable to perform asanas of SP were excluded. A low-fiber diet was advised for one day before the colonoscopy. Patients were advised to drink 400 mL of lukewarm saline water followed by five asanas (exercises) of SP, each done eight times dynamically and sequentially. After completing six such cycles, patients underwent colonoscopy. Boston Bowel Preparation Scale (BBPS) score was used to assess the quality of bowel preparation. RESULTS: Total 238 patients were included. The major indications for colonoscopy were abdominal pain (35.3%), hematochezia (23.9%), diarrhea (20.2%), constipation (10.9%) and anemia (9.7%). The mean age was 37.7 (± 12) years. The mean BBPS was 8 (± 1.2). Bowel preparation was inadequate (BBPS < 6) in only two patients. Mean segmental BBPS for the three segments of the colon (right, transverse and left) was 2.6 (± 0.5), 2.7 (± 0.4) and 2.6 (± 0.7), respectively. Minor adverse events (nausea, abdominal pain, vomiting, giddiness and bloating) were noted in 10 participants (4.2%), which did not require hospitalization. Bowel preparation was completed in 133 (± 35) minutes. CONCLUSION: Shankhaprakshalana is an effective and safe method to achieve adequate bowel preparation before colonoscopy. Since this is a single-center and retrospective study, future multi-centric, prospective studies comparing it with the standard bowel preparation regimens are warranted.

A high-fidelity biomechanical modeling framework for injury prediction during frontal car crash.

Injuries arising from car crashes are ubiquitous across the globe and account for over 1.3 million fatalities annually. 93% of mortalities are observed in middle- and low-income countries owing to the lack of infrastructure in the safety assessment of car designs. It is therefore imperative to predict the extent of injuries to the occupants during car crashes, which would lead to safer vehicle design. To date, conventional computational testing methods use Hybrid III dummies, which fail to reproduce fracture and tear injuries. In this work, a full-frontal collision of a vehicle against a rigid wall with a highly biofidelic human body model of an occupant was simulated for the first time to investigate fractures and tears using a novel fracture modeling technique. Fractures were observed in ribs (5-7), which occurred at stresses of 120 MPa at the left lateral vertebrosternal region. In the lower extremity, tears in the ligaments at 70.80 MPa, and fractures in the tibia and femur at 236 MPa were quantified. Stresses in the skull were limited to 11 MPa, indicating a possibility of concussion rather than fractures. The developed computational model would be indispensable for car manufacturers to test the crash impact on the human body at all possible accident scenarios accurately, which will help design better solutions for automotive injury mitigation.

Effect of plyometric versus complex training on core strength, lower limb, and upper limb power in male cricketers: a randomized controlled trial.

BACKGROUND: Complex training is found effective in improving physical performance in various sports. There is a paucity of research evidence comparing the efficacy of complex vs. plyometric training in cricket players. The study aimed to compare the efficacy of complex and plyometric training on physical performance parameters in cricket players. METHODS: Participants (n = 42 Male; age group = 18-26 years) were randomly allocated into three groups, complex training group (CTG) (n = 14; BMI = 20.51 ± 2.23), plyometric training group (PTG) (n = 14; BMI = 20.57 ± 2.82), and control group (CG) (n = 14; BMI = 20.51 ± 2.23). CTG and PTG received their respective training twice weekly, and CG received routine training for four weeks. Pre and post-intervention assessments of core muscle strength (CM), multistage fitness (MF), push-up (PU), lateral cone jump (LCJ), and stationary vertical jump (SVJ) were performed. This study has been registered in clinicaltrials.gov (ID: NCT05646914, on 05/12/2022). RESULTS: A significant difference was observed between CTG vs. CG for CM (p ≤ 0.01), LCJ (p < 0.05), and SVJ (p ≤ 0.01), similarly in PTG vs. CG for CM (p-value), LCJ (p ≤ 0.05) and SVJ (p ≤ 0.01). However, No significant difference was found between PTG vs. CTG for any variables (p ≥ 0.05). Also, No significant difference in MF and PU was found between the groups (p ≥ 0.05). CONCLUSIONS: Complex training has been found to have effects similar to plyometric training alone. Therefore, either of the two strategies can be used to improve the performance of male cricket players.

Achieving quantitative reproducibility in label-free multisite DIA experiments through multirun alignment.

DIA is a mainstream method for quantitative proteomics, but consistent quantification across multiple LC-MS/MS instruments remains a bottleneck in parallelizing data acquisition. One reason for this inconsistency and missing quantification is the retention time shift which current software does not adequately address for runs from multiple sites. We present multirun chromatogram alignment strategies to map peaks across columns, including the traditional reference-based Star method, and two novel approaches: MST and Progressive alignment. These reference-free strategies produce a quantitatively accurate data-matrix, even from heterogeneous multi-column studies. Progressive alignment also generates merged chromatograms from all runs which has not been previously achieved for LC-MS/MS data. First, we demonstrate the effectiveness of multirun alignment strategies on a gold-standard annotated dataset, resulting in a threefold reduction in quantitation error-rate compared to non-aligned DIA results. Subsequently, on a multi-species dataset that DIAlignR effectively controls the quantitative error rate, improves precision in protein measurements, and exhibits conservative peak alignment. We next show that the MST alignment reduces cross-site CV by 50% for highly abundant proteins when applied to a dataset from 11 different LC-MS/MS setups. Finally, the reanalysis of 949 plasma runs with multirun alignment revealed a more than 50% increase in insulin resistance (IR) and respiratory viral infection (RVI) proteins, identifying 11 and 13 proteins respectively, compared to prior analysis without it. The three strategies are implemented in our DIAlignR workflow (>2.3) and can be combined with linear, non-linear, or hybrid pairwise alignment.