Penoscrotal Decompression-Promising New Treatment Paradigm for Refractory Ischemic Priapism.

BACKGROUND: For prolonged ischemic priapism, outcomes after distal shunt are poor, with only 30% success for priapic episodes lasting longer than 48 hours. AIM: To present a novel, glans-sparing approach of corporal decompression through a penoscrotal approach for cases of refractory ischemic priapism (RIP) after failed distal shunt procedures. METHODS: We describe the technique and present our initial experience with penoscrotal decompression (PSD) for treatment of RIP after failed distal shunt. We compared outcomes of patients with RIP undergoing surgical management using PSD or malleable penile prosthesis (MPP) placement after failed distal penile shunt procedures (2008-2017). OUTCOMES: Our initial experience showed favorable outcomes with PSD compared with early MPP placement in patients with RIP whose distal shunt failed. RESULTS: Of 14 patients with RIP undergoing surgical management after failed distal penile shunt procedures, all patients presented after a prolonged duration of priapism (median = 61 hours) after which the priapism was refractory to multiple prior treatments (median = 3, range = 1-75) including at least 1 distal shunt. MPP was inserted in 8 patients (57.1%), whereas the most recent 6 patients (42.9%) underwent PSD. All patients with PSD (6 of 6, 100%) were successfully treated with corporal decompression without additional intervention and noted immediate relief of pain postoperatively. In contrast, 37.5% of patients (3 of 8) undergoing MPP after failed distal shunt procedures required a total of 8 revision surgeries during a median follow-up of 41.5 months. The most common indications for revision surgery after MPP placement included distal (4 of 8, 50%) and impending lateral (2 of 8, 25%) extrusion. CLINICAL IMPLICATIONS: PSD is a simple, effective technique in the management of RIP after failed distal shunt procedures with fewer complications than MPP placement. STRENGTHS AND LIMITATIONS: Although PSD is effective in the management of RIP after failed distal shunt procedures, long-term assessment of erectile function and ease of future penile prosthetic implantation is needed. CONCLUSION: Corporal decompression resolves RIP through a glans-sparing approach and avoids the high complication rate of prosthetic insertion after failed distal shunt procedures. Fuchs JS, Shakir N, McKibben MJ, et al. Penoscrotal Decompression-Promising New Treatment Paradigm for Refractory Ischemic Priapism. J Sex Med 2018;15:797-802.

Clinical Risk Factors Associated With Urethral Atrophy.

OBJECTIVE: To analyze a series of clinical risk factors associated with pretreatment urethral atrophy. METHODS: We retrospectively reviewed 301 patients who underwent artificial urinary sphincter (AUS) placement between September 2009 and November 2015; of these, 60 (19.9%) transcorporal cuff patients were excluded. Patients were stratified into 2 groups based on intraoperative spongiosal circumference measurements. Men with urethral atrophy (3.5 cm cuff size) were compared to controls (≥4 cm cuff size). Chi-square test, Mann-Whitney U test, and logistic regression analyses were performed to determine risk factors for urethral atrophy. RESULTS: Among 241 AUS patients analyzed, urethral atrophy was present in 151 patients (62.7%) compared to 90 patients (37.3%) who received larger cuffs (range 4-5.5 cm). Patients with urethral atrophy were older (71.1years vs 68.3 years; P < .02), more likely to have received radiation (52.9% vs. 33.3%; P < .007), and had a longer time interval between prostate cancer treatment and AUS surgery (8.9 years vs. 6.6 years; P < .033). On multivariable analysis, radiation therapy was independently associated with risk of urethral atrophy (odds ratio 1.77, 95% confidence interval: 1.01-3.13; P = .046), whereas greater time between cancer therapy and incontinence surgery approached clinical significance (odds ratio 1.05, 95% confidence interval 1.00-1.09; P = .05). CONCLUSION: History of radiation therapy and increasing length of time from prostate cancer treatment are associated with urethral atrophy before AUS placement.

Use of Mitomycin C for Refractory Esophageal Stricture following Tracheoesophageal Fistula Repair.

Esophageal stricture is a well-described complication following tracheoesophageal fistula repair. Herein, we report two patients who had persistent esophageal strictures after several months of repeat balloon dilatations. Each patient was treated with a single application of topical mitomycin C in addition to esophageal dilatation, which resulted in complete resolution of the stricture.

Needle core vs open biopsy for diagnosis of intermediate- and high-risk neuroblastoma in children.

BACKGROUND: Open biopsy has been the mainstay for definitive diagnosis of neuroblastoma in pediatric patients. However, needle core biopsy may represent a faster, less invasive, and safer alternative to open biopsy in children. The purpose of this study was to compare safety and efficacy between needle core and open biopsy in the diagnosis of patients with intermediate- and high-risk neuroblastoma at our institution. METHODS: We retrospectively reviewed the medical records of children with intermediate- and high-risk neuroblastoma who underwent open or needle core biopsies from 2002 to 2010. Data collected included patient demographics, tumor size, sample adequacy for diagnosis and risk stratification (histology and cytogenetics), length of hospital stay, time to initiate chemotherapy after biopsy, need for repeat biopsy, and both intraoperative and postoperative complications. Mann-Whitney U and Fisher's exact tests were used for statistical analysis. RESULTS: During the study period, 7 patients underwent needle core primary biopsies (5 intermediate-risk primary tumors and 2 high-risk primary tumors), and 4 patients underwent needle core biopsy for metastatic tumors, whereas 21 patients had open biopsies (10, intermediate risk; 11, high risk). Median age at biopsy and median tumor size were similar in both groups. There was no significant difference in adequacy of biopsy, need for repeat biopsy, time to initiate chemotherapy, length of stay, or minor complications. The rate of major complications differed significantly between the 2 groups with 0% after needle core biopsy vs 48% after open biopsy (P = .027). CONCLUSIONS: In children, needle core biopsy is comparable in efficacy with open biopsy in the diagnosis of intermediate- and high-risk neuroblastoma with significantly lower rates of major postoperative complications. These findings warrant a larger scale evaluation of diagnostic needle core biopsies in pediatric patients with solid tumor.

Novel use of glycopyrrolate (Robinul) in the treatment of anastomotic leak after repair of esophageal atresia and tracheoesophageal fistula.

Anastomotic leak after tracheoesophageal fistula repair is a well-known complication and can represent a challenging clinical scenario. We present the case of an infant girl with VACTERL syndrome who underwent repair of a type C esophageal atresia and tracheoesophageal fistula repair, which was complicated by an anastomotic leak. Glycopyrrolate (Robinul), an anticholinergic agent, was successfully used to decrease copious salivary secretion and promote spontaneous closure of the leak. This report represents the first description in the medical literature of the use of glycopyrrolate in the treatment of an esophageal anastomotic leak. Glycopyrrolate may be a useful adjunct in the management of anastomotic leak after tracheoesophageal repair.

Signalling of the BCR is regulated by a lipid rafts-localised transcription factor, Bright.

Regulation of BCR signalling strength is crucial for B-cell development and function. Bright is a B-cell-restricted factor that complexes with Bruton's tyrosine kinase (Btk) and its substrate, transcription initiation factor-I (TFII-I), to activate immunoglobulin heavy chain gene transcription in the nucleus. Here we show that a palmitoylated pool of Bright is diverted to lipid rafts of resting B cells where it associates with signalosome components. After BCR ligation, Bright transiently interacts with sumoylation enzymes, blocks calcium flux and phosphorylation of Btk and TFII-I and is then discharged from lipid rafts as a Sumo-I-modified form. The resulting lipid raft concentration of Bright contributes to the signalling threshold of B cells, as their sensitivity to BCR stimulation decreases as the levels of Bright increase. Bright regulates signalling independent of its role in IgH transcription, as shown by specific dominant-negative titration of rafts-specific forms. This study identifies a BCR tuning mechanism in lipid rafts that is regulated by differential post-translational modification of a transcription factor with implications for B-cell tolerance and autoimmunity.

The problem of choice.

Convictions are a driving force for actions. Considering that every individual has a different set of convictions and larger groups act once a consensus decision is reached, one can see that debate is an inherent exercise in decision-making. This requires a sustainably generated surplus to allow time for intellectual exchange, gathering of information and dissemination of findings. It is essential that the full spectrum of options remain treated equally. At the end of this process, a choice has to be made. Looking back at a later time point, a retrospective analysis sometimes reveals that the choice was neither completely free nor a truly conscious one. Leaving the issue of consequences of a once made decision aside, we wish to contribute to the debate of the problem of choice.

Another challenge for scientists.

By nature, scientists contribute to our understanding of nature and ourselves. As communities undergo significant changes, new challenges are presented. Here, we offer alternative views on recent changes in society.

To know or not to know: archiving and the under-appreciated historical value of data.

Surplus goods, produced by a community, allow individuals to dedicate their efforts to abstract problems, while enjoying the benefits of support from the community. In return, the community benefits from the intellectual work, say, efficiently producing goods or profound medical aid. In further elevating quality of life, we need to understand nature and biology on the most detailed level. Inevitably, research costs are increasing along with the need for more scientists to specialize their efforts. As a result, a vast amount of data and information is generated that needs to be archived and made openly accessible with the permission to re-use and re-distribute. With economies undergoing crises and prosperity in an almost cyclic manner, it seems that funding for science and technology follows a similar pattern. Another aspect to the problem of the loss of data is the human propensity, at the level of each individual researcher, to passively discard data in the course of daily life and through a career. In a typical laboratory, significant amounts of information is still stored on disks in file cabinets or on isolated computers, and is lost when a research group disbands. Being conscientious to one's data, to see that it reaches a place in which it can persist beyond the lifespan of any one individual requires responsibility on the part of its creator.

An open democracy.

Sovereign power is retained and shared by the citizens of a country. Using electoral tools, governing structures are formed to ensure protection of national interests. As with any institution, proper control of the government guarantees its adherence to the tasks delegated to it by its citizens. In turn, citizens have to be provided with, and are encouraged to access and evaluate, information generated by the government. On the other hand, governments generate sensitive information (e.g., intelligence, internal reports, etc) that are required for self-evaluation and defense against threats to the nation. Governments are granted a privilege to collect, store and use such information to perform necessary tasks. How far does governmental privilege go relative to the intrinsic right of citizens to access and evaluate information?

Open Access and beyond.

Uncensored exchange of scientific results hastens progress. Open Access does not stop at the removal of price and permission barriers; still, censorship and reading disabilities, to name a few, hamper access to information. Here, we invite the scientific community and the public to discuss new methods to distribute, store and manage literature in order to achieve unfettered access to literature.