Do we need repeated CT imaging in uncomplicated blunt renal injuries? Experiences of a high-volume urological trauma centre.

BACKGROUND: Current guidelines recommend repeat computed tomography (CT) imaging in high-grade blunt renal injury within 48-96 h, yet diagnostic value and clinical significance remain controversial. The aim of this work was to determine the possible gain of CT re-imaging in uncomplicated patients with blunt renal trauma at 48 h after injury, presenting one of the largest case series. METHODS: A retrospective database of patients admitted to our centre with isolated blunt renal trauma due to sporting injuries was analysed for a period of 20 years (2000-2020). We included only patients who underwent repeat imaging at 48 h after trauma irrespective of AAST renal injury grading (grade 1-5) and initial management. The primary outcome was intervention rates after CT imaging at 48 h in uncomplicated patients versus CT scan at the time of clinical symptoms. RESULTS: A total of 280 patients (mean age: 37.8 years; 244 (87.1%) male) with repeat CT after 48 h were included. 150 (53.6%) patients were classified as low-grade (grade 1-3) and 130 (46.4%) as high-grade (grade 4-5) trauma. Immediate intervention at trauma was necessary in 59 (21.1%) patients with high-grade injuries: minimally invasive therapy in 48 (81.4%) and open surgery in 11 (18.6%) patients, respectively. In only 16 (5.7%) cases, intervention was performed based on CT re-imaging at 48 h (low-grade vs. high-grade: 3.3% vs. 8.5%; p = 0.075). On the contrary, intervention rate due to clinical symptoms was 12.5% (n = 35). Onset of clinical progress was on average (range) 5.3 (1-17) days post trauma. High-grade trauma (odds ratio [OR]grade 4 vs. grade 3, 14.62; p < 0.001; ORgrade 5 vs. grade 3, 22.88, p = 0.004) and intervention performed at the day of trauma (OR 3.22; p = 0.014) were powerful predictors of occurrence of clinical progress. CONCLUSION: Our data suggest that routine CT imaging 48 h post trauma can be safely omitted for patients with low- and high-grade blunt renal injury as long as they remain clinically stable. Patients with high-grade renal injury have the highest risk for clinical progress; thus, close surveillance should be considered especially in this group.

Optilume® drug-coated balloon dilation in complex female urethral stricture.

The treatment of female urethral stricture disease is in flux in terms of developing guidelines for surgical treatment. Urethral strictures in women are rare, but frequently result because of urethral instrumentation or surgery. Stricture sites vary from proximal, intrasphincteric, distal or at the meatus. Stricture formation after previous urethral surgery may pose a special challenge. We describe the first Optilume® urethral drug-coated balloon dilation for female urethral stricture disease involving the sphincter. After six months follow-up the patient remains stricture free with full continence and complete bladder emptying.

Impact of a universal perinatal home-visiting program on reduction in race disparities in maternal and child health: Two randomised controlled trials and a field quasi-experiment.

Background: Public health interventions must become accountable for reduction of race disparities, particularly among Black, Hispanic, and Non-Hispanic White families in the United States. Family Connects (FC) is a universal perinatal home-visiting program that assesses family-specific needs, offers support, and provides connections to community resources to address identified needs. Two previously-published randomised controlled trials and a field quasi-experiment have shown positive impact on maternal mental health, infant emergency medical care utilization, and government investigations for child maltreatment; however, these reports have not tested impact on reducing race disparities in these outcomes. The current report examined three questions in these trials: 1) the extent of race disparities in maternal and infant health and well-being, absent intervention; 2) whether intervention can be implemented with high reach and fidelity among all race groups; and 3) whether assignment to intervention reduces race disparities in important outcomes. Methods: Data were re-examined from: 1) a randomised controlled trial of 4777 birthing families in Durham, NC, USA; 2) a replication randomised controlled trial of 923 birthing families in Durham, NC, USA; and 3) a quasi-experiment of 988 birthing families in rural NC, USA. Families were classified as Black, Hispanic, Non-Hispanic White, or Other. Disparity reduction was tested by the interaction effect between treatment assignment and race. Findings: 1) In the absence of intervention, large and statistically significant differences between Black familes and Non-Hispanic White families were found in maternal anxiety, maternal depression, father non-support, child emergency medical care, and child maltreatment investigations. Few differences were found between Non-Hispanic White familes and Hispanic families.2) High rates of participation in treatment were found for each race group.3) Across studies, assignment to FC was associated with statistically significant reductions in 7 of 12 disparities, in maternal anxiety and depression, father non-support, infant emergency medical care, and child maltreatment investigations. Interpretation: This study provides a method, metric, and mandate to prioritise testing of whether public health interventions reduce race disparities in family outcomes. Funding: This research was supported by grant R01HD069981 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and a grant from The Duke Endowment.

Age at surgery is not a prognostic factor for the AdVance-XP male sling efficacy: A post-hoc analysis of a prospective 7-year multicentric study.

OBJECTIVE: To evaluate the factor age at the surgery on long-term postoperative outcomes in patients with postprostatectomy incontinence (PPI) after AdVance XP transobturator male sling implantation. METHODS: A total of 115 male patients with PPI, who had undergone AdVance XP sling implantation, were included. Patients had PPI with endoscopically confirmed good sphincteric-contractility and a positive coaptive response. Kruskal-Wallis test with Dunn post-hoc tests were used to analyze the postoperative outcome differences between the patient groups aged less than 66, 66-75, and over greater than 75 years. Outcome measures were the 24 h pad test, the number of daily pads used, the International Consultation on Incontinence Questionnaire short form (ICIQ-SF), International Quality of Life Score (IQOL), Patient Global Impression of Improvement (PGI-I), International Index of Erectile Function-5 (IIEF-5), International Prostate Symptom Score (IPSS), and Visual Analog Scale scores. Observation time points were 3, 6, 12, 24, 36, 48, 60, and 84 months after surgery. RESULTS: Between the age groups, there was no difference in the success rate of the procedure (defined as 0 pads/24 h and less than 5 g in the 24-h pad test) at any point in time. Subjective parameters measures using the ICIQ-SF, PGI-I, IQOL, and IPSS scores showed no differences between the two cohorts. Only erectile function (IIEF-5 score) was lower in older patients in comparison to the cohort aged less than 66 years (p < 0.05 at 3, 6, 12, 24, 36, and 48 months). CONCLUSIONS: The present study complements the European multicentre AdVance XP follow-up study. Here, we show that age at surgery does not affect the objective success, subjective success, or the complication rate. Thus, we do not recommend factoring in chronological age into surgical selection criteria for the AdVance XP implantation.

Five-Year Results of a Prospective Multicenter Trial: AdVance XP for Postprostatectomy-Incontinence in Patients with Favorable Prognostic Factors.

OBJECTIVE: The aim of this study was to assess the security, value, and efficacy of the second-generation AdVance male sling XP (Boston Scientific®), after implementation in 2010 with advantageous modifications in the sling structure and needle shape, in a prospective multicenter long-term follow-up study. METHODS: In total, 115 patients were included. Exclusion criteria were earlier incontinence (UI) surgery, nocturnal UI, former radiotherapy, or night-time incontinence. We also excluded patients with a functional urethra <1 cm in a preoperatively performed repositioning test. A consistent 24-h pad test, International Quality of Life (IQOL) score, visual analog pain scale (VAS), International Consultation-Incontinence Questionnaire (ICIQ-UI SF), International Index of Erectile Function (IIEF-5), International Prostate Symptom Score (IPSS), and Patient Global Impression of Improvement (PGI-I) scores were requested postoperatively. RESULTS: The 24-month follow-up (114 patients) revealed 64.0% cured and 28.8% improved patients. Mean urine loss was reduced significantly to 19.0 g (p < 0.001). A mean PGI score of 1.5 and a mean VAS score of 0.2 were obtained. The 60-month follow-up (59 patients) revealed 57.6% cured and 25.4% improved patients. Mean urine loss was reduced significantly to 18.3 g (p < 0.001). A mean PGI score of 1.6 and a mean VAS score of 0.2 were obtained. CONCLUSIONS: The AdVance XP displays excellent continence results and secure effectiveness over a 5-year period. Moreover, these data are demonstrating low complication rates and improved quality of life in the long-term use of AdVance XP.

Attachment quality assessed from children's family drawings links to child conduct problems and callous-unemotional behaviors.

OBJECTIVE: Recently, there has been considerable research on the origins of childhood conduct problems (CP) and callous-unemotional (CU) behaviors. This study examined associations between children's attachment representations and CP and CU behaviors during middle childhood. METHOD: At 1st grade, 1,292 children (57% European American, 42.5% African American, 0.5% other race; 50.9% girls) completed a drawing of their family, which was coded by trained raters to assess attachment representations. Primary caregivers reported on children's CP and CU behaviors. RESULTS: Children with disorganized representations showed more CP and CU behaviors than children with secure and resistant representations. They were also more likely than those with secure representations to show elevated CP without CU behaviors, CU behaviors only, and co-occurring CP and CU behaviors. CONCLUSION: These findings provide support for attachment disorganization as a correlate of CP and CU behaviors and suggest that attachment representations are likely important proximal influences on children's behavior.

Female urethral avulsion and bladder neck closure: What now? Trigonal tubularization with placement of an artificial urinary sphincter.

Bladder neck closure after severe polytrauma with an absent urethra poses a huge challenge for a young woman wanting to urinate normally. Considerations are reconstruction of a neourethra and operative means to gain continence. We describe a case of trigonal tubularization to function as a neourethra, together with the implantation of an artificial urinary sphincter. Eleven years after suffering from an open book pelvic rim fracture at 18 years, successful reconstruction of a trigonal neourethra enabled continence and residual-free spontaneous voiding at 29 years.

Salvage perineal-retropubic AUS cuff in paraplegic patient with exstrophy-epispadias complex after previous cuff erosion at bladder neck.

Cuff erosion at the bladder neck of an implanted artificial urinary sphincter (AUS) needs complete explantation of the device. The subsequent scar tissues predispose to repeated cuff erosion, when another AUS is implanted with the cuff at a similar location. We describe a paraplegic patient with exstrophy-epispadias complex that suffered from an AUS cuff erosion at the bladder neck. We use a novel perineal-retropubic route for cuff placement, with preparation similar to a retropubic male sling. At 12 years follow-up the AUS is still functional and the patient continent.

Urethro-cavernosal-spongiosal fistula after intralesional mitomycin C for recurrent urethral stricture disease.

Intralesional mitomycin C after direct visual internal urethrotomy for recurrent urethral stricture disease in patients suboptimal for open urethroplasty is an established option. We report a case of urethro-cavernosal-spongiosal fistula after intralesional mitomycin C into an area of previous dorsal inlay urethroplasty. The patient presented with pus draining from the urethral meatus ten days after treatment. Sterile abscesses developed within the corporal and spongious bodies, draining freely into the urethra. Complete spontaneous healing followed short-term transurethral catheterization and antibiotic prophylaxis.

World record: Single AMS 800 artificial urinary sphincter functioning uninterrupted for 29 years in male paraplegic patient.

Lapides has revolutionized the treatment of neurogenic patients by introducing routine intermittent catheterization in 1971. This drastically lowered mortality from urosepsis. Scott introduced the artificial urinary sphincter (AUS) in 1972. This gave a completely new perspective for incontinent patients by dramatically increasing the quality of life. In patients with neurogenic urinary incontinence, the principles of care are preserving renal function, maintaining a low-pressure reservoir, allowing unobstructed urine flow and providing continence. We describe a male patient that received an AUS with a bladder neck cuff that functioned without revision for 29 years. After 30 years, AUS exchange proved successful.

Excessive fibrosis and non-function after ATOMS (adjustable transobturator male system): A case of capsular contracture?

The adjustable transobturator male system (ATOMS) treats post-prostatectomy urinary incontinence by compression of the proximal bulbous urethra. It reminds of the Kaufman prosthesis described in 1978. We describe a case where an excessive fibrotic reaction occurred around the cushion. Furthermore, the bulbous urethra underneath, developed severe atrophy devoid of any visible blood supply. We suspect ongoing shear forces around the cushion while sitting resulting in a chain reaction of acute through chronic inflammation and progressive fibrosis and encapsulation. Does the encapsulation lead to capsular contracture resulting in non-function?

Poverty, Caregiving, and HPA-Axis Activity in Early Childhood.

The association between poverty and the activity of the hypothalamic pituitary adrenal (HPA) axis in early childhood is well established. Both ecological and transactional theories suggest that one way in which poverty may influence children's HPA-axis activity is through its effects on parents' behaviors, and over the past three decades a substantial literature has accumulated indicating that variations in these behaviors are associated with individual differences in young children's HPA-axis activity. More recent research suggests that non-parental caregiving behaviors are associated with HPA-axis activity in early childhood as well. Here we systematically review the literature on the association between both parental and non-parental caregiving behaviors in the context of poverty and the activity of the HPA-axis in early childhood. We conclude by noting commonalities across these two literatures and their implications for future research.

Intrapelvic bulboprostatic repair after urethral distraction injury and failed bulbomembranous anastomosis.

A failed end-to-end anastomosis after membranous urethral distraction injury post-trauma is a surgical challenge. We present a case of a young man after complex pelvic injury. Revision urethroplasty was done utilizing nerve and vessel sparing techniques. Intrasphincteric dissection enabled bulbous urethral pull-through with intrapelvic anastomosis with good success. Low dose tadalafil was given to optimize penile rehabilitation.

Supernumerary kidneys: a clinical and radiological analysis of nine cases.

BACKGROUND: A supernumerary kidney (SK) is an additional kidney with its own capsule and blood supply that is not fused with the ipsilateral kidney (IK). Because individual case reports indicate a high morbidity rate, the aim of this retrospective study was a detailed analysis of this rare anatomical variant. METHODS: Our systematic imaging-based search for SKs, conducted in the period from 2000 and to 2017, yielded 9 cases in total (5 men, 4 women; mean age: 51.8 ± 22.8 years). RESULTS: The SKs were observed on the right in six and on the left side in three cases. In six subjects (66%) they were located caudal and in three cases (33%) cranial to the ipsilateral kidney. Calculi were found in three (33%) of the renal collecting systems. Five (56%) of the SKs had hydronephrosis grade IV and one SK had recurrent pyelonephritis (11%). Two of the ureters opened into the ipsilateral seminal vesicle (22%). Two (22%) SKs were functional but atrophic. Clinically relevant findings were made in 33% of the IKs: atrophy (n = 2), calculi (n = 1), and reflux with recurrent pyelonephritis (n = 1); another 33% had anatomical anomalies without functional impairment. The correct diagnosis of a SK is possible using CT imaging in all subjects. The prevalence of SK based on CT imaging can be estimated to be 1:26750. CONCLUSIONS: CT is the method of choice for visualizing SKs. The correct diagnosis is crucial in preventing dispensable surgical procedures and for providing optimal patient treatment and outcome.

Extended follow-up of the AdVance XP male sling in the treatment of male urinary stress incontinence after 48 months: Results of a prospective and multicenter study.

OBJECTIVE: To evaluate the efficacy and safety of the AdVance XP male sling in a midterm follow-up for the treatment of male urinary incontinence in a selected patient cohort. MATERIALS AND METHODS: In all, 115 patients with postprostatectomy incontinence were prospectively enrolled. A previous endoscopic evaluation of a sufficient coaptive zone in the repositioning test was mandatory. Patients with urine leakage in supine position or previous incontinence surgery were excluded. Postoperatively a standardized 24-hour pad test and pad usage were evaluated. To compare pre- and postoperative continence status nonparametric t test was used. A P-value of <.05 was seen as statistically significant. RESULTS: Median preoperative urine loss in the 24-hour pad test was 272 g (min. 42-max. 1600) and was significantly improved at any point in follow-up. Success was defined as 0 pads per day and a maximum of 5 g in the 24-hour pad test. After a follow-up of 48 months, 71.7% of the patients were cured, whereas 15.0% of patients had an improved continence situation and 13.3% were classified as failed. Mean urine loss decreased significantly to 24.4 g (P ≤ .001). No severe intra- or postoperative complications are to be reported. Median follow-up was 4.2 years. CONCLUSIONS: A stable effectiveness in a selected patient cohort can also be demonstrated in an extended follow-up. The complication rates are low and no late postoperative complications occurred, indicating the safety of the procedure.

Preservation of erectile function by artery sparing dilation of the corpora cavernosa in prolonged priapism.

Prolonged low-flow priapism causes structural impotence. We describe a case where potency has been preserved by off-centre corporal dilation to spare the cavernosal arteries. The patient suffered from idiopathic priapism lasting more than 72 hours before presentation. Corporoglanular shunts were performed thrice over a period of six days, twice also performing off-centre corporal dilation along the inside of the tunica. The idea was not to damage the central cavernosal arteries. Corporal blood supply spontaneously improved. Successful intercourse was possible after six months. Artery sparing cavernosal dilation techniques might improve spontaneous recovery in select cases.

Visibility of MRI prostate lesions on B-mode transrectal ultrasound.

AIM: Prostate biopsies are usually done with transrectal ultrasound (TRUS) in B-mode (B TRUS) but multiparametric MRI (mpMRI) is the gold imaging standard for the visualization of clinically significant prostate cancer (PCa), since a lowPCa detection rate is reported for B TRUS. The aim of this study was to assess the visibility of MRI lesions on B TRUS and to determine which factors may influence the visibility on B TRUS. MATERIAL AND METHODS: 142 men with 148 lesions reported on mpMRI underwent a B TRUS/mpMRI fusion targeted biopsy of the prostate and were included in this retrospective study. During the biopsy, images were obtained and stored in the institution's PACS. These images were reviewed by two radiologists to determine, whether an mpMRI lesion was or was not visible on B TRUS. RESULTS: Overall 92 from 148 mpMRI lesions (62.2%) were visible on B TRUS. The location of the lesion in the prostate, the PIRADS classification of the lesions and the size of the lesion had no significant influence on the visibility on B TRUS. Only the prostate volume had a significant influence on visibility: in smaller prostates significantly more lesions were visible on B TRUS than in large glands (p+0.041; 45.1 ml vs 54 ml). CONCLUSION: The use of newer high-end ultrasound units as well as experience gained from fusion biopsies enables us to see 62.2 % of all suspicious mpMRI lesions on B TRUS. B TRUS images merit a thorough examination during a conventional biopsy setting.

The Significance of Parenting and Parent-Child Relationships for Sexual and Gender Minority Adolescents.

Adolescents in 21st century America are experiencing the emergence of their sexual and gender identities in a heteronormative society that is steadily adopting more progressive views and policies related to sexual orientation and gender. However, despite these sociocultural changes, parent-child relationships remain as one of the strongest predictors of LGBT adolescent adjustment. This article reviews the extant literature on this topic from family systems and attachment perspectives while highlighting the significance of family experiences within a minority stress framework. The presentation is oriented around the coming out process, including factors influencing this experience and how postdisclosure parenting affects the health and well-being of LGBT adolescents. We end by discussing future directions and the challenges inherent to this research.