Alison M. Rasper

Divergent adaptive and innate immunological responses are observed in humans following blunt trauma

BackgroundThe immune response to trauma has traditionally been modeled to consist of the systemic inflammatory response syndrome (SIRS) followed by the compensatory anti-inflammatory response syndrome (CARS). We investigated these responses in a homogenous cohort of male, severe blunt trauma patients admitted to a University Hospital surgical intensive care unit (SICU). After obtaining consent, peripheral blood was drawn up to 96 hours following injury. The enumeration and functionality of both myeloid and lymphocyte cell populations were determined.ResultsNeutrophil numbers were observed to be elevated in trauma patients as compared to healthy controls. Further, neutrophils isolated from trauma patients had increased raft formation and phospho-Akt. Consistent with this, the neutrophils had increased oxidative burst compared to healthy controls. In direct contrast, blood from trauma patients contained decreased naïve T cell numbers. Upon activation with a T cell specific mitogen, trauma patient T cells produced less IFN-gamma as compared to those from healthy controls. Consistent with these results, upon activation, trauma patient T cells were observed to have decreased T cell receptor mediated signaling.ConclusionsThese results suggest that following trauma, there are concurrent and divergent immunological responses. These consist of a hyper-inflammatory response by the innate arm of the immune system concurrent with a hypo-inflammatory response by the adaptive arm.

Ushering in the era of penile transplantation

Penile transplantation is a novel approach to management of penile loss in the developing field of composite tissue allotransplantation (CTA). Prior management for significant penile loss has been free flap phalloplasty with issues related to function, cosmesis, and functional loss from the location of flap harvest. Transplantation has been an evolving field with advancement in CTA over the past several decades leading to the option of penile transplant. Management of penile injury with replantation provided some preliminary groundwork on the technical aspects for penile transplantation. Additionally, penile transplantation raises many ethical, emotional, and psychological considerations with need for patience amidst ongoing advancement within the field.

Prostate cancer survivorship: Implementation of survivorship care plans to meet the mandate and enhance urologic practice through collaborative care.

Prostate cancer is the most common malignancy among the male survivorship population in the United States, representing 44% of approximately 7 million survivors. In the era of modern medicine and value-based care, successfully treating only the cancer is not sufficient. The cancer survivor represents an individual in need of restoration and protection against future events. A well-designed and well-supported survivorship program not only meets a mandate for accreditation, it logically translates into better patient care. This review summarizes the history of the survivorship movement, outlines some key elements of a survivorship program, and highlights the opportunity to apply these principles to improve cancer-related care, develop relationships with colleagues that may allow increased identification of men at risk, and expand both the experience and outcomes of individual specialists within mens health.

Proof of concept: Exposing the myth of urethral atrophy after artificial urinary sphincter via assessment of circumferential recovery after capsulotomy and intraoperative pressure profiling of the pressure regulating balloon

Purpose Rate of continence after artificial urinary sphincter (AUS) placement appears to decline with time. After appropriate workup to exclude inadvertent device deactivation, development of urge or overflow incontinence, and fluid loss, many assume recurrent stress urinary incontinence (rSUI) to be secondary to nonmechanical failure, asserting urethral atrophy as the etiology. We aimed to characterize the extent of circumferential urethral recovery following capsulotomy and that of pressure regulating balloon (PRB) material fatigue in men undergoing AUS revision for rSUI. Materials and Methods Retrospective review of a single surgeon database was performed. Cases of AUS removal/replacement for rSUI involving ventral subcuff capsulotomy and intraoperative PRB pressure profile assessments were identified. Results The described operative approach involving capsulotomy was applied in 7 patients from November 2015 to September 2017. Mean patient age was 75 years. Mean time between AUS placement and revision was 103 months. Urethral circumference increased in all patients after capsulotomy (mean increase 1.1 cm; range 0.5–2.5 cm). Cuff size increased, remained the same, and decreased in 2, 3, and 2 patients, respectively. Six of 7 patients underwent PRB interrogation. Four of these 6 PRBs (66.7%) demonstrated pressures in a category below the reported range of the original manufacturer rating. Conclusions Despite visual appearance to suggest urethral atrophy, subcuff capsulotomy results in increased urethral circumference in all patients. Furthermore, intraoperative PRB profiling demonstrates material fatigue. Future multicenter efforts are warranted to determine if capsulotomy, with or without PRB replacement, may simplify surgical management of rSUI with reductions in cost and/or morbidity.

Long-Term Voiding Outcomes After Adult Urethral Reconstruction for Stricture Disease

Purpose of ReviewWhile urethral reconstruction may restore luminal patency, voiding symptoms may persist or develop de novo. This review investigates contemporary literature regarding long-term voiding dysfunction after adult urethroplasty.Recent FindingsFollowing anterior repairs, voiding dysfunction occurs in 12.5% after graft-based urethroplasty, compared to 14% after excision and primary anastomosis. After posterior repair, 76% of patients may anticipate normal voiding and maintain continence. Voiding dysfunction in males with prior hypospadias repair(s) has been demonstrated to improve post-puberty. Success following female urethroplasty is reported as 94%.SummaryLong-term success following urethral reconstruction is generally excellent, but elements of voiding dysfunction may be unmasked by relief of obstruction, or may stem from the repair itself. Continued emphasis on collection and validation of patient-reported outcome measures will better identify and characterize voiding dysfunction, and potentially guide preoperative counseling and surgical therapy.