Molecular characterization of plasmacytoid urothelial carcinoma and the impact on treatment implications

Bladder cancer researchers and clinicians have increasingly viewed tumor biology through the lens of genomic and molecular alterations, drastically improving our knowledge of the underlying disease biology. This understanding has led to significant advances in treatment options that allow implementation of a personalized approach to cancer treatment. Large-scale genomic studies initially focused on the most common forms of bladder cancer. However, as genomic and molecular technologies become more widespread and are applied to less common variant histologies, we are gaining additional insight into the unique molecular and genomic characteristics driving the biology of variant histologies of bladder cancer. In this review, we summarize the current state of knowledge of molecular alterations underlying the distinct tumor biology of plasmacytoid urothelial carcinoma and how these alterations may impact treatment options.

Linguistic Differences Based on Gender and Race in Urology Application Personal Statements: A Comparison of 2017 and 2023 Applications

While diversity and inclusion efforts have increased in urology, comparative analysis of personal statements from 2016-2017 and 2022-2023 residency applications showed few linguistic changes over time by gender or race/ethnicity. These results suggest the need for directed efforts to engage, mentor, and coach females and underrepresented minorities during medical school and the urology application process.

Gender Affirming Graft Only Vaginoplasty

OBJECTIVE

To describe our technique for performing gender affirming graft only vaginoplasty.

METHODS

In graft only vaginoplasty, penile skin is used only for the external genitals, and the entire vaginal canal is created from a full thickness skin graft. The inner scrotum is excised and used as a skin graft to line the vaginal canal. The outer scrotum is left in place then moved medially to form the labia majora. The penile skin and Dartos fascia are incised dorsally and ventrally then advanced to the posterior perineum to become the labia minora. The glans clitoris is constructed from a W-shaped dorsally-based portion of the glans penis, and the clitoral hood is constructed from the distal 2-3 cm of penile shaft skin. The posterior wall of the introitus is formed from a posterior perineal flap.

RESULTS

The patient presented here is a 26-year-old transgender woman with marked and sustained gender incongruence. She is circumcised, has typical penile length, scrotal contents are normal, and all hair has been removed on the scrotum and perineum. She underwent graft only vaginoplasty, as shown in the accompanying video.

CONCLUSION

Gender affirming graft only vaginoplasty allows for construction of the vaginal canal from a full thickness skin graft, and construction of external genitals from penile and scrotal skin. Advantages of this approach include availability of more tissue for construction of the external genitals and an external skin to graft anastomosis. The procedure is modified slightly when the patient has a small scrotum, short penis, or is uncircumcised.

Genital Gender Affirming Surgery

Genital gender affirming surgery is an effective treatment for gender dysphoria in transgender individuals. Optimization of medical and mental health conditions, including coordination with a patient's entire care team, is essential. Feminizing procedures include vaginoplasty (creation of female genitalia with a vaginal canal) and vulvoplasty (creation of female genitalia with a short or absent vaginal canal). Masculinizing procedures include metoidioplasty (construction of male genitals via local tissue rearrangement) and phalloplasty (creation of a phallus from extra-genital tissue). We aim to provide an overview of genital gender affirming surgery for providers who are interested in learning more about genital gender affirming surgery.

PENILE PLICATION FOR PEYRONIE'S DISEASE: THE ITERATIVE 8-DOT TECHNIQUE

INTRODUCTION

Penile plication is a minimally invasive and effective technique for managing mild to severe curvature from Peyronie's disease.

METHODS

Retrospective chart review of all patients undergoing penile plication for Peyronie's disease by one surgeon at one academic institution from November 2016 - December 2020 was conducted. Those occurring during IPP placement were excluded. Technical aspects of surgery were detailed and intraoperative video footage was made to illustrate the technique including papaverine injection, incision and variations, tissue dissection, iterative 8-dot plication with absorbable suture, and post-operative evaluation. Primary outcomes were intra-operative and long-term success.

RESULTS

A total of 66 patients were included. Median age was 58 years old (Range 24-73 years old). Average preoperative curvature was 45 degrees (Range 20-90 degrees). Curvature direction included 64% dorsal, 20% dorsolateral, 8% ventral, 5% ventrolateral, 3% lateral. Overall, 55% had complex deformities (biplanar curvature (38%), curvature of >60 degrees (50%), or both (11%)). Hinge effect was present in 14% of patients. Erectile dysfunction was present in 57% of patients. Ventral minimally invasive incisions were most common (64%) followed by circumcising incisions (24%), only 9% of patients had concurrent circumcision. Median number of 8-dot plication sutures used was 3 (Range 1-12). Intraoperative success, defined as completely straight was 97%. The 2 technical failures were directly related to ability to maintain intraoperative erection. Mean follow up was 4.5 months (IQR 1.1-4.2) and 91% of patients reported straight erections at follow up. No patient with hinge effect had a intraoperative failure or recurrence. There were no major complications. Rate of minor complication (superficial dehiscence, hematoma) was 6%. There were no revision plication procedures or patients who proceeded to penile implant surgery.

CONCLUSIONS

This iterative approach to penile plication with absorbable suture is an effective, minimally invasive, and reproducible technique for correcting acquired penile curvature.

Ring Flap Metoidioplasty

OBJECTIVE

To describe our technique for performing ring flap metoidioplasty in transgender men.

METHODS

In a ring flap metoidioplasty, the urethra is created from bilateral anteriorly based labia minora and vestibular flaps. This technique is combined with Ghent scrotoplasty, vaginectomy (distal mucosal excision and proximal mucosal fulguration followed by cavity closure) and perineal masculinization. Suprapubic tube is placed for urinary diversion. To avoid disrupting the anteriorly based urethral pedicles, we do not perform monsplasty, division of the suspensory ligament, or resection of the labial folds adjacent to the penis at the time of ring flap metoidioplasty. Typically, resection of labial folds adjacent to the penis and testicular prosthesis insertion are performed 4-6 months after metoidioplasty.

RESULTS

From November 2017 to June 2021, 52 patients underwent metoidioplasty with urethroplasty and concomitant vaginectomy by two surgeons (BF, MC). Median age was 30 years, and median follow-up was 22 months. Urethrocutaneous fistula developed in 7 (13%) patients, 1 of whom had spontaneous closure of the fistula. Urethral stricture occurred in 4 (8%) patients. Fistula repair and/or urethroplasty was required in 8 (15%) patients. Non urethral complications included bacteremia (1 patient) and venous thromboembolism (1 patient).

CONCLUSION

Ring flap metoidioplasty allows select patients to obtain masculine appearing genitals and the ability to void standing.

Linguistic Differences in Personal Statements of Urology Residency Applicants by Self-Reported Race and Ethnicity

OBJECTIVES

To assess a potential source of bias that could contribute to underrepresentation of minorities in urology, we analyzed differences in linguistic characteristics in personal statements between urology residency applicants of various racial and ethnic groups.

METHODS

Personal statements submitted by urology residency applicants to a urology program were evaluated with Linguistic Inquiry and Word Count, a validated text analysis program. Analyzed statements and application characteristics were compared according to self-identified race/ethnicity of the applicant using multivariable analysis and independent sample T-tests.

RESULTS

Of 342 submitted personal statements, 181 applicants self-identified as White non-Hispanic, 86 as Asian, and 75 as "underrepresented in medicine" (URM) including Black and Hispanic/Latino applicants. Asian and URM applicants listed more research projects (11.7 and 12.9 vs 8.8, P = .01) and URM applicants had slightly lower USMLE Step 1 scores (238.5 vs 244.6, P = .01) compared to White applicants. When evaluating personal statements, all applicants wrote with the same degree of analytical thinking. Asian applicants scored lower in authenticity (P = .03) and emotional tone (P = .04) while URM applicants scored higher in clout (P = .04) compared to White applicants. In use of pronouns, Asian applicants used 'we/us/our' more often (P < .01), URM applicants used 'you' more often (P = .02), and White applicants used 'I' more often (P = .01).

CONCLUSION

Significant linguistic differences exist among urology personal statements by racial/ethnic groups that may perpetuate stereotypes and bias in the application process. Appreciating these differences may help applicants avoid possibly detrimental linguistics and help residency programs recruit and support urology applicants from underrepresented backgrounds.

Orchidopexy and Split-thickness Skin Graft for Scrotal Defects After Necrotizing Fasciitis

OBJECTIVE

To demonstrate a technique for performing orchidopexy and split-thickness skin graft for patients with deficient scrotal skin after debridement for Fournier's gangrene. This is an alternative strategy to healing by secondary intention, flaps, or testicular thigh pouches.

METHODS

Orchidopexy was performed after initial debridement using interrupted Vicryl sutures to bring the testicles and inferior penis together. During this procedure, the testicles and spermatic cord were mobilized, and redundant spermatic cord was coiled under the abdominal wall. Once patients were medically stable with no additional planned debridement, a split-thickness skin graft at a depth of 18/1000 inch and meshed 2:1 was applied to the scrotum. The graft was covered with a bolster dressing that was sutured to the scrotum for 5 to 7 days. An inpatient stay was not required after skin graft and bolster placement. Patients were evaluated for cosmetic appearance, pain, and need for revision.

RESULTS

From 2017-2021, 10 patients underwent orchiopexy and split-thickness skin graft to the scrotum. Etiology of Fournier's gangrene included diabetes (5), urethral stricture (2), alcohol abuse (2), unknown (1). Median age was 56 years and median BMI was 30 kg/m². Median length of stay after orchidopexy and skin graft were 18 and 9 days respectively. At a median follow-up of 8 months, there were no issues with chronic pain, discomfort, or need for further intervention.

CONCLUSION

Orchidopexy and split-thickness skin graft to scrotum is a feasible method of scrotal reconstruction that leads to acceptable clinical and cosmetic results, and does not result in prolonged inpatient hospitalization. Future research should focus on long term sexual function and quality of life outcomes.

Gender-Based Differences in Urology Residency Applicant Personal Statements

OBJECTIVE

To gain insight into the perceptions of urology held by medical students as they enter the field, we analyzed the linguistic characteristics and gender differences in personal statements written by urology residency program applicants.

METHODS

Personal statements were abstracted from residency applications to a urology residency program. Linguistic Inquiry and Word Count, a validated text analysis software, characterized the linguistic content of the statements. Analyzed statements were compared according to gender of the applicant using multivariate analysis, examining the association of applicant gender and statement characteristics. Multivariate analysis was also performed to determine the association of personal statement characteristics with matching into urology residency.

RESULTS

Of 342 analyzed personal statements, no significant difference was found in statement characteristics between matched and unmatched applicants. Male and female applicants wrote with the same degree of overall analytical thinking, authenticity, and emotional tone. Clout, a measure of portrayed confidence, was low for both genders. Female applicants used more social and affective process words. Male applicants used more words indicating a sense of community and acceptance. Female applicants had more references to women within their statements.

CONCLUSION

Significant linguistic differences exist among personal statements written by men and women applying to urology residency. Word usage differences follow societal gender norms. Statement content demonstrates a difference between genders in perceived sense of belonging, highlighting the importance of gender concordant mentorship within the field.

Avascular Necrosis Is Associated With Increased Transfusions and Readmission Following Primary Total Hip Arthroplasty

Avascular necrosis (AVN) may confer an increased risk of complications and readmission following total hip arthroplasty (THA). However, current risk-adjustment models do not account for AVN. A total of 1706 patients who underwent THA for AVN from 2011 to 2013 were selected from the American College of Surgeon's National Surgical Quality Improvement Program database and matched 1:1 to controls using a predetermined propensity score algorithm. Rates of 30-day medical and surgical complications, readmissions, and reoperations were compared between cohorts. Propensity-score logistic regression was used to determine independent associations between AVN and outcomes of interest. Patients with AVN had a higher rate of medical complications than those without AVN (20.3% vs 15.3%, respectively; P<.001). Bleeding transfusion was the most common medical complication, occurring at a significantly higher rate in patients with AVN than those without AVN (19.6% vs 13.9%, respectively; P<.001). Patients with AVN were also twice as likely to experience a readmission after THA (odds ratio, 2.093; 95% confidence interval, 1.385-3.164). Avascular necrosis of the femoral head is an independent risk factor for transfusion up to 72 hours postoperatively and readmission up to 30 days following total hip replacement. [Orthopedics. 2017; 40(3):171-176.].