Faculty Bibliography

OBJECTIVE:To describe the technique of robotic remnant vaginectomy/excision of urethral diverticulum in transmen and report post-operative outcomes. MATERIALS AND METHODS/METHODS:Between 2015 and 2018, 4 patients underwent robotic remnant vaginectomy/excision of urethral diverticulum for relief of urinary symptoms. Patients were of mean age 36 ± 10.1 years (range 26 - 50) at time of vaginal remnant excision, and were 26 ± 9.1 months (range 20 - 39) post-op following their primary vaginectomy and radial forearm free flap (n=3) or anterolateral thigh (n=1) phalloplasty. All had multiple urological complications after primary phalloplasty, most commonly urinary retention (n=4), urethral stricture (n=3), fistula (n=3), dribbling (n=2), and obstruction (n=2). Indication for revision was obstruction and retention (n=3) and/or dribbling (n=2). In each case, the robotic transabdominal dissection freed remnant vaginal tissue from the adjacent bladder and rectum without injury to these structures. Concurrent first- or second-stage urethroplasty was performed in all cases at a more distal portion of the urethra using buccal mucosa, vaginal or skin grafts. Intraoperative cystoscopy was used in each case to confirm complete resection and closure of the diverticulum. RESULTS:At mean follow-up of 294 ± 125.6 days (range 106-412), no patients had persistence or recurrence of vaginal cavity/urethral diverticulum on cystoscopic follow-up. Of 3 patients who wished to ultimately stand to void, 2 were able to do so at follow-up. CONCLUSION/CONCLUSIONS:Robotic transabdominal approach to remnant vaginectomy/excision of urethral diverticulum allows for excision without opening the perineal closure for management of symptomatic remnant/diverticulum in transgender men after vaginectomy.

OBJECTIVE. Masculinizing genital surgeries for transgender individuals are currently performed at only a select few centers; however, radiologists in any geographic region may be confronted with imaging studies of transgender patients. The imaging findings of internal and external genital anatomy of a transgender patient may differ substantially from the imaging findings of a cisgender patient. This article provides the surgical and anatomic basis to allow appropriate interpretation of preoperative and postoperative imaging findings. We also expand on the most common complications and associated imaging findings. CONCLUSION. As these procedures become more commonplace, radiologists will have a growing role in the care of transgender patients and will be faced with new anatomic variants and differential diagnoses. Familiarity with these anatomic variations and postoperative complications is crucial for the radiologist to provide an accurate and useful report.

The transgender and nonbinary (TGNB) population is a significant minority, comprising at least 0.6% of the population. Visibility is growing rapidly, especially in younger generations. Gender affirming health care must adapt to this population's needs. Demographic data regarding TGNB health care are limited, but several disparities are clear, stemming from sociopolitical factors, such as external discrimination and insensitive and/or uninformed care. Most self-identifying TGNB patients receive some type of nonsurgical care, including hormonal and/or mental health. Gender-affirming surgery is highly prevalent as well, with at least one-quarter of TGNB people having had some combination of the procedures in this category.

OBJECTIVES/OBJECTIVE:To evaluate the presenting complications of patients to reconstructive urologists after masculinizing gender affirming genital reconstructive surgery (GRS) performed elsewhere. METHODS:We identified patients who underwent revision surgery by one of the co-authors for sequelae of masculinizing GRS. We reviewed patient demographics, medical history, details of prior GRS, and complications from GRS. Specific attention was paid to the presence of the following: suprapubic tube (SPT) dependence, vaginal remnant, urethrocutaneous fistula (UCF) within the fixed urethra (pars fixa), UCF in the phallic urethra, phallic urethral stricture, meatal stenosis, and anastomotic urethral stricture. Statistical analysis was performed using Fisher's exact test to determine differences in presenting symptoms by GRS. RESULTS:55 patients who had reconstructive surgery for complications from masculinizing GRS from September 2004 to September 2017 were identified. The median age at surgical correction was 33 years. Fifteen (27%) patients had prior metoidioplasty and 40 (73%) had prior phalloplasty. The median time from date of GRS to presentation to a reconstructive urologist was 4 months. Urethral strictures (n=47, 86%) were the most common indication for subsequent surgery, followed by urethrocutaneous fistulae (n=31, 56%) and vaginal remnant (n=26, 47%). The majority of patients presented with two or more simultaneous complications (n=40, 73%). CONCLUSIONS:There are several common presenting urologic complications after masculinizing GRS. Patients may present to reconstructive urologists early after GRS performed elsewhere. The long-term outcomes of GRS deserve further study.

Introduction & Objective: To describe our technique and outcomes for the treatment of posterior urethral stenosis with the da Vinci Single Port (SP) platform.
Method(s): We retrospectively reviewed 5 patients who underwent SP robot-assisted laparoscopic posterior urethroplasty (SPRALPU) by a single surgeon from October 2018-January 2019. Compared to multi-port robotics, the SP robot allows for improved exposure and less instrument clashing in the deep pelvis. We evaluated patient demographics, diagnosis, etiology, prior interventions, intraoperative variables, and outcomes. Success was defined as passage of a 17 Fr. flexible cystoscope or absence of urinary symptoms. The operative technique involves SP port placement at a periumbilical location for transabdominal mobilization of the bladder neck and urethra. Cystoscopy is used to identify the level of the urethral stenosis. The stenotic segment is excised, and the anastomosis completed using either excision and primary anastomosis or Y-V plasty. Combined abdominoperineal approach may be used for distal urethral mobilization to reduce tension.
Result(s): The mean age was 64.8 years. Posterior urethroplasty was performed for vesicourethral anastomotic strictures+/-rectourethral fistula or bladder neck contracture+/-urethral stricture, caused by prostate cancer treatments (brachytherapy, radiation therapy, prostatectomy), or prostatic urethra false passage due to traumatic intermittent catheterization in a patient with neurogenic bladder. Prior interventions included endoscopic balloon dilation, urethral incision under direct vision, and Foley catheter placement. Four patients underwent SPRALPU without open conversion. Mean operative time was 417 minutes, estimated blood loss 220 mL, and length of stay 5.2 days. There were no intraoperative complications. One case required open conversion due to SP robot failure; however, surgery was completed robotically using the Xi robot. Post-operative complications included ileus (n = 2), small bowel obstruction (n = 1), deep venous thrombosis (n = 1), urinary tract infection (n = 3), and hematuria (n = 1). Two patients required cystectomies for osteomyelitis with urethrocutaneous fistula (n = 1) and recurrent necrotic debris (n = 1). Catheters were removed at a median of 44.2 days. All cases had patent urethral anastomoses with a median followup of 4.4 months. No patients experienced de novo urinary incontinence.
Conclusion(s): SPRALPU is a feasible approach to an otherwise difficult reconstructive procedure due to challenges in exposure

Introduction & Objective: We describe a novel skin incision used when performing surgery with the da Vinci Single Port Robotic Surgical System.
Method(s): A 2.7cm diameter circumferential skin incision is made around the umbilicus and carried down through the subcutaneous tissue while leaving the umbilical stalk intact. The fascia adjacent to the umbilicus is exposed by retracting the skin incision in a direction determined by the operative field. The fascia and peritoneum are entered, and the Single Port robotic trocar is inserted in the standard fashion. This technique allows for a cosmetic incision partially hidden within the umbilicus and places less tension on the skin than a standard linear incision.
Result(s): This technique was utilized in approximately 70 patients at a single institution between October 2018 and May 2019. This method of skin incision has been used for a wide variety of robotic reconstructive urologic procedures including penile inversion vaginoplasty, vaginectomy, pyeloplasty, ureteral reimplant, Boari flap, cystectomy and intracorporeal ileal conduit, bladder neck reconstruction, and posterior urethroplasty. No patients have yet to experience complications related to the incision.
Conclusion(s): A circumferential periumbilical skin incision is a versatile skin incision that can be used for a wide array of cases using the Single Port Robotic Surgical System. Moreover, it may have benefits compared to a standard linear incision

BACKGROUND:Penile inversion vaginoplasty (PIV) is the most common procedure for genital reconstruction in transwomen. While PIV usually provides an excellent aesthetic result, the technique may be complicated by vaginal stenosis and inadequate depth, especially in transwomen with limited penile and scrotal tissue. Here, we describe a technique of using peritoneal flaps to augment the neovaginal apex and canal in penile inversion vaginoplasty for transwomen. METHODS:Between 2017 and 2018, 41 female-to-male patients were identified who underwent primary penile inversion and peritoneal flap vaginoplasty. Two approximately 6cm wide by 8cm long peritoneal flaps are raised from the anterior aspect of the rectum and sigmoid colon, and the posterior aspect of the bladder to create the apex of the neovagina. RESULTS:The 41 patients had an average age of 34 +/- 14 years. Average length of procedure was 262 +/- 35 minutes and the average length of stay was 5 days. Average length of follow up was 114 +/- 79 days and at most recent follow up, vaginal depth and width were measured to be 14.2 +/- 0.7 cm and 3.6+/- 0.2 cm respectively. The peritoneal flap added an additional 5 cm of depth beyond the length of the skin graft, forming the vaginal canal in patients with limited scrotal skin. CONCLUSION/CONCLUSIONS:Penile inversion vaginoplasty remains the gold standard for primary genital reconstruction in transwomen. Peritoneal flaps provide an alternative technique for increased neovaginal depth, creating a well-vascularized apex with acceptable anticipated complications.

Transgender and gender non-binary (TGNB) individuals are a growing demographic with unique healthcare needs. Amid changes in public and private insurance coverage of gender confirming surgeries (GCS), utilization of these procedures is increasing. Meanwhile, systemic barriers continue to limit access to gender confirming care and perpetuate health disparities among TGNB individuals. Studies on the prevalence of TGNB identities and utilization of GCS are limited by a lack of gender identity data in population-based surveys and electronic medical records. However, data collection on gender identity is improving, and will be essential for characterizing the healthcare practices and needs of TGNB individuals.

Transgender and gender nonbinary (TGNB) individuals may seek genital gender confirming surgery (GCS) as part of their transition. Outcomes of genital GCS may include gender congruence, sexual functioning and satisfaction, urinary symptoms, aesthetic satisfaction, and overall quality of life, among others. Despite a wide number of studies on results of vaginoplasty, metoidioplasty, phalloplasty, and other genital GCS, data regarding patient reported outcomes are limited. To date, there is no patient reported outcome measure (PROM) validated within the TGNB population to assess subjective outcomes of GCS. In this review, we aim to describe existing tools being utilized to report outcomes following GCS, assessing the merits and limitations of each.

Introduction & Objective: To demonstrate the technique and the outcomes of robot assisted Y-V plasty bladder neck reconstruction (RYVBNR).
Method(s): We present our technique for treatment of recalcitrant bladder neck contracture (BNC) in seven patients who underwent RYVBNR at our institution between March 2016 and September 2017. Indication for the procedure was incomplete emptying, recurrent urinary tract infections and dysuria. On follow-up, patients were assessed for clinical success by absence of infections, symptoms and cystoscopic evaluation. Robotic assisted dissection is performed to open the space of Retzius and mobilize the bladder. The cystoscope is passed to the level of the BNC, and FireflyTM technology is used to localize the BNC. The BNC is incised anteriorly, and a V-shaped bladder flap is advanced into the BNC in a Y-V plasty fashion (figure 1). We place a perioperative closed suction drain, which is removed before discharge, and a catheter which will be removed in the office at approximately two weeks.
Result(s): Six men with recalcitrant BNCs and one with recalcitrant vesicourethral anastomotic stenosis underwent treatment (figure 2). All patients had previously undergone an endoscopic procedure. Median time for last attempt at endoscopic management to RABNR was 4.7 months. The average number of prior attempts at endoscopic management was 2. All patients underwent RYVBNR without conversion to open surgery. The median operative time was 240min, estimated blood loss was 67 ml, and length of stay was 1 day. There were no intraoperative complications. Catheters were removed in the office at a median time of 15 days. At a median follow-up of 8 months, all cases were successful with no evidence of recurrence. Only two patients had persistent urinary incontinence at 1 pad per day.
Conclusion(s): RYVBNR with a Y-V plasty is a feasible and effective technique for managing a difficult reconstructive problem. (Table Presented)