Faculty Bibliography

OBJECTIVES/OBJECTIVE:To report our novel technique and mid-term follow up for robotic-assisted laparoscopic vaginectomy (RALV), a component procedure of staged gender-affirming penile reconstructive surgery (GAPRS). METHODS:The records of patients seeking GAPRS who underwent RALV, performed by a single surgeon at our institution, between May 2016 and January 2020 were reviewed retrospectively for demographic and perioperative data. Patients were included irrespective of history of previous phalloplasty. A subset of these patients elected to have urethral lengthening during second stage phalloplasty for which an anterior vaginal mucosa flap urethroplasty was performed. Postoperative complications and outcomes and most recent follow-up were obtained. RESULTS:A total of 42 patients were reviewed, of whom 19 (45%) patients ultimately had radial forearm free flap, 15 (41%) had anterolateral thigh flap, 5 (12%) had metoidioplasty, and 1 (2.4%) had abdominal phalloplasty. A vaginal mucosa and gracilis flap was used in all of 36 (86%) patients in whom a pars fixa was created. Average operative time was 299 minutes (range 153-506). Median estimated blood loss was 200 ml (range 100-400). Median length of stay was 3 days (range 1-7). Complications within 30 days from surgery occurred in 15 patients (36%), of whom 12/15 were Clavien-Dindo grade 1 or 2, and 11/15 had complications unrelated to vaginectomy. Of the 4 patients who had vaginectomy-related complications, all resolved with conservative management. Median overall follow-up was 15.8 months. CONCLUSIONS:RALV offers a safe and efficient approach during staged gender-affirming penile reconstruction and may mitigate the subsequent risk of urethral complications.

OBJECTIVE:To describe a technique for perineal urethrostomy (PU) revision using a posterior thigh propeller flap for a complex repair at high risk for stenosis. METHODS:Our technique utilizes the consistent posterior thigh perforators for a local flap with ideal length and thickness for repair. The stenotic PU is incised. Potential flaps are marked around a perforator blood supply closest to the defect. The flap is then elevated and rotated on its pedicle with its apex placed directly in the defect. Absorbable sutures partially tubularize the flap apex at the level of the urethrotomy which is calibrated to 30 Fr. We subsequently monitored the patient's clinical progress. RESULTS:With 17 months of follow-up the patient is voiding well without complaint, reports improved quality of life with a patent PU. Post void residuals have been less than 100cc. The patient, who has had a long history of urinary tract infections requiring hospitalization, has only reported one infection during follow up which was treated as an out-patient. CONCLUSION/CONCLUSIONS:For challenging PU revisions a distant local propeller flap of healthy tissue outside the zone of injury is the ideal choice for length, thickness, and minimal morbidity resulting in excellent clinical results for our patient.

With the widespread dissemination of robotic surgical platforms, pathology previously deemed insurmountable or challenging has been treated with reliable and replicable outcomes. The advantages of precise articulation for dissection and suturing, tremor reduction, three-dimensional magnified visualization, and minimally invasive trocar sites have allowed for the management of such diverse disease as recurrent or refractory bladder neck stenoses, and radiation-induced ureteral strictures, with excellent perioperative and functional outcomes. Intraoperative adjuncts such as near-infrared imaging aid in identification and preservation of healthy tissue. More recent developments include robotics via the single port platform, gender-affirming surgery, and multidisciplinary approaches to complex pelvic reconstruction. Here, we review the recent literature comprising developments in robotic-assisted genitourinary reconstruction, with a view towards emerging technologies and future trends in techniques.

PURPOSE/OBJECTIVE:To report multidimensional outcomes encompassing pain, dyspareunia, and recurrent urinary tract infections (UTIs), following suburethral sling removal (SSR) of synthetic midurethral slings (MUS) placed for female stress urinary incontinence. METHODS:We reviewed a prospectively maintained, IRB-approved database of women undergoing SSR at our institution. Demographic data, type of sling, and symptoms along with Urogenital Distress Inventory-Short Form (UDI-6) scores both before and after SSR were analyzed. Success was defined using several modalities including patient-reported symptoms (ideal outcome) and UDI-6 questionnaire. RESULTS:From 3/2006-2/2017, 443 women underwent SSR of which 230 met study criteria with median overall follow-up of 23 months (mean 30 months). 180/230 (78%) patients reported 3 or more symptoms at presentation. Median most recent post-SSR total UDI-6 score was 38 vs. 50 at baseline (p < 0.0001). By UDI-6, 53% of patients achieved success post-SSR. An ideal outcome was attained in 22/230 (10%) patients. A modified outcome allowing for one minimally invasive anti-incontinence procedure and excluding sexual activity classified 112/230 (49%) patients as successes. CONCLUSIONS:While patients with MUS present with multiple symptoms, following SSR, there is sustained improvement in multiple symptom domains, including pain and urinary incontinence. Allowing for minimally invasive anti-incontinence procedures (not inclusive of subsequent suburethral sling), the rate of success was 49%, which was comparable to that derived from UDI-6 scores (53%).

Background/UNASSIGNED:The optimal management strategy for recurrent urethral stricture disease (USD) following urethroplasty remains undefined. We aim to evaluate the role and efficacy of endoscopic urethral balloon dilation in temporizing recurrent USD after failed urethroplasty. Methods/UNASSIGNED:Between 2007-2018 at our institution, 80 patients underwent balloon dilation procedures for bulbomembranous urethral strictures. Balloon dilation was performed with an 8-cm, 24-French UroMax Ultraâ„¢ balloon dilator, under direct vision, guided by a 16-French flexible cystoscope. Patients who underwent concomitant open or endoscopic urethral procedures were excluded. Treatment failure was defined as the need for subsequent surgical intervention for stricture recurrence. Stricture characteristics including etiology, length, location, severity stage, and prior surgical procedures were compared between patients with and without treatment failure. Results/UNASSIGNED:. the no-failure group (27/53, 51%)]. Among the 27/80 (33.8%) failures with a median follow-up of 8.4 months (IQR, 3.9-22.5 months), median time to recurrence was 4 months (IQR, 2-12 months). These patients had a greater incidence of prior stricture intervention in general (P=0.01) and prior urethroplasty specifically (P=0.03). On multivariable analysis, the number of prior treatments specifically independently remained associated with treatment failure. Complications of balloon dilation were uncommon (6/80, 7.5%) and minor in nature. Conclusions/UNASSIGNED:Endoscopic balloon dilation performs poorly as a salvage strategy after failed open urethral reconstruction in addition to prior urethral dilations.

Background/UNASSIGNED:Scrotal hematoma formation is a dreaded complication of penile prosthesis surgery that increases patient pain and healthcare costs, as well the risk for eventual device infection and failure. The efficacy of hemostatic agents in reducing the incidence of scrotal hematoma development has not been extensively studied in urologic prosthetic surgery. In this paper we further evaluate our experience with oxidized regenerated cellulose (ORC; Surgicel Fibrillarâ„¢) as an adjunct to standard hemostatic practices in inflatable penile prosthesis (IPP) implantation. Methods/UNASSIGNED:From April 2016 onward, intracorporal ORC pledgets were placed during corporotomy closure in all patients undergoing IPP implantation or revision by a single surgeon using an identical surgical technique. Perioperative parameters and outcomes-primarily postoperative cumulative drain output, secondarily patient phone calls in the postoperative period-were compared among successive cases with ORC (April 2016 to February 2019) and without ORC (April 2013 to March 2016). Results/UNASSIGNED:1.1 calls per patient; P=0.03). A total of 9 patients underwent IPP explantation during the study period, all due to device infection; 5 of these were in the ORC group, while 4 were in the non-ORC group (P=0.73). ORC use did not constitute any additional infection risk. Conclusions/UNASSIGNED:Bilateral incorporation of ORC pledgets during corporotomy closure in IPP surgery significantly decreases postoperative scrotal drain output, a well-documented risk factor for scrotal hematoma formation.

Background/UNASSIGNED:Among men with bulbar strictures, we aimed to analyze stricture characteristics, repair type, and treatment success in younger versus older patient cohorts. Methods/UNASSIGNED:We retrospectively reviewed our single surgeon database with patients undergoing bulbar urethroplasty from 2007 to 2017. This population was then age-stratified into ≤40 and >40-year-old cohorts. Exclusion criteria included patients with penile strictures and those with history of hypospadias. Patient characteristics, surgical approach, and outcome were compiled by medical record and database review. Criterion for success included functional emptying and lack of repeat surgical intervention. Parameters associated with failure were included in multivariate logistic regression models. Results/UNASSIGNED:. 29.2%, P<0.0001) relative to older men. Over a median follow-up of 52.4 months, success rates were higher in the ≤40 cohort (97.4%) than the >40 cohort (87.3%, P<0.0001). On multivariate logistic regression, independent predictors of urethroplasty success include younger age), utilization of EPA, and lack of pelvic radiation. Conclusions/UNASSIGNED:Although men ≤40 years old have a higher incidence of traumatic etiology, bulbar urethroplasty has a higher success rate when compared to patients >40 years old. Bulbar strictures are more amenable to EPA in the younger population, likely due to fewer endoscopic treatments and favorable tissue characteristics.

Background/UNASSIGNED:We sought to compare outcomes between inpatient and outpatient buccal mucosal graft (BMG) urethroplasty among a large tertiary referral center series. Methods/UNASSIGNED:A retrospective review of consecutive patients who underwent BMG urethroplasty between 2007 and 2018 was performed, including only first stage and one stage graft procedures. Patients were divided into inpatient and outpatient groups. Demographic and outcome data were collected and analyzed, with success defined as no need for further endoscopic or open reoperative management. Results/UNASSIGNED:26.8% outpatient, P=0.07). Conclusions/UNASSIGNED:BMG urethroplasty can be safely performed in an ambulatory setting without increased complications or compromised outcomes.

OBJECTIVES:To present a multi-institutional experience with functional and patient-reported outcomes among men undergoing excision and primary anastomosis (EPA) urethroplasty for pendulous urethral strictures. METHODS:We describe the technique and present our experience with EPA for focal penile strictures. Patients undergoing urethroplasty (2004-2017) at 2 tertiary referral centers were reviewed, of whom 14 (0.7%) underwent EPA of radiographically confirmed pendulous urethral strictures. Validated questionnaires were utilized to evaluate overall improvement (Patient Global Impression of Improvement), urinary bother (International Prostate Symptom Score), and sexual function (International Index of Erectile Function-5). Treatment success was defined as urethral patency without need for subsequent reconstruction. RESULTS:Among 14 men undergoing penile EPA, 13/14 (93%) had durable treatment success over a median follow-up of 43 months. No patient reported penile curvature postoperatively. Stricture etiology in most cases was posttraumatic (12/14), of which 4 had a history of urethral disruption secondary to penile fracture and 8 iatrogenic trauma. Median age was 51 years (IQR 30-60) and stricture length 1.0 cm (IQR 1.0-1.4). Erectile function was normal in 8/14 patients preoperatively, and postoperative median International Index of Erectile Function was 21. Most men reported significant global improvement in condition (median Patient Global Impression of Improvement 2, IQR 1-3) and most had only mild urinary bother (median International Prostate Symptom Score 4, quality of life 1). The single treatment failure had a history of hypospadias with multiple prior urethral procedures. CONCLUSION:For men with short strictures of the pendulous urethra, EPA has a high success rate, without adverse sequelae such as erectile function or penile curvature.