Faculty Bibliography

OBJECTIVE:To describe the outcomes of single-stage and staged repairs in properly selected patients with phalloplasty anastomotic strictures. METHODS:A bi-institutional retrospective review was performed of all patients who underwent anastomotic stricture repairs between 7/2014-8/2020. Those who had prior augmented urethroplasties or poorly vascularized tissue underwent two-stage repairs (Group-2), all others underwent single-stage repair with a double-face (dorsal inlay and ventral onlay) buccal mucosal graft urethroplasty (Group-1). Postoperatively, urethral patency and patient reported outcome measures (PROMs) were assessed. RESULTS:Twenty-three patients with anastomotic strictures were identified. Fourteen patients met inclusion criteria and had 1-year follow-up (9 in Group-1; 5 in Group-2). Nine patients (64%) had prior failed interventions (56% Group-1; 80% Group-2). At a mean follow-up of 33.9 (Group-1) and 35.2 months (Group-2) there were two stricture recurrences in Group-1 (22%) and none in Group-2. PROMs were completed by 12 patients. All patients reported the ability to void standing. Post-void dribbling was present in the majority of patients (7/7 Group-1; 2/4 in Group-2). Mean IPSS was 3.9 (0-14) for Group-1 and 1 (0-3) for Group-2. All reported at least a moderate improvement in their condition on GRA (Group-1 +3 71%, +2 29%; Group-2 +3 100%). CONCLUSION/CONCLUSIONS:Single-stage repairs are feasible for patients with anastomotic strictures who have well vascularized tissue and no prior single-stage buccal mucosa augmented urethroplasty failures. Staged repairs are feasible for patients with poor tissue quality. Proper patient selection is important for successful reconstruction.

BACKGROUND:Vaginoplasty is a gender-affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed. OBJECTIVES/OBJECTIVE:To investigate sexual health after gender-affirming vaginoplasty for TGD patients. DATA SOURCES/METHODS:MEDLINE/PubMed, Embase, Scopus, and PsycINFO databases were searched, unrestricted by dates or study design. METHODS:We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences, or aids. RESULTS:Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4%-100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 to 28.6). 64%-98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia. CONCLUSIONS:The heterogenous methods of measuring sexual outcomes reflect the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires, and inclusive metrics. Systematic review registration number: PROSPERO 01/01/2021: CRD42021224014.

BACKGROUND:Current literature on surgical outcomes after gender affirming genital surgery is limited by small sample sizes from single-center studies. AIM:To use a community-based participatory research model to survey a large, heterogeneous cohort of transmasculine patients on phalloplasty and metoidioplasty outcomes. METHODS:A peer-informed survey of transmasculine peoples' experience was constructed and administered between January and April 2020. Data collected included demographics, genital surgery history, pre- and postoperative genital sensation and function, and genital self-image. OUTCOMES:Of the 1,212 patients completing the survey, 129 patients underwent genital reconstruction surgery. Seventy-nine patients (61 percent) underwent phalloplasty only, 32 patients (25 percent) underwent metoidioplasty only, and 18 patients (14 percent) underwent metoidioplasty followed by phalloplasty. RESULTS:Patients reported 281 complications requiring 142 revisions. The most common complications were urethrocutaneous fistula (n = 51, 40 percent), urethral stricture (n = 41, 32 percent), and worsened mental health (n = 25, 19 percent). The average erect neophallus after phalloplasty was 14.1 cm long vs 5.5 cm after metoidioplasty (P < .00001). Metoidioplasty patients report 4.8 out of 5 erogenous sensation, compared to 3.4 out of 5 for phalloplasty patients (P < .00001). Patients who underwent clitoris burial in addition to primary phalloplasty did not report change in erogenous sensation relative to primary phalloplasty patients without clitoris burial (P = .105). The average postoperative patient genital self-image score was 20.29 compared with 13.04 for preoperative patients (P < .00001) and 21.97 for a historical control of cisgender men (P = .0004). CLINICAL IMPLICATIONS:These results support anecdotal reports that complication rates following gender affirming genital reconstruction are higher than are commonly reported in the surgical literature. Patients undergoing clitoris burial in addition to primary phalloplasty did not report a change in erogenous sensation relative to those patients not undergoing clitoris burial. Postoperative patients report improved genital self-image relative to their preoperative counterparts, although self-image scores remain lower than cisgender males. STRENGTHS & LIMITATIONS:These results are unique in that they are sourced from a large, heterogeneous group of transgender patients spanning 3 continents and dozens of surgical centers. The design of this study, following a community-based participatory research model, emphasizes patient-reported outcomes with focus on results most important to patients. Limitations include the recall and selection bias inherent to online surveys, and the inability to verify clinical data reported through the web-based questionnaire. CONCLUSION:Complication rates, including urethral compromise and worsened mental health, remain high for gender affirming penile reconstruction. Robinson IS, Blasdel G, Cohen O, et al. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021;18:800-811.

Background Robotic pelvic surgery is increasingly utilized for reconstruction proximal to the genitourinary diaphragm. We describe a combined robotic transabdominal and open transperineal approach for complex anastomotic posterior urethroplasty. Methods We performed a multi-institutional retrospective study of patients who underwent anastomotic posterior urethroplasty by a combined robotic transabdominal and open transperineal approach between 1/2012 and 12/2018. Patient demographics; preoperative, intraoperative, and postoperative clinical data; and complications were reviewed. Urethroplasty success, de novo stress urinary incontinence (SUI), and de novo erectile dysfunction (ED) were evaluated. Results 12 patients were identified with a mean follow-up of 596 (range 73-1618) days. Mean patient age was 65.9 (range 53.4-76.8). Reconstruction required corporal splitting, prostatectomy, and gracilis muscle flap use in 1 (8.3%), 8 (66.7%), and 4 (33.3%) patients, respectively. Postoperative urinary leak, thromboembolic event, and wound abscess occurred in 1 (8.3%), 1 (8.3%), and 2 (16.7%) patients, respectively. Stenosis recurrence occurred in 2 patients (16.7%) at a mean 187.5 (20-355) postoperative days. De novo ED and de novo SUI were reported in 2 (16.7%) and 4 (33.3%) patients, respectively. Nine patients (75.0%) underwent placement of an artificial urinary sphincter at a mean interval of 359.2 (111-1456) days after the index procedure with no subsequent erosion. Conclusions Complex posterior urethroplasty by a combined robotic transabdominal and open transperineal approach is associated with success and complications rates comparable to open techniques and may allow for adjunctive procedures such as prostatectomy. This technique allows for reconstruction of posterior urethral stenoses that would otherwise have been managed conservatively or with urinary diversion.

BACKGROUND:To optimize neovaginal dimensions, several modifications of the traditional penile inversion vaginoplasty are described. Options for neovaginal lining include skin grafts, scrotal flaps, urethral flaps, and peritoneum. Implications of these techniques on outcomes remain limited. METHODS:A systematic review of recent literature was performed to assess evidence on various vaginal lining options as adjunct techniques in penile inversion vaginoplasty. Study characteristics, neovaginal depth, donor-site morbidity, lubrication, and complications were analyzed in conjunction with expert opinion. RESULTS:Eight case series and one cohort study representing 1622 patients used additional skin grafts when performing penile inversion vaginoplasty. Neovaginal stenosis ranged from 1.2 to 12 percent, and neovaginal necrosis ranged from 0 to 22.8 percent. Patient satisfaction with lubrication was low in select studies. Three studies used scrotal flaps to line the posterior vaginal canal. Average neovaginal depth was 12 cm in one study, and neovaginal stenosis ranged from 0 to 6.3 percent. In one study of 24 patients, urethral flaps were used to line the neovagina. Neovaginal depth was 11 cm and complication rates were comparable to other series. Two studies used robotically assisted peritoneal flaps with or without skin grafts in 49 patients. Average neovaginal depth was approximately 14 cm, and complication rates were low. CONCLUSIONS:Skin grafts, scrotal flaps, urethral flaps, and peritoneal flaps may be used to augment neovaginal canal dimensions with minimal donor-site morbidity. Further direct comparative data on complications, neovaginal depth, and lubrication are needed to assess indications in addition to advantages and disadvantages of the various lining options.

OBJECTIVES/OBJECTIVE:To present the technique and early outcomes of salvage neovaginal reconstruction using robotic dissection and peritoneal flap mobilization. METHODS:Twenty-four patients underwent robotic peritoneal flap revision vaginoplasty from 2017-2020. A canal is dissected between the bladder and rectum towards the stenosed vaginal cavity, which is incised and widened. Peritoneal flaps from the posterior bladder and pararectal fossa are advanced and sutured to edges of the stenosed cavity. Proximal peritoneal flap edges are approximated to form the neovaginal apex. Patient demographics, comorbidities, surgical indications, and operative details are described. Outcome measures include postoperative neovaginal dimensions and complications. RESULTS:Mean age at revision was 39 years (range 27-58). All patients had previously undergone PIV, with revision surgery occurring at a median 35.3 months (range 6-252) after primary vaginoplasty. Surgical indications included short or stenotic vagina or absent canal. Average procedure length was 5 hours. At mean follow up of 410 days (range 179-683), vaginal depth and width were 13.6 cm (range 10.9-14.5) and 3.6 cm (range 2.9-3.8), respectively. There were no immediate or intraoperative complications related to peritoneal flap harvest. No patient had rectal injury. One patient had post-operative canal bleeding requiring return to the operating room for hemostasis. CONCLUSIONS:Robotic peritoneal flap vaginoplasty is a safe, novel approach to canal revision after primary PIV with minimal donor site morbidity.

OBJECTIVE:To evaluate the outcomes of excision and primary anastomosis (EPA) for radiation-associated bulbomembranous stenoses using a multi-institutional analysis. The treatment of radiation-associated urethral stenosis is typically complex owing to the adverse impact of radiation on adjacent tissue. METHODS:An IRB-approved multi-institutional retrospective review was performed on patients who underwent EPA for bulbomembranous urethral stenosis following prostate radiotherapy. Preoperative patient demographics, operative technique, and postoperative outcomes were abstracted from 1/2007-6/2018. Success was defined as voiding per urethra without the need for endoscopic treatment and a minimum follow-up of 12 months. RESULTS:One hundred and thirty-seven patients from 10 centers met study criteria with a mean age of 69.3 years (50-86), stenosis length of 2.3 cm (1-5) and an 86.9% (119/137) success rate at a mean follow-up 32.3 months (12-118). Univariate Cox regression analysis identified increasing patient age (P = .02), stricture length (P <.0001) and combined modality radiotherapy (P = .004) as factors associated with stricture recurrence while body mass index (P = .79), diabetes (P = .93), smoking (P = .62), failed endoscopic treatment (P = .08) and gracilis muscle use (P = .25) were not. On multivariate analysis, increasing patient age (H.R.1.09, 95%CI 1.01-1.16; P = .02) and stenosis length (H.R.2.62, 95%CI 1.49-4.60; P = .001) remained associated with recurrence. Subsequent artificial urinary sphincter was performed in 30 men (21.9%), of which 25 required a transcorporal cuff and 5 developed cuff erosion. CONCLUSIONS:EPA for radiation-associated urethral stenosis effectively provides unobstructed instrumentation-free voiding. However, increasing stenosis length and age are independently associated with surgical failure. Patients should be counseled that further surgery for incontinence may be necessary.