Faculty Bibliography

Penile inversion vaginoplasty involves creation of vulva and a vaginal canal. Few studies describe techniques for creating aesthetic vulvar components, particularly the clitoral hood and labia minora. The authors present their approach to primary vulvoplasty, aiming to achieve the following: (1) labia minora that are well-defined and three-dimensional; (2) labia minora that frame the introitus; (3) sufficient clitoral hooding; (4) a patent introitus that appears closed at rest; and (5) prominent labia majora. In this technique, the labia majora are created by first pulling the superolateral scrotal skin inferiorly and medially toward the perineum. The labia majora incisions may be made laterally, medially, or both laterally and medially, dependent on the amount of penile and scrotal skin available. Initial approximating sutures are placed to anchor the labia inferiorly, and then excess skin is removed medially. The surgeon should avoid excess defatting of the labia majora, which are subject to initial edema and often atrophy with time. The preputial or distal penile shaft skin is used for the clitoral hood and medial aspect of the labia minora, with proximal penile shaft skin used for the lateral surface. The penile skin used for the lateral aspect of the labia minora must be pulled inferomedially toward the perineum, to create a narrow, tapered appearance and avoid effacement of the labia minora. Interrupted horizontal mattress quilting sutures are used to define the labia minora as distinct subunits. By considering homologous structures and anatomical subunits, we are able to create well-defined, aesthetic vulva in trans women and nonbinary individuals.

PURPOSE/OBJECTIVE:To analyze outcomes of posterior urethroplasty following pelvic fracture urethral injuries (PFUI) and to determine risk factors for surgical complexity and success. METHODS:Patients who underwent posterior urethroplasty following PFUI were identified in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) database. Demographics, injury patterns, management strategies, and prior interventions were evaluated. Risk factors for surgical failure and the impact of ancillary urethral lengthening maneuvers (corporal splitting, pubectomy and supracrural rerouting) were evaluated. RESULTS:Of the 436 posterior urethroplasties identified, 122 were following PFUI. 83 (68%) patients were acutely managed with suprapubic tubes, while 39 (32%) underwent early endoscopic realignment. 16 (13%) patients underwent pelvic artery embolization in the acute setting. 116 cases (95%) were completed via a perineal approach, while 6 (5%) were performed via an abdominoperineal approach. The need for one or more ancillary maneuvers to gain urethral length occurred in 4 (36%) patients. Of these, 44 (36%) received corporal splitting, 16 (13%) partial or complete pubectomy, and 2 (2%) supracrural rerouting. Younger patients, those with longer distraction defects, and those with a history of angioembolization were more likely to require ancillary maneuvers. 111 patients (91%) did not require repeat intervention during follow-up. Angioembolization (p = 0.03) and longer distraction defects (p = 0.01) were associated with failure. CONCLUSIONS:Posterior urethroplasty provides excellent success rates for patients following PFUI. Pelvic angioembolization and increased defect length are associated with increased surgical complexity and risk of failure. Surgeons should be prepared to implement ancillary maneuvers when indicated to achieve a tension-free anastomosis.

Background/UNASSIGNED:The omentum provides abundant lymphatic tissue with reliable vascular anatomy, representing an ideal donor for vascularized lymph node transfer without risk for donor site lymphedema. We describe a novel, robotically assisted approach for omental flap harvest. Methods/UNASSIGNED:All patients undergoing robotically assisted omentum harvest for vascularized lymph node transfer from 2017 to 2019 were identified. Patient demographics, intraoperative variables, and postoperative outcomes were reviewed. Results/UNASSIGNED:, respectively. Indications for lymph node transfer were upper extremity lymphedema following mastectomy, radiation, and lymphadenectomy (60.0%); congenital unilateral lower extremity lymphedema (20.0%); and bilateral lower extremity/scrotal lymphedema following partial penectomy and bilateral inguinal/pelvic lymphadenectomy (20.0%). Four patients (80.0%) underwent standard robotic harvest, whereas 1 patient underwent single-port robotic harvest. The average number of port sites was 4.4. All patients underwent omentum flap transfer to 2 sites; in 2 cases, the flap was conjoined, and in 3 cases, the flap was segmented. The average overall operative time was 9:19. The average inpatient hospitalization was 5.2 days. Two patients experienced cellulitis, which is resolved with oral antibiotics. There were no major complications. All patients reported subjective improvement in swelling and softness of the affected extremity. The average follow-up was 8.8 months. Conclusions/UNASSIGNED:Robotically assisted omental harvest for vascularized lymph node transfer is a novel, safe, and viable minimally invasive approach offering improved intra-abdominal visibility and maneuverability for flap dissection.

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.

PURPOSE/OBJECTIVE:Risk factors for complications after artificial urinary sphincter surgery include a history of pelvic radiation and prior artificial urinary sphincter complication. The survival of a second artificial urinary sphincter in the setting of prior device complication and radiation is not well described. We report the survival of redo artificial urinary sphincter surgery and identify risk factors for repeat complications. MATERIALS AND METHODS/METHODS:A multi-institutional database was queried for redo artificial urinary sphincter surgeries. The primary outcome was median survival of a second and third artificial urinary sphincter in radiated and non-radiated patients. A Cox proportional hazards survival analysis was performed to identify additional patient and surgery risk factors. RESULTS:The median time to explantation of the initial artificial urinary sphincter in radiated (n=150) and non-radiated (n=174) patients was 26.4 and 35.6 months respectively (p=0.043). For a second device the median time to explantation was 30.1 and 38.7 (p = 0.034) and for a third device it was 28.5 and 30.6 months (p=0.020). The 5-year revision free survival for patients undergoing a second AUS with no risk factors, history of radiation, history of urethroplasty, and both a history of radiation and urethroplasty are 83.1%, 72.6%, 63.9%, and 46% respectively. CONCLUSIONS:AUS surgeries experience similar revision free rates to their initial AUS devices. Patients who have been treated with pelvic radiation have earlier AUS complications. When multiple risk factors exist, revision free rates decrease significantly.

PURPOSE/OBJECTIVE:To assess the functional Queryoutcome of patients with cystoscopic recurrence of stricture post-urethroplasty and to evaluate the role of cystoscopy as initial screening tool to predict future failure. METHODS:Cases with cystoscopy data after anterior urethroplasty in a multi-institutional database were retrospectively studied. Based on cystoscopic evaluation, performed within 3-months post-urethroplasty, patients were categorized as small-caliber (SC) stricture recurrence: stricture unable to be passed by standard cystoscope, large-caliber (LC) stricture accommodating a cystoscope, and no recurrence. We assessed the cumulative probability of intervention and the quality of life scores in association with cystoscopic recurrence 1-year post-urethroplasty. Patients with history of hypospadias, perineal urethrostomy, urethral fistula, and meatal pathology were excluded. RESULTS:From a total of 2630 men in our cohort, 1054 patients met the inclusion criteria: normal (n = 740), LC recurrence (n = 178), and SC recurrence (n = 136) based on the first cystoscopic evaluation performed at median 111 days postoperatively. Median follow-up was 350 days (IQR 121-617) after urethroplasty. Cystoscopic recurrence was significantly associated with secondary interventions (2.7%, 6.2%, 33.8% in normal, LC, and SC groups, respectively). Quality of life variables were not statistically significantly different among the three study groups. CONCLUSIONS:Many patients with cystoscopic recurrence do not need an intervention after initial urethroplasty. Despite good negative predictive value, cystoscopy alone may be a poor screening test for stricture recurrence defined by patient symptoms and need for secondary interventions.

As more transgender patients undergo gender-affirming genital reconstructive surgery, such as vaginoplasty and phalloplasty, it is imperative for health care providers, including urologists, to understand the new anatomy and most common complications to diagnose and treat patients effectively. Although there have been several modifications to prior techniques as well as development of new techniques over the years, complications are still common after vaginoplasty and phalloplasty. This article focuses on the most common complications as well as the evaluation and management of those complications.