Faculty Bibliography

OBJECTIVE:To demonstrate our hypothesis that the presence of extravasation on postoperative urethrogram is inconsequential for disease recurrence in urethroplasty postoperative follow-up. MATERIALS AND METHODS/METHODS:We utilized the Trauma and Urologic Reconstructive Network of Surgeons database to assess 1691 patients who underwent urethroplasty and post-operative urethrogram. Anatomic and functional recurrence were defined as <17 Fr stricture documented at 12-month cystoscopy and need for a secondary procedure during 1 year of follow-up, respectively. Our primary outcomes were the sensitivity and positive predictive value of post-operative urethrogram for predicting anatomic and functional recurrence of urethral stricture disease. RESULTS:Among 1101 patients with cystoscopy follow-up, 54 (4.9%) had extravasation on initial postoperative urethrogram. Among those 54, 74.1% developed an anatomic recurrence vs 13% without extravasation (P <.001). Similarly, functional recurrence was 9.3% with extravasation vs 3.2 % without extravasation (P = .04). Patients with extravasation more often reported a postoperative urinary tract infection (12.9% vs 2.7%; P <.01) or wound infection (7.4% vs 2.6%; P = .04). Sensitivity of postoperative urethrogram in predicting any recurrence was 27.3%, specificity 98.7%, positive predictive value 77.8%, and negative predictive value 89.3%. Fourty-five of 54 patients with extravasation had a recurrence of some kind, equating to a 22.2% urethroplasty success rate at 1 year. CONCLUSION/CONCLUSIONS:Postoperative urethrogram has a high specificity but low sensitivity for anatomic and functional recurrence during short term follow-up. The positive predictive value of urinary extravasation is high: patients with extravasation incur a high risk of anatomic recurrence within 1 year and such patients may warrant increased monitoring.

Gender-affirming surgery is becoming more accessible, and radiologists must be familiar with both terminology and anatomy following gender-affirming surgical procedures. This essay will review the most common gender-affirming genital surgeries, their post-operative anatomy, and common complications by providing intraoperative photographs, illustrations, and cross-sectional images. Routine radiologic imaging recommendations for transgender patients will also be reviewed.

OBJECTIVES/OBJECTIVE:To report a multi-institutional experience with robotic appendiceal ureteroplasty. METHODS:This is a retrospective review of 13 patients undergoing right appendiceal flap ureteroplasty at two institutions between April 2016 and October 2019. The primary endpoint was surgical success defined by the absence of flank pain and radiographic evidence of ureteral patency. RESULTS:8/13 (62%) underwent appendiceal onlay while 5/13 (38%) underwent appendiceal interposition Mean length of stricture was 6.5 cm (range 1.5-15 cm) affecting anywhere along the right ureter. Mean operative time was 337 minutes (range 206-583), mean estimated blood loss was 116 mL (range 50-600), and median length of stay was 2.5 days (range 1-9). Balloon dilation was required in 1/12 (8%). One patient died on post-operative day 0 due to a sudden cardiovascular event. Otherwise, there were no complications (Clavien-Dindo > 2) within 30 days from surgery. At a mean follow up of 14.6 months, 11/12 (92%) were successful. CONCLUSION/CONCLUSIONS:Robotic appendiceal ureteroplasty for right ureteral strictures is a versatile technique with high success rates across institutions.

OBJECTIVES/OBJECTIVE:To describe surgical techniques and peri-operative outcomes with secondary robotic pyeloplasty (RP), and compare them to those of primary RP. METHODS:We retrospectively reviewed our multi-institutional, Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database for all consecutive patients who underwent RP between 04/2012-09/2019. Patients were grouped according to whether they underwent a primary or secondary pyeloplasty (performed for a recurrent stricture after previously failed pyeloplasty). Perioperative outcomes and surgical techniques were compared using nonparametric independent sample median tests and chi-square tests; p<0.05 was considered significant. RESULTS:Of 158 patients, 28 (17.7%) and 130 (82.3%) underwent secondary and primary RP, respectively. Secondary RP, compared to primary RP, was associated with a higher median estimated blood loss (100.0 versus 50.0 milliliters, respectively; p<0.01) and longer operative time (188.0 versus 136.0 minutes, respectively; p=0.02). There was no difference in major (Clavien>2) complications (p=0.29). At a median follow-up of 21.1 (IQR: 11.8-34.7) months, there was no difference in success between secondary and primary RP groups (85.7% versus 92.3%, respectively; p=0.44). Buccal mucosa graft onlay ureteroplasty was performed more commonly (35.7% versus 0.0%, respectively, p<0.01) and near-infrared fluorescence imaging with indocyanine green was utilized more frequently (67.9% versus 40.8%, respectively; p<0.01) for secondary versus primary repair. CONCLUSIONS:Although performing secondary RP is technically challenging, it is a safe and effective method for recurrent ureteropelvic junction obstruction after a previously failed pyeloplasty. Buccal mucosa graft onlay ureteroplasty and utilization of near-infrared fluorescence with indocyanine green may be particularly useful in the re-operative setting.

BACKGROUND:To determine if the number of endoscopic treatments of urethral stricture disease (USD) prior to urethroplasty has changed in the context of new AUA guidelines on management of USD. In addition to an increase in practicing reconstructive urologists and published reconstructive literature, the AUA guidelines regarding the management of male USD were presented in May 2016, advocating consideration of urethroplasty in patients with 1 prior failed endoscopic treatment. METHODS:A retrospective review of a prospectively maintained, multi-institutional urethral stricture database of high volume, geographically diverse institutions was performed from 2006 to 2017. We performed a review of relevant literature and evaluated pre-urethroplasty endoscopic treatment patterns prior to and after the AUA male stricture guideline. RESULTS:2964 urethroplasties were reviewed in 10 institutions. There was both a decrease in the number of endoscopic treatments prior to urethroplasty in the pre-May 2016 compared to post-May 2016 cohorts both for overall urethroplasties (2.3 vs 1.6, P = 0.0012) and a gradual decrease in the number of pre-urethroplasty endoscopic treatments over the entire study period. CONCLUSION/CONCLUSIONS:There was a decrease in the number of endoscopic treatments of USD prior to urethroplasty in the observed period of interest. Declining endoscopic USD management is not likely to be a reflection of a solely unique influence of the guidelines as endoscopic treatment decreased over the entire study period. Further research is needed to determine if there will be a continued trend in the declining use of endoscopic treatment and elucidate the barriers to earlier urethroplasty in patients with USD.

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.

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.

The medial sural artery perforator (MSAP) flap is a versatile fasciocutaneous flap that has been used successfully in the reconstruction of defects across the body. In specific cases, it may prove superior to more commonly used options (e.g., anterolateral thigh flap and radial forearm free flap). Historically, a disadvantage of the MSAP flap is the relatively small surface area it provides for reconstruction. We recently encountered a patient with extensive pelvic injuries from prior trauma resulting in significant scarring and contracture of the groin, tethering of the penis, and loss of the scrotum and one testicle. The patient was unable to achieve erection from tethering and his remaining testicle had been buried in the thigh. In considering the reconstructive options, he was not a suitable candidate for a thigh-based or forearmbased flap. An extended MSAP flap measuring 25 cm×10 cm was used for resurfacing of the groin and pelvis as well as for the formation of a neoscrotum. This report is the first to document an MSAP flap utilized for simultaneous groin resurfacing and scrotoplasty. Additionally, the dimensions of this flap make it the largest recorded MSAP flap to date.