Faculty Bibliography

OBJECTIVE:To describe a novel technique of ureteral reimplantation via robotic non-transecting side-to-side anastomosis. While the standard approach to ureteroneocystostomy has a high rate of success, it involves transection of the ureter which may impair vascularity and contribute to recurrent strictures. Our method seeks to maximally preserve distal ureteral blood flow which may reduce this risk. METHODS:We retrospectively reviewed a multi-institutional ureteral reconstruction database to identify patients who underwent this operation between 2014-2018, analyzing perioperative and postoperative outcomes. RESULTS:Our technique was utilized in 16 patients across three U.S. academic institutions. Median operative time and estimated blood loss were 178 minutes (IQR 150 - 204) and 50 mL (IQR 38 - 100) respectively. The median length of stay was 1 day (IQR 1-2). No intraoperative complications or post-operative complications with Clavien score ≥3 were reported. Post-operatively, 15/16 (93.8%) patients reported clinical improvement in flank pain, and all patients who underwent follow-up imaging had radiographic improvement with decrease in hydronephrosis at a median follow-up of 12.5 months. CONCLUSIONS:Ureteral reimplantation via a robotic non-transecting side-to-side anastomosis is a feasible and effective operation for distal ureteral stricture which may have advantages over the standard of care transecting ureteroneocystostomy.

BACKGROUND:We describe the technique of robotic vaginectomy, anterior vaginal flap urethroplasty, and use of a longitudinally split pedicled gracilis muscle flap to recreate the bulbar urethra and help fill the vaginal defect in female-to-male gender affirming phalloplasty. METHODS:Vaginectomy is performed via robotic assisted laparoscopic transabdominal approach. Concurrently, gracilis muscle is harvested and passed through a tunnel between the groin and vaginal cavity. It is then split longitudinally and the inferior half is passed into the vaginal cavity, where it is inset into the vaginal cavity. Following urethroplasty, the superior half of the gracilis flap is placed around the vaginal flap to buttress this suture line with well-vascularized tissue. RESULTS:From May 2016 to March 2018, 16 patients underwent this procedure, of average age 35.1 ± 8.8 years, BMI 31.4 ± 5.5, and ASA class 1.8 ± 0.6. The average length of operation was 423.6 ± 84.6 minutes, with an estimated blood loss of 246.9 ± 84.9 mL. Patients were generally out of bed on post-operative day 1, ambulating on post-operative day 2, and discharged home on post-operative day 3 (average day of discharge 3.4 ± 1.4 days). At mean follow-up time of 361.1 ± 175.5 days, no patients developed urinary fistula at the urethroplasty site. CONCLUSIONS:Our use of the longitudinally split gracilis muscle in first stage phalloplasty represents a novel approach to providing well-vascularized tissue to achieve both urethral support and closure of intra-pelvic dead space, with a single flap, in a safe, efficient, and reproducible manner.

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.

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: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.

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.