Faculty Bibliography

OBJECTIVE:To analyze contemporary urethroplasty trends and urethral stricture etiologies over a 7-year study period among urologists from a large multi-institutional surgical outcomes group. METHODS:Review of a multi-institutional, prospectively maintained urethroplasty database was performed on 2098 anterior urethroplasties done between 2010 and 2017 by 10 surgeons. Stricture characteristics, including etiology, length, and anatomic location were analyzed and compared to urethroplasty type over the study period using chi-squared analysis to assess for linear trends within the group and by surgeon. RESULTS:Average stricture lengths for bulbar (2.8 ± 1.8 cm), penile (3.6 ± 2.6 cm), and penile-bulbar strictures (8.7 ± 5.0) remained stable. The most common stricture etiology was idiopathic/unknown in all study years (63%). In the bulbar urethra, the group performed significantly (1) fewer excisional repairs (-31%) and more substitutional repairs (+78%); (2) of substitutional repairs, more grafts are being placed dorsally (+95%) vs ventrally (-75%) (3) of the bulbar excisional repairs, more are being performed without transection of the bulbar urethra (+430%); and in the penile urethra (4) the fasciocutaneous flap is in decline (-86%), while single-stage dorsal repairs are increasing (+280%). CONCLUSION/CONCLUSIONS:Anterior urethroplasty techniques continue to evolve in the absence of robust clinical data or randomized controlled trials, with a general movement in this cohort toward an initial dorsal approach for most strictures. Inter- and intrasurgeon variability in the surgical management of similar strictures was noted, and the feasibility of any future randomized controlled trials, without apparent surgical equipoise, must be questioned.

OBJECTIVES/OBJECTIVE:To evaluate the presenting complications of patients to reconstructive urologists after masculinizing gender affirming genital reconstructive surgery (GRS) performed elsewhere. METHODS:We identified patients who underwent revision surgery by one of the co-authors for sequelae of masculinizing GRS. We reviewed patient demographics, medical history, details of prior GRS, and complications from GRS. Specific attention was paid to the presence of the following: suprapubic tube (SPT) dependence, vaginal remnant, urethrocutaneous fistula (UCF) within the fixed urethra (pars fixa), UCF in the phallic urethra, phallic urethral stricture, meatal stenosis, and anastomotic urethral stricture. Statistical analysis was performed using Fisher's exact test to determine differences in presenting symptoms by GRS. RESULTS:55 patients who had reconstructive surgery for complications from masculinizing GRS from September 2004 to September 2017 were identified. The median age at surgical correction was 33 years. Fifteen (27%) patients had prior metoidioplasty and 40 (73%) had prior phalloplasty. The median time from date of GRS to presentation to a reconstructive urologist was 4 months. Urethral strictures (n=47, 86%) were the most common indication for subsequent surgery, followed by urethrocutaneous fistulae (n=31, 56%) and vaginal remnant (n=26, 47%). The majority of patients presented with two or more simultaneous complications (n=40, 73%). CONCLUSIONS:There are several common presenting urologic complications after masculinizing GRS. Patients may present to reconstructive urologists early after GRS performed elsewhere. The long-term outcomes of GRS deserve further study.

INTRODUCTION/BACKGROUND:Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction. There may be insufficient BMG for applications requiring large grafts, such as urethral stricture after gender-affirming phalloplasty. Rectal mucosa in lieu of BMG avoids oral impairment, while potentially affording less postoperative pain and larger graft dimensions. Transanal minimally invasive surgery (TAMIS) using laparoscopic instruments has been described. Due to technical challenges of harvesting a sizable graft within the rectal lumen, we adopted a new robotic approach. We demonstrate the feasibility and safety of a novel technique of Robotic TAMIS (R-TAMIS) in the harvest of rectal mucosa for the purpose of onlay graft urethroplasty. METHODS:Path Transanal Access. Mucosa was harvested robotically after submucosal hydrodissection. Graft size harvested correlated with surface area needed for urethral or vaginal reconstruction. Following specimen retrieval, flexible sigmoidoscopy confirmed hemostasis. The graft was placed as an onlay for urethroplasty. RESULTS:There were no intraoperative or postoperative complications. Mean graft size was 11.4 × 3.0 cm. All reconstructions had excellent graft take. All patients recovered without morbidity or mortality. They reported minimal postoperative pain and all regained bowel function on postoperative day one. Patients with prior BMG harvests subjectively self-reported less postoperative pain and greater quality of life. There have been no long-term complications at a median follow-up of 17 months. CONCLUSIONS:To our knowledge, this is the first use of R-TAMIS for rectal mucosa harvest. Our preliminary series indicates this approach is feasible and safe, constituting a promising minimally invasive technique for urethral reconstruction. Prospective studies evaluating graft outcomes and donor site morbidity with more long-term follow-up are needed.

PURPOSE/OBJECTIVE:We report multi-institutional outcomes in patients who underwent urethroplasty with a rectal mucosa graft. MATERIALS AND METHODS/METHODS:We used the TURNS (Trauma and Urologic Reconstructive Network of Surgeons) database to identify patients who underwent urethral reconstruction with transanal harvest of a rectal mucosa graft. We reviewed preoperative demographics, stricture etiology, previous management and patient outcomes. RESULTS:We identified 13 patients from April 2013 to June 2017. Median age at surgery was 54 years. The stricture etiology was lichen sclerosus in 6 of 13 patients (46%), idiopathic in 2 (15%), hypospadias in 1 (7%), prior gender confirming surgery in 3 (23%) and rectourethral fistula after radiation for prostate cancer in 1 (7%). Prior procedures included failed urethroplasty with a buccal mucosa graft in 9 of 13 patients (69%), direct vision internal urethrotomy in 2 (15 %) and none in 2 (15%). Median stricture length was 13 cm. Stricture location in the 9 cisgender patients was panurethral in 5 (56%), bulbopendulous in 2 (22%) and bulbar in 2 (22%). It was located at the junction of the fixed urethra extending into the neophallus in all 3 patients (100%) who underwent prior gender confirming surgery. Mean rectal mucosa graft length for urethroplasty was 10.6 cm (range 3 to 16). Repair types included dorsal or ventral onlay, or 2-stage repair. Stricture recurred at a median followup of 13.5 months in 2 of 13 patients ( 15%). Postoperative complications included glans dehiscence, urethrocutaneous fistula and compartment syndrome in 1 patient each (7%). No rectal or bowel related complications were reported. CONCLUSIONS:Urethral reconstruction with a transanal harvested rectal mucosa graft is a safe technique when a buccal mucosa graft is unavailable or not indicated.

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.

BACKGROUND:Penile inversion vaginoplasty (PIV) is the most common procedure for genital reconstruction in transwomen. While PIV usually provides an excellent aesthetic result, the technique may be complicated by vaginal stenosis and inadequate depth, especially in transwomen with limited penile and scrotal tissue. Here, we describe a technique of using peritoneal flaps to augment the neovaginal apex and canal in penile inversion vaginoplasty for transwomen. METHODS:Between 2017 and 2018, 41 female-to-male patients were identified who underwent primary penile inversion and peritoneal flap vaginoplasty. Two approximately 6cm wide by 8cm long peritoneal flaps are raised from the anterior aspect of the rectum and sigmoid colon, and the posterior aspect of the bladder to create the apex of the neovagina. RESULTS:The 41 patients had an average age of 34 +/- 14 years. Average length of procedure was 262 +/- 35 minutes and the average length of stay was 5 days. Average length of follow up was 114 +/- 79 days and at most recent follow up, vaginal depth and width were measured to be 14.2 +/- 0.7 cm and 3.6+/- 0.2 cm respectively. The peritoneal flap added an additional 5 cm of depth beyond the length of the skin graft, forming the vaginal canal in patients with limited scrotal skin. CONCLUSION/CONCLUSIONS:Penile inversion vaginoplasty remains the gold standard for primary genital reconstruction in transwomen. Peritoneal flaps provide an alternative technique for increased neovaginal depth, creating a well-vascularized apex with acceptable anticipated complications.

OBJECTIVE:To compare the utility of generic health quality of life (QOL) and condition specific indicators as patient reported outcomes measures for urethral stricture surgery. MATERIALS AND METHODS/METHODS:Patient data were obtained from the Trauma and Urologic Reconstructive Network of Surgeons collaborative database. Patients who underwent any successful urethroplasty and completed both pre- and postoperative generic and condition-specific questionnaires were included. RESULTS:A total of 201 patients met inclusion criteria. Urethral-stricture specific measures improved after surgery: mean LUTS score (13.1-4.0, p<0.05), Peeling curve (3.1-1.7, p < 0.05), and overall interference of urinary symptoms on life (3.0-1.6, p < 0.05). Mean overall health status visual analog scale (74.2-80.0, p < 0.05) and generic health QOL EQ-5D index scores (0.90-0.95, p < 0.05) also improved; however, individual EQ-5D measures assessing mobility, self-care, and activity level did not change. EQ-5D measures for pain/discomfort (1.48-1.23, p < 0.05) and anxiety/depression (1.33-1.21, p < 0.05) improved, but not to the same extent as stricture-specific measures. More patients reported improvement in condition-specific urethra/penis pain and bladder pain compared to improvement in generic EQ-5D pain/discomfort (p < 0.001). CONCLUSION/CONCLUSIONS:Generic health QOL indicators are less meaningful in the assessment of urethral stricture surgery and should be replaced with condition-specific outcomes measures. It is important to ensure that appropriate condition-specific outcomes measures are utilized as patient reported outcomes measures become more prevalent in medicine and potentially become utilized to evaluate surgeon outcomes and determine surgeon reimbursement.

INTRODUCTION AND OBJECTIVE/OBJECTIVE:To identify predictors of thirty-day perioperative complications after urethroplasty and create a model to predict patients at increased risk. METHODS:We selected all patients recorded in the National Surgery Quality Improvement Program (NSQIP) from 2005 to 2015 who underwent urethroplasty, determined by Current Procedural Terminology (CPT) codes. The primary outcome of interest was a composite 30-day complication rate. To develop predictive models of urethroplasty complications we used random forest and logistic regression with tenfold cross-validation employing demographic, comorbidity, laboratory, and wound characteristics as candidate predictors. Models were selected based on the receiver operating characteristic (ROC) curve, with the primary measure of performance being the area under curve (AUC). RESULTS:We identified 1135 patients who underwent urethroplasty and met inclusion criteria. The mean age was 53 years with 84% being male. The overall incidence of complications was 8.6% (n = 98). Patients who experienced a complication more commonly had diabetes, a preoperative blood transfusion, preoperative sepsis, lower hematocrit and albumin, as well as a longer operative time (p < 0.05). LASSO logistic and random forest logistic models for predicting urethroplasty complications had an AUC (95% CI) 0.73 (0.58-0.87), and 0.48 (0.33-0.68), respectively. The variables that were determined to be most important and included in the predictive models were operative time, age, American Society of Anesthesiologists (ASA) classification and preoperative laboratory values (white blood cell count, hematocrit, creatinine, platelets). CONCLUSION/CONCLUSIONS:Our predictive models of complications perform well and may allow for improved preoperative counseling and risk stratification in the surgical management of urethral stricture.

Introduction& Objective: Penile inversion vaginoplasty (PIV) is the standard operation for genital reconstruction in transwomen. Despite usually providing an excellent aesthetic result, the technique can be complicated by vaginal stenosis and inadequate depth, particularly in transwomen with limited penile and scrotal tissue. Vascularized peritoneal flaps have been used to augment vaginal depth in neovaginal creation in patients with congenital vaginal agenesis.Here, we review our experience with the novel application of peritoneal flaps in penile inversion vaginoplasty in transwomen, to augment the neovaginal apex with well-vascularized tissue.
Method(s): Between 2017 and 2018, 20 female-to-male patients were identified who underwent a robotically assisted PIV using peritoneal flaps. In brief, approximately 5cm by 5cm peritoneal flaps are raised from the anterior rectum and posterior bladder to create the apex of the neovagina and serve as an attachment for inverted penile skin and scrotal skin graft. Patient demographics, medical comorbidities, intra-operative details, peri-operative complications, and neovagina measurements served as primary outcome measures.
Result(s): In our cohort of 20 patients, average age at time of surgery was 33.5+/-11.2 years. Average length of procedure was 319.3+/-41.6 minutes and the average inpatient stay was 5 days. Average length of follow up was 54.6+/-42.1 days and at most recent follow up, vaginal depth and width were measured to be 12.83+/-1.1 cm and 2.85+/-.3 cm respectively. The peritoneal flap added an additional 5 cm of depth. There were no complications related to peritoneal flap harvest.
Conclusion(s): Penile inversion vaginoplasty remains the gold standard for primary genital reconstruction in transwomen. Neovaginal depth can be limited by available donor tissue. With increased use of puberty blockade, we believe that there will be an increase in women presenting with limited natal tissue. While intestinal flaps or extragenital skin grafts have been used when there is inadequate penile and scrotal skin, there can be considerable donor site morbidity. Peritoneal flaps provide an alternative technique for increased neovaginal depth, creating a wellvascularized apex without additional donor morbidity

Introduction & Objective: To present our technique of robotic reconstruction of bilateral long segment proximal ureteral obstruction with appendix onlay and buccal mucosa.
Method(s): We report a case of a 32 year-old female with idiopathic bilateral ureteral obstruction of the proximal ureters (Figure). She was previously managed with intermittent stent placement and ureteroscopic treatment at an outside institution. The patient was placed in supine position with trendelenberg, ports were placed horizontally below the umbilicus, and the DaVinci XI robot was docked to allow access to both ureters. Simultaneously, bilateral ureteroscopy was performed to identify the location of the obstruction. The right ureter was opened anteriorly at the level of the obstruction. After excision of the obstructing tissue, an 8cm segment of right ureter required reconstruction. Frozen section analysis of the obstructing tissue confirming no malignancy. An appendix flap onlay was performed by opening the appendix on its anti-mesenteric border. Intravenous Indocyanine Green (ICG) confirmed good perfusion to the appendix. The appendix was then sutured onto the ureteral defect with running 5-0 PDS. Next, a 5 cm area of left ureteral obstruction was identified and the anterior surface of the ureter was opened sharply. After excision of the obstructing tissue, a 5 x 1cm segment of buccal mucosa was harvested. Buccal mucosa graft ureteroplasty was performed with a running anastomosis with 5-0 PDS after ureteral stent placement. An omental flap was used to provide perfusion to the grafted segment. Intravenous ICG confirmed good perfusion to the ureter and the omentum.
Result(s): The patient had a prolonged hospital course due to infection but otherwise uneventful. The patient developed pyelonephritis which delayed discharge on day 9. On post-operative day 3, the Foley catheter was removed and she had return of bowel function. Final ureteral pathology demonstrated nephrogenic adenoma. Ureteral stents were removed after 1 month followed by nephrostomy removal at 2months. Antegrade nephrostograms and diuretic renal scan demonstrate no obstruction.
Conclusion(s): Long segment bilateral ureteral strictures can be managed in a single setting with robotic ureteral reconstruction. Appendix onlay and buccal mucosa graft ureteroplasty are safe and technically feasible options for a complex ureteral reconstruction