Faculty Bibliography

BACKGROUND: Urethral strictures or fistulas are common complications after phalloplasty. Neourethral defects pose a difficult reconstructive challenge using standard techniques as there is generally insufficient ventral tissue to support a graft urethroplasty. We report our experience with local fasciocutaneous flaps for support of ventrally-placed buccal mucosal grafts (BMGs) in phalloplasty. METHODS: A retrospective review of patients who underwent phalloplasty and subsequently required revision urethroplasty using BMGs between 2011 and 2015 was completed. Techniques, complications, additional procedures, and outcomes were examined. RESULTS: A total of three patients previously underwent phalloplasty with sensate radial forearm free flaps (RFFFs): two female-to-male (FTM) gender reassignment, and one oncologic penectomy. Mean age at revision urethroplasty was 41 years (range 31-47). Indications for surgery were: one meatal stenosis, four urethral strictures (mean length 3.6 +/- 2.9 cm), and two urethrocutaneous fistulas. The urethral anastomosis at the base of the neophallus was the predominant location for complications: 3/4 strictures, and 2/2 fistulas. Medial thigh (2) or scrotal (1) fasciocutaneous flaps were used to support the BMG for urethroplasty. One stricture recurrence at 3 years required single-stage ventral BMG urethroplasty supported by a gracilis musculocutaneous flap. All patients were able to void from standing at mean follow up of 8.7 months (range 6-13). A total of two patients (66%) subsequently had successful placement of a penile prosthesis. CONCLUSIONS: Our early results indicate that local or regional fasciocutaneous flaps enable ventral placement of BMGs for revision urethroplasty after phalloplasty.

OBJECTIVE: To describe the technique of ultrasound urethrogram for the diagnosis of anterior urethral stricture performed in an ambulatory setting without any adjunctive imaging. METHODS: Between September 2013 and September 2015, thirty-five consecutive adult men (>18 years old) presenting for anterior urethral reconstruction underwent outpatient ultrasound urethrogram prior to definitive management. No alternative imaging test was performed. Lengths of the strictures as determined by outpatient ultrasound urethrogram and via direct intra-operative measurements were compared by a paired t-test. RESULTS: Strictures were in the bulbar urethra in 24 men and the penile urethra in 11 men. The differences between the outpatient ultrasound urethrogram length measurements (mean=1.86 cm) and the intra-operative stricture length measurements (mean=2.02 cm) were not significantly different (p=0.10). Additionally, the correlation coefficient between these length measurements was 0.84 (p<0.001). CONCLUSIONS: Preoperative ultrasound urethrogram performed in the ambulatory setting for the diagnosis and characterization of anterior urethral strictures is safe and feasible. This outpatient imaging modality offers an alternative to retrograde urethrogram.

The objective of this study was to anatomically describe the relationship of penile intracavernosal pillars to penile surgery, specifically corporal dilation during penile prosthesis placement. Corpora cavernosa from four embalmed male cadavers were dissected and subjected to probe dilation. Corpora were cross-sectioned and examined for the gross presence and location of pillars and dilated spaces. Infrapubic penile prosthesis insertion was performed on one fresh-frozen cadaveric male pelvis, followed by cross-sectioning. A single patient had intracavernosal pillars examined intraoperatively during Peyronie's plaque excision and penile prosthesis insertion. Intracavernosal pillars were identified in all cadavers and one surgical patient, passing obliquely from the dorsolateral tunica albuginea across the sinusoidal space to the ventral intercorporal septum. This delineated each corpus into two potential compartments for dilation: dorsomedial and ventrolateral. Dorsal dilation seated instruments and prosthetics satisfactorily in the dorsal mid glans and provided additional tissue coverage over weak ventral areas of the tunica albuginea, while ventrolateral dilation appeared to result in ventral seating and susceptibility to perforation. Intracavernosal pillars are an important anatomic consideration during penile prosthesis placement. Dorsal dilation appears to result in improved distal seating of cylinder tips, which may be protective against tip malposition, perforation or subsequent erosion.International Journal of Impotence Research advance online publication, 7 April 2016; doi:10.1038/ijir.2016.12.

OBJECTIVE: To review the guidelines released in the last decade by several organisations for the optimal evaluation and management of genitourinary injuries (renal, ureteric, bladder, urethral and genital). METHODS: This is a review of the genitourinary trauma guidelines from the European Association of Urology (EAU) and the American Urological Association (AUA), and renal trauma guidelines from the Societe Internationale d'Urologie (SIU). RESULTS: Most recommendations are guided by the American Association for the Surgery of Trauma (AAST) organ injury severity system. Grade A evidence is rare in genitourinary trauma, and most recommendations are based on Grade B or C evidence. The findings of the most recent urological trauma guidelines are summarised. All guidelines recommend conservative management for low-grade injuries. The major difference is for haemodynamically stable patients who have high-grade renal trauma; the SIU guidelines recommend exploratory laparotomy, the EAU guidelines recommend renal exploration only if the injury is vascular, and the AUA guidelines recommend initial conservative management. CONCLUSION: There is generally consensus among the three guidelines. Recommendations are based on observational or retrospective studies, as well as clinical principles and expert opinions. Multi-institutional collaborative research can improve the quality of evidence and direct more effective evaluation and management of urological trauma.

Patients with continuous flow left ventricular assist devices (CF-LVADs) are at increased risk of bleeding. We reviewed our institutional experience with bleeding in the urinary tract following CF-LVAD implantation andquantified the impact on hospital resource utilization in comparison to bleeding in the gastrointestinal tract, the most commonly reportedmucosal site of bleeding following LVAD implantation. Records were retrospectively reviewed for patients undergoing CF-LVAD implantation at our institution between October 2011 and April 2015. Major adverse events of gross hematuria and gastrointestinal bleeding were identified, and patient demographics and hospital course were reviewed.

Urologists in the United States may see a greater number of transgender or gender-variant patients in their practices due to changing legislation, insurance coverage, and greater social acceptance of transgender individuals. While gender-confirming surgeries should only be attempted by experienced reconstructive surgeons, patients may seek care from general urologists for orchiectomy and management of voiding dysfunction or other concerns that may be complicated by prior reconstructions

Introduction & Objective: The management of concurrent ipsilateral ureteral strictures is challenging as the ureter cannot be transected in two places. The mainstays of reconstruction in this clinical scenario include renal autotransplant or ileal ureter, both of which are associated with morbid short and long-term complications. The concept of an onlay graft or flap to increase the size of the lumen is a well-established technique for urethral reconstruction. We demonstrate the feasibility of this concept to the ureter by placing an onlay of bladder and appendix to manage concurrent ureteral strictures. Materials and Methods: A 66-year-old man with bilateral proximal ureteral stones who developed a 3 cm right distal ureteral stricture, and a 6 cm right proximal ureteral after undergoing ureteroscopy and laser lithotripsy at an outside institution. These strictures were refractory to endoscopic management. The patient had an elevated creatinine. Robotic reconstruction was performed. Simultaneous intraoperative ureteroscopy was performed to delineate the stricture. As the ureteroscope was passed retrograde, the 3 cm distal and 6 cm proximal ureteral strictures were incised using the robot along the anterior aspect of the ureter. The patient's appendix was mobilized, detubularized, and placed as an onlay flap onto the proximal stricture. The distal ureteral stricture was repaired by marsupializing a flap of bladder onto the ureter for a non-transecting reimplant. Results: The patient had an uneventful postoperative course and went home on postoperative day 4. Nephrostogramperformed at 6 weeks post op demonstrated prompt drainage of contrast after stent removal. Patient did not have flank pain after stent removal, and ultrasound at 4 months post op demonstrated no hydronephrosis. Conclusions: For the appropriate patient, ureteral reconstruction using onlay of appendix and bladder is a feasible option for multiple ureteral strictures. Long-term outcomes need to be elucidated

OBJECTIVE: To evaluate our long-term outcomes of robotic assisted laparoscopic (RAL) upper urinary tract (UUT) reconstruction. MATERIALS AND METHODS: Data from 250 consecutive patients undergoing RAL UUT reconstruction including pyeloplasty with or without stone extraction, ureterolysis, ureteroureterostomy, ureterocalicostomy, ureteropyelostomy, ureteral reimplantation and buccal mucosa graft ureteroplasty was collected at a tertiary referral center between March 2003 and December 2013. The primary outcomes were symptomatic and radiographic improvement of obstruction and complication rate. The mean follow-up was 17.1 months. RESULTS: Radiographic and symptomatic success rates ranged from 85% to 100% for each procedure with a 98% radiographic success rate and 97% symptomatic success rate for the entire series. There were a total of 34 complications; none greater than Clavien grade 3. CONCLUSION: RAL UUT can be performed with few complications, with durable long-term success, and is a reasonable alternative to the open procedure in experienced robotic surgeons