Faculty Bibliography

INTRODUCTION AND OBJECTIVES/UNASSIGNED:Several factors influence recurrence after urethral stricture repair. The impact of socioeconomic factors on stricture recurrence after urethroplasty is poorly understood. This study aims to assess the impact that social deprivation, an area-level measure of disadvantage, has on urethral stricture recurrence after urethroplasty. METHODS/UNASSIGNED:We performed a retrospective review of patients undergoing urethral reconstruction by surgeons participating in a collaborative research group. Home zip code was used to calculate Social Deprivation Indices (SDI; 0-100), which quantifies the level of disadvantage across several sociodemographic domains collected in the American Community Survey. Patients without zip code data were excluded from the analysis. The Cox Proportional Hazards model was used to study the association between SDI and the hazard of functional recurrence, adjusting for stricture characteristics as well as age and body mass index. RESULTS/UNASSIGNED:= .027). CONCLUSIONS/UNASSIGNED:Patient social deprivation identifies those at higher risk for functional recurrence after anterior urethral stricture repair, offering an opportunity for preoperative counseling and postoperative surveillance. Addressing these social determinants of health can potentially improve outcomes in reconstructive surgery.

The 2 most common techniques for gender-affirming mastectomy are the double-incision free nipple graft and periareolar techniques. However, some patients are not well suited for either technique. When the nipples are high and on the pectoralis muscle, but there is marked breast tissue and skin redundancy, a double-incision free nipple graft would land the incision above the pectoral shadow, but a periareolar approach would not adequately remove the excess skin. In these patients, a nipple-preserving inferior-ellipse incision allows for appropriate chest contouring, leaving the nipple position unchanged and placing the incision in the pectoralis muscle shadow. A retrospective review identified all consecutive patients undergoing nipple-preserving inferior-ellipse mastectomy by the senior author (R.B.-L.). Indications were patients with moderate glandular tissue, skin excess, and a high nipple-areola complex (NAC) above the inferior border of the pectoralis major. Sixteen patients underwent inferior-ellipse mastectomy and were included. Mean follow-up was 203 days. Two patients (14%) required revision of the NAC. There was no partial or complete NAC loss. One patient (7%) developed postoperative seroma, which resolved with aspiration. For patients with moderate glandular tissue, excess skin in the inferior pole, and NAC position above the inferior border of the pectoralis major, the nipple-preserving inferior-ellipse mastectomy technique achieves excellent chest contour.

OBJECTIVE/UNASSIGNED:Secondary pyeloplasty for recurrent ureteropelvic junction obstructions may be a safe and feasible surgical option for patients. This study aimed to demonstrate outcomes of utilizing a non-transecting buccal mucosa graft ureteroplasty for management of recurrent ureteropelvic junction obstruction after prior failed pyeloplasty. METHODS/UNASSIGNED:We performed a retrospective review of our Collaborative of Reconstructive Robotic Ureteral Surgery database for all consecutive patients who underwent buccal mucosa graft ureteroplasty between April 2012 and June 2022 for management of recurrent ureteropelvic junction obstructions after prior failed pyeloplasty. The primary outcome included surgical success which was defined as the absence of flank pain and no obstruction on imaging. RESULTS/UNASSIGNED:Overall, ten patients were included in our analysis. The median stricture length was 2.5 (interquartile range [IQR] 1.8-4.0) cm. The median operative time was 230.5 (IQR 199.5-287.0) min and median estimated blood loss was 50.0 (IQR 28.8-102.5) mL. At a median follow-up of 10.3 (IQR 6.2-14.8) months, 80% of patients were surgically successful and there were no major (Clavien-Dindo Grade>2) complications. CONCLUSION/UNASSIGNED:Buccal mucosa graft ureteroplasty is a valuable non-transecting surgical option for patients with recurrent ureteropelvic junction obstructions who failed prior pyeloplasty and has comparable outcomes to the literature regarding standard transecting techniques.

OBJECTIVE/UNASSIGNED:Bladder neck contracture and vesicourethral anastomotic stenosis are difficult to manage endoscopically, and open repair is associated with high rates of incontinence. In recent years, there have been increasing reports of robotic-assisted bladder neck reconstruction in the literature. However, existing studies are small, heterogeneous case series. The objective of this study was to perform a systematic review of robotic-assisted bladder neck reconstruction to better evaluate patency and incontinence outcomes. METHODS/UNASSIGNED:We performed a systematic review of PubMed from first available date to May 2023 for all studies evaluating robotic-assisted reconstructive surgery of the bladder neck in adult men. Articles in non-English, author replies, editorials, pediatric-based studies, and reviews were excluded. Outcomes of interest were patency and incontinence rates, which were pooled when appropriate. RESULTS/UNASSIGNED:incontinence rates ranged from 0% to 33%, and pooled incontinence was 17% (8/47). Our findings were limited by small sample sizes, relatively short follow-ups, and heterogeneity between studies. CONCLUSION/UNASSIGNED:Despite limitations, current available evidence suggests comparable patency outcomes and improved incontinence outcomes for robotic bladder neck reconstruction compared to open repair. Additional prospective studies with longer-term follow-ups are needed to confirm these findings.

BACKGROUND/UNASSIGNED:Sexual health is critical to overall health, yet sexual history taking is challenging. LGBTQ+ patients face additional barriers due to cis/heteronormativity from the medical system. We aimed to develop and pilot test a novel sexual history questionnaire called the Sexual Health Intake (SHI) form for patients of diverse genders and sexualities. METHODS/UNASSIGNED:The SHI comprises four pictogram-based questions about sexual contact at the mouth, anus, vaginal canal, and penis. We enrolled 100 sexually active, English-speaking adults from a gender-affirming surgery clinic and urology clinic from November 2022 to April 2023. All surveys were completed in the office. Patients also answered five feedback questions and 15 questions from the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction (PROMIS-SexFS) survey as a validated comparator. RESULTS/UNASSIGNED:One hundred patients aged 19-86 years representing an array of racial/ethnic groups, gender identities, and sexuality completed the study. Forms of sexual contact varied widely and included all possible combinations asked by the SHI. Feedback questions were answered favorably in domains of clinical utility, inclusiveness of identity and anatomy, and comprehensiveness of forms of sexual behavior. The SHI captured more positive responses than PROMIS-SexFS in corresponding questions about specific types of sexual activity. The SHI also asks about forms of sexual contact that are not addressed by PROMIS-SexFS, such as penis-to-clitoris. CONCLUSIONS/UNASSIGNED:SHI is an inclusive, patient-directed tool to aid sexual history taking without cisnormative or heteronormative biases. The form was well received by a diverse group of participants and can be considered for use in the clinical setting.

OBJECTIVE:To evaluate the incidence of gender-affirming phalloplasty and complications in a large population-based dataset. METHODS:Retrospective cohort study was done using the California Department of Health Care Access and Information datasets which include patient-level data from all licensed hospitals, emergency departments, and ambulatory surgery facilities in California. Adult patients 18 years or older undergoing gender-affirming phalloplasty in California from January 1, 2009 to December 31, 2019 were included. We examined phalloplasty-related complications using International Classification of Disease diagnosis and procedure codes and Current Procedural Terminology codes. Unique record linkage number identifiers were used to follow patients longitudinally. Statistical analysis included Kaplan-Meier survival analysis and Cox proportional hazards analysis. RESULTS:We identified 766 patients who underwent gender-affirming phalloplasty in 23 facilities. Of 475 patients with record linkage numbers, 253 (55.3%) had subsequent re-presentations to the inpatient, emergency department, and ambulatory surgery settings related to phalloplasty complications. Survival analysis indicated that 50% of patients re-presented by 1 year post-phalloplasty. Asian/Pacific Islander patients had lower risk of complications, and California residents had higher risk of complications. CONCLUSIONS:This population-based study confirms that gender-affirming phalloplasty has a high complication rate, and demonstrates for the first time an association with high rates of return to hospitals, emergency departments, and ambulatory centers. These findings provide additional higher-level evidence that may aid patient counseling, shared surgical decision making, and institutional and government policy.