Faculty Bibliography

BACKGROUND:Many patients have goals related to sexual health when seeking gender-affirming vaginoplasty, and previous investigations have only studied the ability to orgasm at cross-sectional timepoints. AIM/OBJECTIVE:Our aim is to quantify the time to orgasm postoperative gender-affirming vaginoplasty and describe potential correlative factors, including preoperative orgasm, to improve preoperative counseling. METHODS:A retrospective chart review was utilized to extract factors thought to influence pre and postoperative orgasm in patients undergoing robotic peritoneal flap vaginoplasty. Mean days to orgasm plus one standard deviation above that mean was used to define the time at which patients would be considered anorgasmic. OUTCOMES/RESULTS:Orgasm was documented as a categorical variable on the basis of surgeon interviews during pre and postoperative appointments while time to orgasm was measured as days from surgery to first date documented as orgasmic in the medical record. RESULTS:A total of 199 patients underwent surgery from September 2017 to August 2020. The median time to orgasm was 180 days. 178 patients had completed 1 year or greater of follow-up, and of these patients, 153 (86%) were orgasmic and 25 patients (14%) were not. Difficulty in preoperative orgasm was correlated only with older age (median age 45.9 years vs 31.7, P = .03). Postoperative orgasm was not significantly correlated with preoperative orgasm. The only factor related to postoperative orgasm was smoking history: 12 of 55 patients (21.8%) who had a positive smoking history and sufficient follow-up reported anorgasmia (P-value .046). Interventions for anorgasmic patients include testosterone replacement, pelvic floor physical therapy, and psychotherapy. CLINICAL IMPLICATIONS/CONCLUSIONS:Preoperative difficulty with orgasm improves with gender-affirming robotic peritoneal flap vaginoplasty, while smoking had a negative impact on postoperative orgasm recovery despite negative cotinine test prior to surgery. STRENGTHS & LIMITATIONS/UNASSIGNED:This investigation is the first effort to determine a timeline for the return of orgasmic function after gender-affirming vaginoplasty. It is limited by retrospective review methodology and lack of long-term follow-up. The association of smoking with postoperative orgasm despite universal nicotine cessation prior to surgery may indicate prolonged smoking cessation improves orgasmic outcomes or that underlying, unmeasured exposures correlated with smoking may be the factor inhibiting recovery of orgasm. CONCLUSION/CONCLUSIONS:The majority of patients were orgasmic at their 6-month follow-up appointments, however, patients continued to become newly orgasmic in appreciable numbers more than 1 year after surgery.

INTRODUCTION/BACKGROUND:Reducing donor site morbidity after deep inferior epigastric artery perforator (DIEP) flap harvest relies mainly upon maintaining integrity of the anterior rectus sheath fascia. The purpose of this study is to describe our minimally-invasive technique for robotic DIEP flap harvest. METHODS:), respectively. Average follow-up was 6.31 months (range: 5.73-7.27 months). Robotic flap harvest was performed with intramuscular perforator dissection in standard fashion, followed by the transabdominal preperitoneal (TAPP) approach to DIEP pedicle harvest using the da Vinci Xi robot. Data was collected on demographic information, perioperative characteristics. Primary outcomes included successful flap harvest as well as donor site morbidity (e.g., abdominal bulge, hernia, bowel obstruction, etc.). RESULTS:All four patients underwent bilateral abdominally-based free flap reconstruction. Three patients received bilateral robotic DIEP flaps, and one patient underwent unilateral robotic DIEP flap reconstruction. The da Vinci Xi robot was used in all cases. Average flap weight and pedicle length were 522 g (range: 110-809 g) and 11.2 cm (range: 10-12 cm), respectively. There were no flap failures, and no patient experienced abdominal wall donor site morbidity on physical exam. CONCLUSION/CONCLUSIONS:While further studies are needed to validate its use, this report represents the largest series of robotic DIEP flap harvests to date and is a valuable addition to the literature.

Background/UNASSIGNED:Gender-affirming mastectomy has become one of the most frequently performed procedures for transgender and nonbinary patients. Although there are a variety of potential surgical approaches available, the impact of technique on outcomes remains unclear. Here we present our experience performing periareolar and double incision mastectomies, with a focus on comparing patient demographics, preoperative risk factors, and surgical outcomes and complication rates between techniques. Methods/UNASSIGNED:Retrospective review identified patients undergoing gender-affirming mastectomy by the senior author between 2017 and 2020. Patients were stratified according to surgical technique, with demographics and postoperative outcomes compared between groups. Results/UNASSIGNED:= 0.84) based on technique. Conclusions/UNASSIGNED:Our results demonstrate no difference in the rates of postoperative complications or revision procedures based on surgical technique. These results also suggest that with an experienced surgeon and proper patient selection, both techniques of gender-affirming mastectomy can be performed safely and with comparable outcomes.

Transgender and non-binary (TGNB) individuals often experience gender dysphoria. TGNB individuals with gender dysphoria may undergo genital gender-affirming surgery including vaginoplasty, phalloplasty, or metoidioplasty so that their genitourinary anatomy is congruent with their experienced gender. Given decreasing social stigma and increasing coverage from private and public payers, there has been a rapid increase in genital gender-affirming surgery in the past few years. As the incidence of genital gender-affirming surgery increases, a concurrent increase in the development and utilization of patient reported outcome measurement tools is critical. To date, there is no systematic way to assess and measure patients' perspectives on their surgeries nor is there a validated measure to capture patient reported outcomes for TGNB individuals undergoing genital gender-affirming surgery. Without a systematic way to assess and measure patients' perspectives on their care, there may be fragmentation of care. This fragmentation may result in challenges to ensure patients' goals are at the forefront of shared- decision making. As we aim to increase access to surgical care for TGNB individuals, it is important to ensure this care is patient-centered and high-quality. The development of patient-reported outcomes for patients undergoing genital gender-affirming surgery is the first step in ensuring high quality patient-centered care. Herein, we discuss the critical need for development of validated patient reported outcome measures for transgender and non-binary patients undergoing genital reconstruction. We also propose a model of patient-engaged patient reported outcome measure development.

PURPOSE/OBJECTIVE:A successful urethroplasty has been defined in different ways across studies. This variety in the literature makes it difficult to compare success rates and techniques across studies. We aim to evaluate the success of anterior urethroplasty based on different definitions of success in a single cohort. MATERIALS AND METHODS/METHODS:Data was collected from a multi-institutional, prospectively maintained database. We included men undergoing first-time, single-stage, anterior urethroplasty between 2006 - 2020. Exclusion criteria included lack of follow-up, hypospadias, extended meatotomy, perineal urethrostomy, posterior urethroplasty, and staged repairs. We compared five different ways to define a "failed" urethroplasty: 1) stricture retreatment, 2) anatomic recurrence on cystoscopy, 3) peak flow rate <15ml/s, 4) weak stream on questionnaire, and 5) failure by any of these measures. Kaplan-Meier survival curves were generated for each of the definitions. We also compared outcomes by stricture length, location, and etiology. RESULTS:A total of 712 men met inclusion criteria including completion of all types of follow-up. The 1- and 5-year estimated probabilities of success were: "retreatment", 94% and 75%; "cystoscopy", 88% and 71%; "uroflow", 84% and 58%; "questionnaire", 67% and 37%; and "any failure", 57% and 23%. This pattern was inconsistent across stricture length, location, and etiology. CONCLUSIONS:The estimated probability of success after first-time, anterior urethroplasty is highly dependent on the way success is defined. The variability in definitions in the literature has limited our ability to compare urethroplasty outcomes across studies.

OBJECTIVE:To examine the safety, feasibility and durability of robotic reimplantation of ureteroenteric stricture after radical cystectomy. MATERIAL AND METHODS/METHODS:A retrospective multi-institutional review was performed for all patients undergoing robotic repair of ureteroenteric stricture from January 2010-January 2019. Functional outcomes and complications were followed and data were analyzed with SPSS statistical software. RESULTS: CONCLUSION/CONCLUSIONS:Robotic reimplantation of ureteroenteric strictures following radical cystectomy is safe and feasible in experienced centers with high success rates.

BACKGROUND:Refractory vesicourethral anastomotic stenosis (VUAS) after radical prostatectomy poses challenges distinct from bladder neck contracture, due to close proximity to the sphincter mechanism. Open reconstruction is technically demanding, risking de novo stress urinary incontinence (SUI) or recurrence. OBJECTIVE:To demonstrate patency and continence outcomes of robotic-assisted VUAS repair. DESIGN, SETTING AND PARTICIPANTS/METHODS:Patients with VUAS underwent robotic-assisted reconstruction from 2015 to 2020 in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) consortium of institutions. The minimum postoperative follow-up was 3 mo. SURGICAL PROCEDURE/METHODS:The space of Retzius is dissected and fibrotic tissue at the vesicourethral anastomosis is excised. Reconstruction is performed with either a primary anastomotic or an anterior bladder flap-based technique. MEASUREMENTS/METHODS:Patency was defined as either the passage of a 17 French flexible cystoscope or a peak flow on uroflowmetry of >15 ml/s. De novo SUI was defined as either more than one pad per day or need for operative intervention. RESULTS AND LIMITATIONS/CONCLUSIONS:A total of 32 patients met the criteria, of whom 16 (50%) had a history of pelvic radiation. Intraoperatively, 15 (47%) patients had obliterative VUAS. The median length of hospital stay was 1 d. At a median follow-up of 12 mo, 24 (75%) patients had patent repairs and 26 (81%) were voiding per urethra. Of five men with 30-d complications, four were resolved conservatively (catheter obstruction and ileus). In eight patients, recurrent stenoses were managed with redo robotic reconstruction (in two), endoscopically (in four), or catheterization (in two). Of 13 patients without preexisting SUI, 11 (85%) remained continent at last follow-up. No patients underwent urinary diversion. CONCLUSIONS:Robotic-assisted VUAS reconstruction is a viable and successful management option for refractory anastomotic stenosis following radical prostatectomy. The robotic transabdominal approach demonstrates high patency and continence rates. PATIENT SUMMARY/RESULTS:We studied the outcomes of robotic-assisted repair for vesicourethral anastomotic stenosis. Most patients, after the procedure, were able to void per urethra and preserve existing continence.

Introduction & Objectives: The most widely accepted definition of female urethral stricture (FUS) is a symptomatic, anatomical narrowing of the urethra based on a failure of catheterization, urethral calibration, visual inspection, endoscopy or radiography. Thus it is a rare condition, its diagnostic and treatment are challenging for the reconstructive urologist.
Material(s) and Method(s): We present the case of a 47 year-old female, with a urethral stricture due to vulvar lichen sclerosus inducing incomplete bladder emptying and recurrent urinary tract infections. We decided to use lingual mucosa because the buccal mucosa was also affected by the lichen. The aim of this video was to describe the procedure of dorsal onlay lingual mucosa graft urethroplasty.
Result(s): The operating time was 70 minutes. The procedure began with the injection of adrenaline and xylocaine serum. An inverted U incision was performed anterior to the urethra. Dissection was carried out in the plane developed between the underlying urethra and overlying clitoral cavernous tissue. A dorsal urethrotomy was performed at a 12 o' clock position until healthy proximal urethra was reached. The lingual mucosa graft was harvested after having identified the Wharton's duct orifices. The graft edges were incised using a scalpel and the graft was removed using sharp scissors. The graft was maturated by removing the fat and muscular tissue of its non-mucosal side. The graft was sutured to the margins of the urethral plate. The distal part of the graft was quilted to the above periurethral flap in order to recreate the ventral aspect of the urethral meatus. A 18FR silicone catheter was placed carefully at the end of the procedure. No peri operative complication occurred. The patient was discharged two days after surgery and did not have recurrence of stricture after 6 months.
Conclusion(s): Dorsal onlay lingual mucosa graft urethroplasty is a feasible option for female urethral stricture with satisfactory postoperative outcomes.
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BACKGROUND:The limitations of metoidioplasty and phalloplasty have been reported as deterrents for transgender and other gender expansive individuals (T/GE) desiring gender affirming surgery, and thus penile transplantation, epithesis, and composite tissue engineering (CTE) are being explored as alternative interventions. AIM/OBJECTIVE:We aim to understand the acceptability of novel techniques and factors that may influence patient preferences in surgery to best treat this diverse population. METHODS:Descriptions of metoidioplasty, phalloplasty, epithesis, CTE, and penile transplant were delivered via online survey from January 2020 to May 2020. Respondents provided ordinal ranking of interest in each intervention from 1 to 5, with 1 representing greatest personal interest. Demographics found to be significant on univariable analysis underwent multivariable ordinal logistic regression to determine independent predictors of interest. OUTCOMES/RESULTS:Sexual orientation, gender, and age were independent predictors of interest in interventions. RESULTS:There were 965 qualifying respondents. Gay respondents were less likely to be interested in epithesis (OR: 2.282; P = .001) compared to other sexual orientations. Straight individuals were the least likely to be interested in metoidioplasty (OR 3.251; P = .001), and most interested in penile transplantation (OR 0.382; P = .005) and phalloplasty (OR 0.288, P < .001) as potential interventions. Gay and queer respondents showed a significant interest in phalloplasty (Gay: OR 0.472; P = .004; Queer: OR 0.594; P = .017). Those who identify as men were more interested in phalloplasty (OR 0.552; P < .001) than those with differing gender identities. Older age was the only variable associated with a decreased interest in phalloplasty (OR 1.033; P = .001). No demographic analyzed was an independent predictor of interest in CTE. CLINICAL IMPLICATIONS/CONCLUSIONS:A thorough understanding of patient gender identity, sexual orientation, and sexual behavior should be obtained during consultation for gender affirming penile reconstruction, as these factors influence patient preferences for surgical interventions. STRENGTHS AND LIMITATIONS/UNASSIGNED:This study used an anonymous online survey that was distributed through community channels and allowed for the collection of a high quantity of responses throughout the T/GE population that would otherwise be impossible through single-center or in-person means. The community-based methodology minimized barriers to honesty, such as courtesy bias. The survey was only available in English and respondents skewed young and White. CONCLUSION/CONCLUSIONS:Despite previously reported concerns about the limitations of metoidioplasty, participants ranked it highly, along with CTE, in terms of personal interest, with sexual orientation, gender, and age independently influencing patient preferences, emphasizing their relevance in patient-surgeon consultations. A. Parker, G. Blasdel, C. Kloer et al. "Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?". J Sex Med 2021;XX:XXX-XXX.