Faculty Bibliography

Increased access to care and insurance coverage has led to an increase in gender-affirming surgeries performed in the United States. Gender-affirming phalloplasty has a variety of donor sites and surgical techniques including both pedicled and free flaps. Although surgical techniques and patient outcomes are well-described, no reports in the literature specifically discuss postoperative management, which plays a crucial role in the success of these operations. Here, we present a postoperative protocol based on our institution's experience with gender-affirming phalloplasty with the hope it will serve as a standardized, reproducible reference for centers looking to offer these procedures.

SUMMARY:The surgical treatment of gender incongruence with gender-affirming surgery requires a sophisticated understanding of the substantial diversity in patient expectations and desired outcomes. There are patients with gender incongruence who desire surgical intervention to achieve the conventional bodily configuration typical for cisgender men and women and those who desire surgery without the goal of typical cisgender presentation. Proper communication regarding diverse expectations poses a challenge to those unfamiliar with the nuances of this heterogeneous population; such difficulties have led to mistakes during patient care. Based on the lessons learned from these experiences, the authors provide conceptual recommendations with specific examples to account for cultural context and conceptions of gender within surgical practice and scientific research.

The landscape for upper genitourinary tract reconstruction continues to evolve with innovations in technology and surgical techniques. While the use of flaps and grafts in reconstructive surgery is not a novel concept, the application of buccal mucosal grafts in ureteral reconstruction has only been described over the last 20 years and is now an important adjunct for approaching ureteral strictures. Alongside the increasing use of robotics in urologic surgery, the options available for reconstruction of the upper tract with decreasing patient morbidity are multiplying. Herein, we aim to highlight various patient characteristics which may favor the use of buccal mucosa for addressing ureteral strictures.

OBJECTIVE:To provide a summary of surgical technique and outcomes for Heineke-Mikulicz preputioplasty (HMP), a foreskin-preserving surgical treatment for phimosis in the adult population. METHODS:We retrospectively reviewed 7 patients who underwent HMP by a single surgeon from May 2017 to May 2021. Variables included patient demographics, intraoperative considerations, and post-operative course. HMP is performed using a 2-3 cm vertical incision over the phimotic band on the dorsal surface to just above Buck's fascia. Additional incisions are made on the ventral surface if phimosis remains persistent after dorsal release. The incision is closed horizontally in 2 layers. RESULTS:Seven patients underwent HMP. Median age was 47.3 and median BMI was 24.3. Five patients reported bothersome phimosis and 1 each reported paraphimosis and frenular tethering. Six patients requested foreskin sparing surgery as a personal preference and 1 patient was an intraoperative consult. Topical betamethasone was attempted in 3 of 7 patients. The median time from diagnosis to surgery was 2 months. Median operative time was 45.5 minutes and median estimated blood loss was 5 mL. Two patients required both dorsal and ventral incisions. No intraoperative complications were reported and all patients were discharged the same day. At median follow-up of 1.8 months, 1 patient reported bothersome phimosis secondary to scar formation treated successfully with triamcinolone. CONCLUSION/CONCLUSIONS:HMP is a safe and effective method of treating even very significant phimosis in patients trying to avoid circumcision or intraoperative consults where preferences may be unclear. Our method takes less time than traditional circumcision with a comparable recovery and complication profile.

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.

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.

BACKGROUND:Following gender-affirming penile inversion vaginoplasty or vulvoplasty, patients may seek vulvar revision procedures for a variety of common aesthetic and functional concerns. These indications for revision and accompanying techniques are not well-described in the literature. METHODS:Patients who underwent vulvar revision surgery at the authors' institution were identified, and patient demographics, surgical indications, operative details, and complications were described. Common complaints requiring external genital revision were sorted into four categories: clitoral, labial, introital, and urethral. RESULTS:Thirty-five patients with a history of vaginoplasty underwent vulvar revision between May of 2017 and December of 2019. The mean age at surgical correction was 38.9 years. Ten patients (28.6 percent) had undergone prior secondary procedures (range, 1 to 3). Mean follow-up after revision surgery was 10.7 ± 8.7 months (range, 0 to 30.6 months). The majority of patients underwent concurrent revisions in multiple "categories". Labial aesthetic concerns were most common (n = 27, 77.1 percent), followed by clitoral (n = 20, 57.1 percent), urologic (n = 17, 48.6 percent), and introital complaints (n = 12, 34.3 percent). Twelve patients (34.3 percent) had canal stenosis requiring concurrent robot-assisted canal revision with peritoneal flaps. Complications included labial abscess (n = 1) and deep vein thrombosis (n = 1). Three patients (8.6 percent) underwent subsequent external genital revisions. Management approaches and surgical techniques for each of these common revision categories are provided. CONCLUSION/CONCLUSIONS:As more individuals seek vaginoplasty and vulvoplasty, surgeons must be prepared to address a range of common aesthetic and functional complaints requiring vulvar revision. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.

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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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.