Faculty Bibliography

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.

BACKGROUND:Sexually transmitted infections (STIs) following penile reconstruction in transgender, nonbinary, and other gender expansive (T/GE) populations has not previously been described, despite known risk factors in the population. Following T/GE penile reconstruction, care providers may underdiagnose STI without anatomically appropriate guidelines. METHODS:A detailed anonymous online survey of experiences of T/GE penile reconstruction patients was constructed with community input. Respondents were recruited from online support groups. RESULTS:128 T/GE people with experience of penile reconstruction responded to an anonymous survey posted in online support groups January to May 2020. Seven respondents (5.5%) self-reported one or more of the listed STIs at any point after penile reconstruction. All respondents with neourethras were diagnosed with localized STIs in nonurethral (extrapenile) locations only, and lack of vaginectomy was correlated with STI (p = 0.002). STIs were correlated with reporting sex with cisgender men (p = 0.001), transgender men (p = 0.009), and transgender women (p = 0.012). Of healthcare access variables, only receiving healthcare at a Community Health Center was correlated with STI history (p = 0.003). CONCLUSION/CONCLUSIONS:This exploratory survey indicates STI occurs after penile reconstruction in T/GE patients. Clinical confirmation is needed to identify specific risk factors and relative susceptibility of post-reconstruction anatomy to STIs. Given no previous surveillance recommendations for this population and the correlation of healthcare provider location with STI prevalence, underdiagnoses are likely. Based on the authors' clinical experience, we describe a urogenital screening algorithm following gender affirming penile reconstruction.

OBJECTIVE:To describe the authors' experience diagnosing and managing intra-abdominal complications following robotic peritoneal flap vaginoplasty. The peritoneal flap vaginoplasty is a technique used to achieve consistent vaginal depth regardless of available natal tissue. Intra-abdominal complications following robotic peritoneal flap creation are rare but prompt diagnosis and management is critical to preventing patient harm. Given the infancy of the technique there is limited data on associated complications and their management. METHODS:Retrospective chart review identified patients undergoing robotically assisted peritoneal flap vaginoplasty by the senior authors between 2017 and 2020 who subsequently developed intra-abdominal complications requiring readmission and/or return to the operating room. Patient charts were analyzed for preoperative demographics, medical comorbidities, intraoperative details, postoperative complication presentation, diagnosis, management, and long-term outcomes. RESULTS:Out of 274 patients undergoing peritoneal flap vaginoplasty during the study period, six patients were identified who developed intra-abdominal complications (2.2%). One patient developed a postoperative hematoma requiring return to the operating room for diagnostic laparoscopy and hematoma evacuation. Two patients developed intraabdominal abscesses requiring diagnostic laparoscopy and abscess drainage. One patient developed recurrent episodes of small bowel obstructions that resolved with bowel rest. Two patients developed incarcerated internal hernias requiring diagnostic laparoscopy and internal hernia reduction. In one case, the hernia occurred at the peritoneal flap closure site, and in the other case the hernia occurred at the peritoneal flap donor site. CONCLUSIONS:Intra-abdominal complications following robot assisted peritoneal flap vaginoplasty are rare.  In addition to hematoma and abscess, small bowel incarceration and internal hernias are potential complications of peritoneal flap vaginoplasty that require prompt attention.

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.

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: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.

Silber and Kelly first described the successful autotransplantation of an intra-abdominal testis in 1976. Subsequent authors incorporated laparoscopy and demonstrated the viability of transplanted testes based on serial postoperative exams. We sought to extend this experience with use of the da Vinci surgical robot, thereby demonstrating a novel robotic technique for the management of cryptorchidism. The procedure was performed for an 18-year-old male with a solitary left intra-abdominal testis. Following establishment of pneumoperitoneum, the robot is docked with four trocars oriented towards the left lower quadrant. Testicular dissection is carried out as shown. The gonadal and inferior epigastric vessels are isolated and mobilized; once adequate length is achieved, the former is clipped and transected, and the testicle and inferior epigastric vessels are delivered out of the body. The robot is then undocked and exchanged for the operating microscope. Arterial and venous anastomoses are completed with interrupted and running 9-0 Nylon, respectively, and satisfactory re-anastomosis is confirmed visually and with Doppler. The transplanted testicle is then fixed inferiorly and laterally within the left hemiscrotum, and all incisions are closed. We note that intraoperative testicular biopsy was not performed, for three reasons: (1) to avoid further risk to an already tenuous, solitary organ, (2) because our primary aim was to preserve testicular endocrine function, and (3) because the presence of ITGCN would neither prompt orchiectomy nor obviate the need for ongoing surveillance via periodic self-examination and ultrasonography. The patient is maintained on bed rest for two days and discharged on postoperative day seven in good condition. Over one year since autotransplantation, his now intra-scrotal testicle remains palpable and stable in size. Serum testosterone is unchanged from preoperative measurements. Robotic-assisted testicular autotransplantation is a feasible and efficacious management option for the solitary intra-abdominal testis.

OBJECTIVE:To describe the technique, feasibility and short-term outcomes of buccal mucosa grafts in robotic lower urinary tract reconstruction. METHODS:We reviewed 9 patients who underwent single-port robotic posterior urethroplasty with buccal mucosa graft from May-December 2019. Variables included patient demographics, diagnosis/etiology, and intraoperative parameters. Intraabdominal or extraperitoneal transvesical approaches are used for the stricture via supraumbilical access, and if necessary, perineal dissection is performed. Cystoscopy identifies the extent of stenosis. Anastomosis is completed with buccal mucosal graft and rectus abdominis, omental or gracilis flaps as needed. RESULTS:The mean age was 65.4 years. Robotic urethroplasty with buccal mucosa graft was performed for vesicourethral anastomotic strictures (n = 7), urethral strictures (n = 4), pubic fistula after robotic posterior urethroplasty (n = 1), and anastomotic distraction (n = 1). Strictures occurred after prostate cancer treatments (n = 8) and trauma (n = 1). All patients had prior failed endoscopic interventions: balloon dilatation, resection/incision of bladder neck, internal urethrotomy under direct vision, urethral stents, and posterior urethroplasty. Mean defect length was 3.9 cm. Five of 9 patients had ancillary procedures including rectus abdominis (n = 3), omental or gracilis (both n = 1) flap harvests. No intraoperative complications occurred. Median operative time was 377 minutes, blood loss was 200 mL, and length of stay was 2 days. Postoperative 30-day complications included urinary tract infection, epididymitis, anemia, recurrent stricture, and small bowel obstruction requiring surgery (all n = 1). Median follow-up was 11.7 months. CONCLUSION/CONCLUSIONS:Buccal mucosa grafts with ancillary maneuvers such as flap interposition or adjacent tissue transfer in robotic lower tract reconstruction is durable, safe, and comparable to open approaches.