J. Terrier

Surgical Outcomes and Patients' Satisfaction with Suprapubic Phalloplasty

INTRODUCTION Many techniques, specifically forearm free flap phalloplasty, are used in penile reconstructive surgery. Although satisfying, a major disadvantage is the large, stigmatizing scar on the donor site, which leads many patients to explore alternatives. AIM The aim of this study is to assess the outcomes and satisfaction of patients offered the choice between metaidioplasty, forearm free flap, and suprapubic phalloplasty. METHODS Medical outcomes from the three-stage surgery were collected from the hospital files of 24 patients, who were also interviewed to assess their satisfaction, sexual function, and psychosexual well-being. MAIN OUTCOME MEASURES Medical complications, anthropometric measures, and interviewing questionnaire on satisfaction with appearance, sexual function, and psychological variables. RESULTS Duration of surgery and of hospital stay was relatively short in the first (1 hour 30 minutes; 3 days) and last (1 hour 40 minutes; 3 days) stage of surgery involving tissue expansion and neophallus release. These two stages were associated with few complications (17% and 4% minor complications respectively, 12% additional complications with hospitalization for the first stage). The second stage involving tubing was associated with longer surgery and hospital stay (2 hour 15 minutes; 5 days) and had more complications (54% minor complications and 29% requiring hospitalization) although fewer than one-step surgery. No loss of neophallus was reported. Overall, 95% of patients were satisfied with their choice of phalloplasty, 95% with the appearance, 81% with the length (Mean = 12.83 cm), and 71% with the circumference (Mean = 10.83 cm) of their neophallus. Satisfactory appearance was significantly correlated (P < 0.01) with penile length (r = 0.69) and diameter (r = 0.77). Sexual satisfaction was significantly correlated with penile diameter (r = 0.758), frequency of orgasm (r = 0.71), perceived importance of voiding while standing (r = 0.56), presurgery satisfaction with sexuality (r = 0.58), current masculine-feminine scale (r = 0.58), attractive-unattractive scale (r = 0.69), and happy-depressed scale (r = 0.63). CONCLUSION Suprapubic phalloplasty, despite the lack of urethroplasty, offers an interesting alternative for patients concerned with the stigmatizing scar on the donor site.

Surgical Staff Radiation Protection During Fluoroscopy-Guided Urologic Interventions.

INTRODUCTION Over the past 20 years, the use of fluoroscopy to guide urologic surgical interventions has been constantly growing. Thus, in their daily practice, urologists and other operating room (OR) staff are exposed to X-radiation increasingly frequently. This raises questions as to the risks they encounter and the actions needed to reduce them. OBJECTIVE Evaluate X-ray dose exposure in the members of the surgical team and determine urologist radioprotection knowledge and practices. MATERIALS AND METHODS A prospective bicenter study was conducted within AFUF (French urology resident association) and in association with The French Nuclear Safety Authority/The Institute for Radiological Protection and Nuclear Safety (ASN/IRSN). Radiation exposure was measured on 12 operators using dosimeters (seven per operator), in staff-occupied locations in the OR using ionization chambers, and on anthropomorphic phantoms. A survey was used to gather information on radiation knowledge and safety practices of the AFUF members. RESULTS Annual whole-body radiation doses were low (0.1-0.8 millisieverts [mSv], mostly at around 0.3 mSv), and equivalent doses were low for the fingers (0.7-15 mSv, mostly at around 2.5 mSv), and low for the lens of the eye (0.3-2.3 mSv, mostly at around 0.7 mSv). In percutaneous nephrolithotomy, extremity doses were lower when the patient was placed in dorsal decubitus compared with ventral decubitus. Pulsed fluoroscopy reduced radiation dose exposure by a factor of 3 compared with continuous fluoroscopy with no image quality loss. Radiation safety practices were poor: only 15% of urologists wore dosimeters and only 5% had been trained in the handling of X-ray generators. CONCLUSION In the present study, radiation exposure for urologists was low, but so was knowledge of radiation safety and optimization practices. This absence of training for radiation safety and reduction, teamed with novel techniques involving long fluoroscopy-guided interventions, could result in unnecessarily high exposure for patients and OR personnel.

Technique of Injection of Hyaluronic Acid as a Prostatic Spacer and Fiducials Before Hypofractionated External Beam Radiotherapy for Prostate Cancer

OBJECTIVE To describe a technique combining the implantation of fiducials and a prostatic spacer (hyaluronic acid [HA]) to decrease the rectal toxicity after an image-guided external beam radiotherapy (EBRT) with hypofractionation for prostate cancer and to assess the tolerance and the learning curve of the procedure. MATERIALS AND METHODS Thirty patients with prostate cancer at low or intermediate risk were included in a phase II trial: image-guided EBRT of 62 Gy in 20 fractions of 3.1 Gy with intensity-modulated radiotherapy. A transrectal implantation of 3 fiducials and transperineal injection of 10 cc of HA (NASHA gel spacer, Q-Med AB, Uppsala, Sweden) between the rectum and the prostate was performed by 1 operator. The thickness of HA was measured at 10 points on magnetic resonance imaging to establish a quality score of the injection (maximum score = 10) and determine the learning curve of the procedure. RESULTS The quality score increased from patients 1-10, 11-20, to 21-30 with respective median scores: 7 [2-10], 5 [4-7], and 8 [3-10]. The average thicknesses of HA between the base, middle part, and apex of the prostate and the rectum were the following: 15.1 mm [6.4-29], 9.8 mm [5-21.2], and 9.9 mm [3.2-21.5]. The injection of the HA induced a median pain score of 4 [1-8] and no residual pain at mid-long term. CONCLUSION Creating an interface between the rectum and the prostate and the implantation of fiducials were feasible under local anesthesia with a short learning curve and could become a standard procedure before a hypofractionated EBRT for prostate cancer.

Patient-reported long-term sexual outcomes following plication surgery for penile curvature: A retrospective 58-patient study

OBJECTIVE To evaluate long-term sexual function results following plication surgery for the correction of penile curvature using patient questionnaires. METHODS We performed a single-center, retrospective study in a cohort of patients with Peyronies disease or congenital penile curvature. All patients who underwent plication surgery on the convex aspect using the Nesbit, Yachia or diamond-shaped techniques were included. At a mean 34 months after the interventions, the patients were asked to respond to the IIEF5 questionnaire and a 19-item questionnaire. RESULTS Forty-six patients operated for Peyronies disease and 12 for congenital curvature (total: 58) were included in the study. The questionnaire response rate was 69% (40/58). The shortened penis bothered 47.5% of patients in their sexuality at least regularly. Involuntary exit from the vagina occurred for 35% of the patients in at least one out of two sexual intercourse sessions. Postoperative sexual life was as good as or better than preoperative sexual life for 35% of the patients and 95% stated that they could achieve erection at least sometimes, in coherence with the mean IIEF5 result of 19.3/25. CONCLUSION Our study suggests that even when successful, a relatively high rate of patients may be unsatisfied with the results of plication surgery, and there may be a relatively low rate of maintenance or improvement of postoperative sexual life. Furthermore, our in-house questionnaire, although not validated, shed light on how bothersome the loss of penis length is in postoperative sexuality, an aspect the IIEF5 and its sole evaluation of erectile quality cannot detect. LEVEL OF EVIDENCE 4.

[Impact of anastomotic strictures on treatment of post-prostatectomy stress incontinence by artificial urinary sphincter].

INTRODUCTION Stress urinary incontinence (SUI) is a degradation of the quality of life factor in the consequences of radical prostatectomy. Artificial urinary sphincter (AUS) is the standard treatment. Screening and preoperative treatment of anastomotic strictures (AS) is an essential step for the success of the intervention. The objective of the study was to assess the impact of AS on the results of AUA. METHODS We retrospectively studied 147 AUS settlements from 2005 to 2013 in the urology department of the Centre Hospitalier Lyon by three operators. The demographic characteristics, the irradiation history, the severity of incontinence, the complications of AUS, the continence rate and the postoperative satisfaction were collected. Wilcoxon statistical tests and Fischer and a Kaplan-Meier curve were used to compare the two control groups and AS. Logistic regression analysis looked for predictors of surgical reintervention. RESULTS Of the 147 patients included, 24 (16.3%) had a history of AS. Of these, 21 (87.5%) were treated with endoscopic urethrotomy. Patients in the AS group had more severe incontinence (P<0.05) than in the control group. Explantation rates, recurrence of incontinence and reoperation was 12.5%, 8.3% and 33.3% in the AS group against 4.9%, 15.4% and 27.6% in the control group. In logistic regression, history of AS has not been found as reoperation risk factor. Continents and satisfied patients rate were 77.8% and 76.5%, respectively in the AS group against 91.1% and 81.1% in the control group. CONCLUSION The history of AS does not appear to be predictive of poor outcome after implementation of a AUS. Larger cohort studies are needed to confirm these results. LEVEL OF EVIDENCE 4.

Robot-Assisted Partial Nephrectomy: Is routine urinary catheterization still mandatory in the era of enhanced recovery?

OBJECTIVE To assess the benefits and safety of noncatheterization during robot-assisted partial nephrectomy within an enhanced recovery protocol. MATERIALS AND METHODS A single-center retrospective comparative study was carried out of consecutive patients who underwent a robot-assisted partial nephrectomy between February 2015 and December 2017 within an early recovery program. The patients who received a urinary catheter were compared with those who did not in terms of postoperative complications, acute urinary retention rates, urinary tract infection rates, and lengths of hospital stay. RESULTS Of the 145 patients who followed an early recovery program after robot-assisted partial nephrectomy in the study period, 96 received a urinary catheter and 49 did not. There was no significant difference between these 2 groups in terms of the rates of acute urinary retention (3% vs 6%, respectively; P = .393), urinary tract infection (3% vs 2%; P = .707), postoperative complications (14% vs 18%; P = .445), or readmissions within 30 days (8% vs 6%; P = .636). However, patients who did not receive a catheter had shorter initial and total (including readmissions) lengths of hospital stay (respectively 2.16 days vs 2.56 days; P = .058, and 2.27 days vs 3.40 days; P <.001). CONCLUSION Our findings challenge the routine use of urinary catheterization during robot-assisted partial nephrectomies. Noncatheterization does not seem to increase the risk of postoperative urinary retention. Only catheterizing specific at-risk patients may prove beneficial.