Jack M. Zuckerman

Extended Outcomes in the Treatment of Male Stress Urinary Incontinence With a Transobturator Sling

OBJECTIVE To review extended patient outcomes after male transobturator sling placement for stress urinary incontinence. METHODS A retrospective review of a prospectively maintained database for patients with at least 12 months of postoperative follow-up after AdVance male sling placement was performed. Success was defined as a dry safety pad or less (cured) or >50% improvement in pads used per day and patient satisfaction (improved). Patients requiring repeat continence procedures were considered failures. RESULTS We reviewed data from 102 patients with a minimum of 12 months of follow-up (mean ± standard deviation 36.2 ± 16.5 months). The mean age at surgery was 66.1 years, and 86.4% had previously undergone a prostatectomy. At 12 months, 24 months, and final follow-up, success rates were 74%, 63%, and 62%, respectively. Although cure rates also declined over time, 40% of patients experienced a durable cure with no complaints of wet pads at final follow-up. Complications were minimal and similar with previous reports. Multivariate Cox regression analysis revealed detrusor overactivity and an elevated detrusor pressure and peak flow negatively predicted being cured using sling placement. CONCLUSION AdVance sling placement continues to represent a viable option in the treatment of male stress incontinence. Although a decrease in efficacy over time was observed, a substantial portion of patients can expect a durable cure.

Outcome of Penile Revascularization for Arteriogenic Erectile Dysfunction After Pelvic Fracture Urethral Injuries

OBJECTIVE To review our experience with penile revascularization for patients with bilateral occlusion of the deep internal pudendal arteries after pelvic fracture urethral injury (PFUI). MATERIALS AND METHODS We identified 17 patients who had undergone penile revascularization with end-to-side anastomosis of the deep inferior epigastric artery to the dorsal penile artery from July 1991 to December 2010. Success was defined as achieving erections sufficient for intercourse with or without pharmacologic assistance. RESULTS All patients had had a PFUI causing arterial insufficiency and erectile dysfunction not responsive to pharmacologic intervention. Of the 17 patients, 4 (24%) underwent revascularization before and 13 (76%) after PFUI repair. The mean age at revascularization was 32.7 years (range 17-54). At an average follow-up of 3.1 years, the surgery was successful in 14 of the 17 patients (82%). In patients with erectile dysfunction as an indication for surgery, successful erections were achieved in 11 of 13. For those who underwent revascularization to prevent ischemic stenosis of the urethral repair, 3 of 4 achieved successful erections, and all subsequent urethral surgeries were successful. The penile duplex ultrasound parameters showed clinically and statistically significant improvements after revascularization. No operative complications developed. The average hospital length of stay was 4.7 days. Four patients experienced early postoperative complications, including an abdominal wall hematoma requiring evacuation in one, penile edema in two, and a superficial surgical site infection in one. No late complications occurred. CONCLUSION Penile arterial revascularization in select patients can allow for successful treatment of PFUIs and the refractory erectile dysfunction caused by them.

Evaluation of Salvage Male Transobturator Sling Placement Following Recurrent Stress Urinary Incontinence After Failed Transobturator Sling

OBJECTIVE To evaluate the outcome of patients treated with a salvage AdVance male sling after a failed primary transobturator sling placement. METHODS Retrospective review of patients treated at our center with a primary and subsequent salvage AdVance sling. Success was defined as a dry safety pad or no pads (cured), or >50% improvement in pads used per day and patient satisfaction (improved). Early primary sling failures (<6 months) were compared with late (≥6 months) failures with regard to continence outcomes. RESULTS We identified 18 patients who underwent a salvage AdVance sling placement at our institution. Overall success was 72% at 6 months postoperatively and 56% at a mean follow-up of 17.5 months, including 50% and 39% of patients who were dry at those same time periods. Patients failing late after their primary sling (n = 8) enjoyed improved outcomes with salvage sling placement compared with patients who failed early (n = 10) after the primary sling. At 6 months, more patients in the late primary failure group were cured (75% vs. 30%; P = .031). These improved cure rates remained significant through final follow-up with cure rates of 63% and 20%, respectively (P = .041). CONCLUSION Salvage AdVance male sling is a viable treatment option after a failed primary sling procedure, especially in patients who demonstrated a prolonged efficacy period before primary sling failure.

Minimally invasive surgical approach to excision of symptomatic ectopic inverted-Y ureteral duplications

Inverted-Y ureteral duplications are a rare duplication anomaly with few cases reported in the literature. We report a novel minimally invasive approach to managing inverted-Y duplications in two females who presented with continuous urinary incontinence and were found to have an ectopic insertion of the duplicated ureter. The ectopic segment was excised laparoscopically without complication in the outpatient setting with resultant cure of the continuous incontinence. This represents the first report of a laparoscopic approach to this rare anomaly.

Specialty within a specialty: posterior urethroplasty

Posterior urethral distractions occur in up to 25% of cases of blunt force pelvic fractures. Proper repair of these pelvic fracture urethral injuries (PFUI) is an art that requires exquisite attention to technique and tissue handling. Koraitim and Kamel [1] recently reported their singlesurgeon series of PFUI repairs on 86 patients, with the specific aim of characterizing risk factors for treatment failure. Success was defined subjectively as absence of urinary symptoms and normal postoperative urethrography. Requirement for repeat procedures constituted failure. At a mean 5.5 years of direct follow-up, 88% of patients were considered to have had successful treatment. Multivariate logistic regression showed that incomplete scar excision and lateral prostatic displacement (as opposed to superior or no displacement) were predictive of treatment failure (odds ratios 122 and 34, respectively). All other factors analysed, including previous treatment, relative bulbar urethral scarring, mucosal fixation, suture size and number of sutures, were not significant predictors of urethral outcomes.

MP79-11 COMPARISON OF OUTCOMES BETWEEN ULNAR AND RADIAL FREE FLAPS FOR NEOPHALLUS CONSTRUCTION

METHODS: 15 transgender patients who were already living as females presented to our institution from 1/2016 to 10/2016, and underwent our previously defined RAPiV. Briefly, the RAPiv is performed in the low lithotomy position and the penis is degloved through a circumcision incision. An additional perineal incision is made to the bulbar urethra. The dissected penis, urethra, neurovascular bundle, glans and corpora are delivered through the perineal incision (Figure 1a). We spare the dorsal aspect of the tunica of the corpora cavernosa to reduce risk of glans necrosis. Four robotic ports were placed and the abdomen was insufflated (1b) and robot docked. Denonviller’s fascia is opened (1c) and the abdominal dissection is continued to the peritoneal one (1d), the neovagina is passed into robotic field (1e) and pexed to the anterior reflection of the posterior peritoneum (1f). The peritoneal reflection is then closed (1g). We then complete the labioplasty and clitoroplasty. RESULTS: The average operative time for RAPiV was 5.8 hours (5-7), 8/15 (53%) required mobilization of additional tissue flaps (4/15, 27%) or underwent concomitant abdominoplasty and skin graft harvest (4/15 27%) to supplement penile skin. EBL was 386cc (100600) and LOS was 3.7 (2-6). Average postoperative vaginal depth was 11.3cm (10.2-12.7). Two patients had complications, 1 dehiscence of labioplasty treated with conservative therapy and 1 had loss of neovagina depth and distal urethral stenosis secondary to wound infection requiring debridement. CONCLUSIONS: We have performed 15 cases utilizing our novel method for robot assisted penile inversion vaginoplasty. Under direct visualization the neovaginal canal is created. This technique achieves maximal vaginal length in a reproducible manner.

MP46-17 ASSOCIATION BETWEEN EARLY POSTOPERATIVE URINARY RETENTION AND OUTCOMES AFTER TRANSOBTURATOR SLING INSERTION FOR TREATMENT OF MALE STRESS URINARY INCONTINENCE

INTRODUCTION AND OBJECTIVES: Male stress urinary incontinence (SUI) is a common sequela of radical prostatectomy and occasionally benign prostatic hyperplasia surgery, causing significant impact on quality of life. The AdVance transobturator sling has been described as a safe and effective minimally invasive treatment for male SUI, but early postoperative urinary retention (EPUR) is not uncommon. This study evaluates the outcomes of patients who have EPUR after insertion of an AdVance transobturator male sling for treatment of SUI. Our hypothesis is that although EPUR can be concerning, it is usually transient and may be associated with favorable continence outcomes. METHODS: A review of all men with SUI treated with an AdVance transobturator sling by a single surgeon during the period of January 1, 2006 through August 1, 2016, was performed. Perioperative, continence and complication outcomes (including urinary retention, mesh erosion and reoperation) were assessed. Outcomes of men who experienced EPUR were compared with men who did not experience EPUR. Statistical analyses such as Chi Square test were performed in Microsoft Excel 2016. RESULTS: 257 men (mean age 68 years) underwent insertion of a transobturator sling for SUI during the study period. Mean follow up was 25 months; 5 men were lost to follow up. Overall, success rate was 84%, with 45% (114/252) of men reporting complete continence and 39% (98/252) reporting improvement only. Overall, the mean number of pads used per patient per day improved from 3.7 pre-sling to 1.3 post-sling insertion. 16% (41/252) of patients experienced EPUR which was treated with reinsertion of indwelling Foley urethral catheter and repeat void trial. Most cases of urinary retention resolved within weeks; one patient required explantation of the sling due to ongoing urinary retention beyond 3 months. In the group of patients who had EPUR, success rate was 98%, with 61% of men achieving complete continence and 37% reporting improvement only. By comparison, in the group of patients who did not have EPUR, success rate was 82%, with 42% of men reporting complete continence and 39% of men stating improvement only. The difference in continence success rate between the EPUR and no EPUR groups was statistically significant (p<0.05). CONCLUSIONS: Insertion of an AdVance transobturator sling for treatment of male SUI was complicated by EPUR in 16% of men. Most cases of EPUR were transient. The continence success rate in the group of men who experienced EPUR was significantly better than in the group of men without EPUR.

Robotic-assisted laparoscopic partial cystectomy for symptomatic urachal hamartoma.

We report a case of an urachal hamartoma in a 30-year-old African American woman. The urachal lesion was excised with a robotic-assisted laparoscopic partial cystectomy. Pathologic analysis revealed cysts, smooth muscle, and ciliated epithelium consistent with a hamartoma. The patient recovered without complication. This case highlights an unusual pathology that is infrequently reported following urachal remnant excision.

Reconstruction and Salvage of Failed Male Urethral Slings

Male urethral slings are becoming an accepted treatment for men with persistent post-prostatectomy incontinence (PPI) who do not desire, or are not candidates for artificial urinary sphincters (AUS). Initial and midterm results following AdVance sling placement have been encouraging, with success rates approaching 70–80 %. Patients with persistent or recurrent PPI following sling placement may be candidates for salvage treatments, depending on patient preference. After removal of the original mesh, repeat AdVance slings are placed in a similar manner to the primary procedure, other than being placed more distal on the corpus spongiosum. Patients competent and willing to operate an AUS may undergo AUS placement following failed AdVance. This is easily accomplished without removing the sling mesh, by placing the cuff around the spongiosum distal to the urethral sling. Early success rates following repeat AdVance placement has approached 70 %, and success following salvage AUS is expected to be similar to a primary AUS placement.