Jeremy Scott

Classification System for Individualized Treatment of Adult Buried Penis Syndrome.

Background: The authors present their experience with reconstructive strategies for men with various manifestations of adult buried penis syndrome, and propose a comprehensive anatomical classification system and treatment algorithm based on pathologic changes in the penile skin and involvement of neighboring abdominal and/or scrotal components. Methods: The authors reviewed all patients who underwent reconstruction of adult buried penis syndrome at their referral center between 2007 and 2015. Patients were stratified by location and severity of involved anatomical components. Procedures performed, demographics, comorbidities, and clinical outcomes were reviewed. Results: Fifty-six patients underwent reconstruction of buried penis at the authors’ center from 2007 to 2015. All procedures began with a ventral penile release. If the uncovered penile skin was determined to be viable, a phalloplasty was performed by anchoring penoscrotal skin to the proximal shaft, and the ventral shaft skin defect was closed with scrotal flaps. In more complex patients with circumferential nonviable penile skin, the penile skin was completely excised and replaced with a split-thickness skin graft. Complex patients with severe abdominal lipodystrophy required adjacent tissue transfer. For cases of genital lymphedema, the procedure involved complete excision of the lymphedematous tissue, and primary closure with or without a split-thickness skin graft, also often involving the scrotum. The authors’ overall success rate was 88 percent (49 of 56), defined as resolution of symptoms without the need for additional procedures. Conclusion: Successful correction of adult buried penis often necessitates an interdisciplinary, multimodal approach. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Delayed Reconstruction of Bulbar Urethral Strictures is Associated with Multiple Interventions, Longer Strictures and More Complex Repairs

Purpose: Prior to urethral reconstruction many patients with stricture undergo a variable period during which endoscopic treatments are performed for recurrent obstructive symptoms. We evaluated the association among urethroplasty delay, endoscopic treatments and subsequent reconstructive outcomes. Materials and Methods: We reviewed the records of men who underwent primary bulbar urethroplasty from 2007 to 2014. Those with prior urethroplasty, penile and/or membranous strictures and incomplete data were excluded from analysis. Men were stratified by a urethroplasty delay of less than 5, 5 to 10 or greater than 10 years from diagnosis. Results: A total of 278 primary bulbar urethroplasty cases with complete data were evaluated. Median time between stricture diagnosis and reconstruction was 5 years (IQR 2–10). Patients underwent an average ± SD of 0.9 ± 2.4 endoscopic procedures per year of delay. Relative to less than 5 and 5 to 10 years a delay of greater than 10 years was associated with more endoscopic treatments (median 1 vs 2 vs 5), repeat self‐dilations (13% vs 14% vs 34%), strictures longer than 2 cm (40% vs 39% vs 56%) and complex reconstructive techniques (17% vs 17% vs 34%). An increasing number of endoscopic treatments was independently associated with strictures longer than 2 cm (OR 1.06, p = 0.003), which had worse 24‐month stricture‐free survival than shorter strictures (83% vs 96%, p = 0.0003). Each consecutive direct vision internal urethrotomy was independently associated with the risk of urethroplasty failure (HR 1.19, p = 0.02). Conclusions: Urethroplasty delay is common and often associated with symptomatic events managed by repeat urethral manipulations. Endoscopic treatments appear to lengthen strictures and increase the complexity of repair.

Improving Outcomes of Bulbomembranous Urethroplasty for Radiation-induced Urethral Strictures in Post-Urolume Era

OBJECTIVE To evaluate contemporary outcomes of excision and primary anastomosis (EPA) for the treatment of radiation-induced urethral strictures (RUS). PATIENTS AND METHODS A retrospective review of 72 patients undergoing EPA for RUS from 2007 to 2015 by a single surgeon was performed. We analyzed overall and long-term success rates of EPA urethroplasty and compared patient cohorts from two groups, 2007-2012 vs 2013-2015 (post-Urolume). RESULTS During the course of the study, we noted a near doubling of patient volume from the earlier (6.2 patients/year) to later (11.7 patients/year) cohorts. Among the 37 men treated from 2007 to 2012, we identified an EPA success rate of 70% compared with the improved 86% success rate in the subsequent cohort of 35 men treated from 2013 to 2015 (P = .07). Single dilation was successful in 50% of initial and 40% of subsequent cohort patients in the treatment of recurrence. Initial and subsequent cohorts varied only in regard to stricture length (mean 2.0 cm vs 3.0 cm in initial and subsequent cohorts, P = .001) and number treated with Urolume stent (initial 5 vs none in the later cohort, P = .03). Length of follow-up (median 50 [17-97] months for the initial and 22 [6-34] months for the later cohort) was not associated with recurrence. CONCLUSION Increasing numbers of RUS patients are presenting for urethral reconstruction in the post-Urolume era. With increasing experience, we improved success rates of EPA urethroplasty to over 85% despite increased stricture length.

Low Testosterone Levels Result in Decreased Periurethral Vascularity via an Androgen Receptor-mediated Process: Pilot Study in Urethral Stricture Tissue

OBJECTIVE To compare expression of androgen receptor (AR) and angiopoietin 1 receptor TIE-2 and vessel density of urethral stricture tissue among eugonadal and hypogonadal men to identify a pathophysiological basis for our observations that low testosterone is associated with urethral atrophy. METHODS Among 1200 men having urethroplasty at our institution, we retrospectively identified 11 patients with testosterone levels drawn within 2 years of surgery. Low testosterone was defined as <280 ng/dL and detected in 5 of 11 (45.5%) patients. Urethral tissue samples were analyzed using immunohistochemistry for AR, TIE-2 (a downstream target of activated AR linking it to angiogenesis), and CD31 expression. RESULTS Mean testosterone was 179.4 ng/dL for patients classified as having low testosterone and 375.0 ng/dL for controls (P = .003). We found a significant decrease of AR expression (1.11%high power field [HPF] vs 1.62, P = .016), TIE-2 expression (1.84%HPF vs 3.08, P = .006), and vessel counts (44.47 vessels/HPF vs 98.33, P = .004) in men with low testosterone. Expression levels of AR and TIE-2 were directly correlated to testosterone levels (rho: 0.685, P = .029, and rho: 0.773, P = .005, respectively). We did not find a difference in age, radiation, or comorbidities among patients with normal or low testosterone levels, with the exception of higher body mass index in the latter. CONCLUSION Men with low testosterone levels demonstrate decreased AR and TIE-2 expression and lower vessel counts in periurethral tissue samples of urethral strictures. Our results provide a rationale for a mechanistic relationship between low testosterone levels and decreased periurethral vascularity that may contribute to urethral atrophy in patients with urethral strictures.

Clinical Risk Factors Associated With Urethral Atrophy

OBJECTIVE To analyze a series of clinical risk factors associated with pretreatment urethral atrophy. METHODS We retrospectively reviewed 301 patients who underwent artificial urinary sphincter (AUS) placement between September 2009 and November 2015; of these, 60 (19.9%) transcorporal cuff patients were excluded. Patients were stratified into 2 groups based on intraoperative spongiosal circumference measurements. Men with urethral atrophy (3.5 cm cuff size) were compared to controls (≥4 cm cuff size). Chi-square test, Mann-Whitney U test, and logistic regression analyses were performed to determine risk factors for urethral atrophy. RESULTS Among 241 AUS patients analyzed, urethral atrophy was present in 151 patients (62.7%) compared to 90 patients (37.3%) who received larger cuffs (range 4-5.5 cm). Patients with urethral atrophy were older (71.1years vs 68.3 years; P < .02), more likely to have received radiation (52.9% vs. 33.3%; P < .007), and had a longer time interval between prostate cancer treatment and AUS surgery (8.9 years vs. 6.6 years; P < .033). On multivariable analysis, radiation therapy was independently associated with risk of urethral atrophy (odds ratio 1.77, 95% confidence interval: 1.01-3.13; P = .046), whereas greater time between cancer therapy and incontinence surgery approached clinical significance (odds ratio 1.05, 95% confidence interval 1.00-1.09; P = .05). CONCLUSION History of radiation therapy and increasing length of time from prostate cancer treatment are associated with urethral atrophy before AUS placement.

Penile Plication as Salvage Strategy for Refractory Peyronie's Disease Deformities

Introduction: We identified clinical and/or surgical factors contributing to failure of penile plication for Peyronies reconstruction and assessed outcomes of repeat plications. Methods: We conducted a retrospective review of patients who underwent penile plication between 2007 and 2016. Plication was performed after inducing an artificial erection intraoperatively using corrective longitudinal 2‐zero Ethibond™ sutures placed systematically in a uniform manner without circumcision. Penile length, and angle and direction of curvature were recorded, along with number and location of plication sutures and clinical outcome. Results: Of 340 patients undergoing penile plication during the study period 7 (2.1%) underwent repeat plication for insufficient straightening. Two additional patients underwent salvage plication after initial surgery performed elsewhere. Median time to revision was 6 months (range 3.4 to 27.4). The most common clinical features at reoperation were severe erectile dysfunction in 5 cases (71%), multiplanar curvature in 5 (71%) and severe curvature (60 degrees or greater) in 3 (43%). Most revisions involved a greater number of sutures during revision (mean 9) compared to initial plication (6), and in 4 cases (44%) sutures were placed on the proximal shaft. After revision all cases were noted to be functionally straight, with a mean postoperative curvature of 4 degrees (range 0 to 20) at a median followup of 27 months (3 to 76). Conclusions: Inadequate correction of Peyronies disease curvature by penile plication is rare but salvageable by a second plication procedure. Poor erectile response to intracavernous injection intraoperatively may mask the severity of the deformity, thus leading to inadequate numbers of corrective sutures.

Permanent Bulbar Urethral Ligation: Emerging Treatment Option for Incontinent Men With End-stage Urethra

OBJECTIVE To report our experience with permanent urethral ligation for severe incontinence among men with end-stage urethra. MATERIALS AND METHODS From our institutional artificial urinary sphincter database of 512 patients from 2010 to 2016, 10 men underwent permanent urethral ligation with concurrent suprapubic tube diversion following recurrent artificial urinary sphincter cuff erosion. Clinical characteristics and outcomes were evaluated. Quality of life was assessed using the Michigan Incontinence Symptom Index and the Patient Global Index of Improvement. RESULTS Urethral ligation resulted in resolution of incontinence in 8 men (80%), including 7 (70%) after 1 surgery and in 1 (10%) after a single revision. The average American Society of Anesthesiologists physical status rating was 2.7 (range 2-3). Seven patients (70%) experienced postoperative complications (4 Clavien-Dindo grade II complications [1 Clostridium difficile infection, 3 refractory bladder spasms) and 5 grade III complications (2 abscesses, 2 urethrocutaneous fistula, and 1 bladder stone formation]). Overall, satisfactory Michigan Incontinence Symptom Index urinary scores were reported in 8 (80%) men. On the Patient Global Index of Improvement, 6 (60%) men reported improvement in overall condition following surgery. All men (10/10) stated that they would recommend this procedure to others. CONCLUSION For debilitated men with end-stage urethra and severe refractory stress urinary incontinence, permanent urethral ligation with chronic suprapubic tube drainage can restore continence and improve quality of life without the need for more invasive formal urinary diversion, though with a high risk of complication.

Expanding Applications of Renal Mobilization and Downward Nephropexy in Ureteral Reconstruction

OBJECTIVE To evaluate renal mobilization with downward nephropexy as an adjunct maneuver to facilitate various methods of reconstruction of the upper urinary tract with limited ureteral length. MATERIALS AND METHODS We retrospectively reviewed all upper urinary tract reconstructive procedures performed from 2007 to 2015 to identify those requiring downward renal mobilization with nephropexy. Data including concomitant maneuvers, stricture location, prior surgeries, and intraoperative details were analyzed. Success rates, defined by resolution of symptoms and avoidance of further intervention, and complications were evaluated. RESULTS Of 92 patients undergoing ureteral reconstruction during the study period, 18 (19.6%) involved renal mobilization with downward nephropexy to gain additional ureteral length (5/7 [71.4%] of ureterocalycostomies, 8/26 [30.1%] of Boari flap bladder reconfigurations, 4/12 [33.3%] of ureteroureterostomies, and 1/12 [8.3%] of ileal ureters). Two-thirds of patients (12/18, 66.7%) had undergone unsuccessful prior open, laparoscopic, or endoscopic reconstruction attempts. Renal mobilization was performed open in 15/18 (83.3%) cases and laparoscopically in 3/18 (16.7%). After renal mobilization, the average distance of downward movement achieved was 3.3 cm (range 3-5 cm). With a mean follow-up of 50.4 months (range 3-87 months), overall success rate defined as ureteral patency was 88.9%, with 2/18 patients (11.1%) requiring a subsequent nephrectomy for failed upper tract reconstruction and persistent symptomatic hydronephrosis. CONCLUSION Downward renal mobilization and nephropexy is a safe and versatile technique that can be effectively combined with many other reconstructive maneuvers.

CHANGING TRENDS IN RECONSTRUCTION OF COMPLEX ANTERIOR URETHRAL STRICTURES: FROM SKIN FLAP TO PERINEAL URETHROSTOMY

OBJECTIVE To evaluate procedural trends and outcomes for reconstruction of complex strictures at our tertiary center over the last decade. METHODS We retrospectively reviewed complex urethral reconstruction comparing 3 techniques: (1) buccal mucosal graft (BMG), (2) penile skin flap, or (3) perineal urethrostomy (PU) at our center (2007-2017) with ≥6 months follow-up. Strictures amenable to anastomotic repair were excluded. Success was defined as no need for further operative management. RESULTS Among 1129 strictures cases, 403 complex strictures were identified for analysis (median length 4.5 cm). Median age was 53.2 years (standard deviation ± 14.9). Reconstruction was most commonly performed using BMG (61.3%), followed by penile skin flap (21.6%) and PU (19.1%). PU use has increased steadily over the past decade, rising from 4.3% of case volume in 2008 to 38.7% in 2017 (P = .01). Over time, the proportion of reconstruction using BMG has remained stable, while penile skin flaps are now less commonly utilized. Over a median follow-up of 50.7 months, 16.9% (68/403) patients failed at a median of 13.9 months. Success rates were higher following PU (94.8%) compared to BMG and skin flaps (78.5% and 78.2%, respectively) (P = .003) despite PU patients being older (median age 62.6 years), having longer strictures (median 5.0 cm) and more commonly having lichen sclerosus (LS) (22.1%). CONCLUSION Over a decade of a urethral reconstructive practice, PU has increasingly become preferred for older patients with long strictures and adverse etiology. BMG urethroplasty rates remain stable, while penile skin flap use is decreasing. Success rates of PU for these complex strictures are markedly higher than those of grafts and flaps.

Improving Male Sling Selectivity and Outcomes—A Potential Role for Physical Demonstration of Stress Urinary Incontinence Severity?

Introduction: We reviewed our 9‐year experience with AdVance™ Male Sling System cases to determine clinical features associated with treatment success and to refine procedure selectivity. We hypothesized that preoperative physical demonstration of stress urinary incontinence by the standing cough test improves patient selection for male sling surgery. Methods: Retrospective review of primary AdVance sling surgeries between 2008 and 2016 was performed. Patients without standing cough test results were excluded from study. Success was defined as 1 pad per day or less postoperatively and no further intervention. Standing cough test was performed during preoperative consultation and objectively graded using the MSIGS (Male Stress Incontinence Grading Scale). Results: Of the 203 male patients who underwent sling placement 80 (39%) experienced treatment failure during a median followup of 63.5 months. From 2008 to 2016 the proportion of AdVance slings performed as a surgical treatment modality for stress urinary incontinence decreased from 66% to 13%. Increasing selectivity correlated with greater treatment success. Success was greater among men using 2 pads per day or less preoperatively (77% vs 36%, p <0.0001), having physical findings of mild stress urinary incontinence (MSIGS grade 0‐2 on standing cough test, 67% vs 26%, p <0.0001) and without a history of radiation (64% vs 41%, p=0.02). In combination, men without prior radiation with mild stress urinary incontinence and favorable standing cough test were “ideal patients” with an 81% success rate. Incremental increases in pad per day use (OR 1.8 per pad, p <0.0001) and MSIGS grade (OR 1.7 per grade, p=0.005) were independently associated with treatment failure. Conclusions: Increasing selectivity has improved sling outcomes for men with stress urinary incontinence. Ideal sling candidates have not received radiation therapy, and have history and physical findings suggestive of mild stress urinary incontinence.