Jeremy Tonkin

Management of distal anterior urethral strictures

Management of men with anterior urethral stricture disease is a relatively common issue faced by practicing urologists today. Anterior urethral strictures, which can be the result of congenital, idiopathic, iatrogenic or inflammatory causes, can affect patients of all ages and might present as some or all of the following disorders: difficulty with voiding, urinary tract infection, acute urinary retention and high bladder emptying pressures. A thorough understanding of the urethral anatomy and etiology of the stricture followed by effective treatment are crucial if successful outcomes for the patient are to be achieved. Historically, urologists viewed open repair as an option that should only be offered to patients who had failed to respond to repeated endoscopic treatments—the so-called reconstructive ladder. This dogma has, however, been scrutinized; urologists should be aware that this process may subject patients to repeated procedures with a low success rate, such as dilatation and internal urethrotomy, rather than one potentially curative operation, such as graft or flap urethroplasty.

Penile Prosthesis Implantation in Patients with a History of Total Phallic Construction

INTRODUCTION Outcomes following penile prosthesis implantation in patients with a history of total phallic construction are not well described. AIM The aim of this study was to evaluate outcomes following neophallus penile prosthesis placement. METHODS Retrospective review penile prosthesis placement in patients with prior total phallic construction. GORE-TEX® (Gore Medical, Flagstaff, AZ) sleeve neotunica construction was utilized in all patients. MAIN OUTCOME MEASURE Success defined as patient sexual activity with a functioning prosthesis. RESULTS Thirty-one patients underwent neophallic prosthesis implantation at a mean 35.6 years of age. Prosthesis placement occurred at an average 56.3 months following phallic construction and follow-up was a mean of 59.7 months. Malleable prostheses were placed in 21 patients and inflatable in 10; implants were bilateral in 94%. Six percent experienced operative complications including a bladder injury (1) and phallic flap arterial injury (1). Postoperative complications occurred in 23% at a median 5.5 months following placement. Five prostheses were explanted secondary to infection or erosion and two additional required revisions. Of the explanted prosthesis two were later replaced without further complication. Eighty-one percent of patients were sexually active following prosthesis placement. CONCLUSIONS Penile prosthesis placement is possible in patients with prior penile reconstruction/phallic construction. Although complications rates appear to be elevated in this population compared with historic controls of normal anatomic men, the majority of patients in this series were sexually active following prosthesis placement. This demonstrates the utility of prosthesis implantation in these difficult patients.

Penile Amputation: Cosmetic and Functional Results

INTRODUCTION Penile amputation is a rare type of external genital trauma. It may arise from accidental trauma, assault or self-inflicted mutilation. As with all trauma, initial management focuses on assessment and resuscitation of the patient. When available, hypothermic preservation of the detached penis should be undertaken. AIM This review serves to compile the current available information on etiology and management of penile amputation injuries, with focus on functional and cosmetic results. MAIN OUTCOME MEASURES Main outcome measures were penile cosmetics, viability, and sensation; urethral patency and graft survival, functionality. METHODS A literature search using Medline, PubMed (U.S. National Library of Medicine and the National Institutes of Health), and abstracts from scientific meetings was performed from 1980-2013. RESULTS Due to the rarity of penile amputation injuries, no randomized trials exist. Likewise, available published series on management of this condition are comprised of a small number of patients. CONCLUSIONS Penile amputation is rare but challenging. Current microreplantation procedures have a uniformly good result with a minimum number of post-operative complications. When microreplantation cannot be performed, older corporal reattachment techniques may be offered. When phallic reconstruction is required, a microsurgical free forearm flap phalloplasty may be performed to restore the patient with an acceptable cosmetic and functional phallus. Virasoro R, Tonkin JB, McCammon KA, and Jordan GH. Penile amputation: Cosmetic and functional results. Sex Med Rev 2015;3:214-222.

Augmented perineal urethrostomy using a dorsal buccal mucosal graft, bi-institutional study

PurposeTo present our technique and outcomes for perineal urethrostomy augmented with a dorsal onlay buccal mucosa graft (BMG). Results from initial series and collaboration from an international center are included.MethodsA retrospective chart review of all adult patients who underwent urethral reconstruction with perineal urethrostomy utilizing a buccal mucosal graft between January 1, 2002 and January 1, 2013 was performed. All surgeries were performed by three surgeons using the same technique (GHJ, KAM, and RV). Success was defined as no need for additional treatment following definitive surgery.ResultsA total of 44 patients met inclusion criteria. Mean patient age was 60 (range 44–81) years. All strictures were pananterior. Etiologies included unknown in 16 (36%), failed hypospadias repair in six (14%), lichen sclerosus in ten (23%), iatrogenic in seven (16%), Fournier’s in three (7%), urethral cancer in one (2%) and penile cancer in one (2%). Mean follow-up was 45 (range 6–136) months. Overall success was 80%. Nine patients recurred, of which four had a successful revision, two are awaiting potential revision, and three are being managed with periodic dilations.ConclusionsBMG perineal urethrostomy is a valid alternative for complex urethral strictures due to lichen sclerosus, previous failed reconstructions or hypospadias cripples. Midterm results are encouraging for this novel technique.

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.

COMPLICATIONS ASSOCIATED WITH MINIMALLY INVASIVE SURGERY FOR PELVIC ORGAN PROLAPSE (POP)

maintained in 28/29 (95.5%) patients. Four patients showed de novo urinary incontinence (3 # stress urinary incontinence SUI, and 1 # urgency incontinence -UI). Thirty-nine of 47 patients (82.97%) were satisfied. No one develop pelvic neoplasms. CONCLUSIONS: Long-term follow-up showed that uterus sparing surgery seems to be feasible and safe in women who wants to preserve the integrity of vaginal function and to be satisfied with their self image of body. We should always advise them about the risks of pregnancy and delivery and the need for a long-term follow-up to rule out malignant disease.