Ramon Virasoro

Management of recurrent anastomotic stenosis following radical prostatectomy using holmium laser and steroid injection

To present our experience with the management of recurrent and resistant anastomotic stenosis following radical prostatectomy (RP) using transurethral laser incision of the stenotic area and injection of steroids.

Comparing Taguchi and Lich-Gregoir Ureterovesical Reimplantation Techniques for Kidney Transplants

PURPOSE We compared the incidence of urological and anastomotic complications, and the duration of ureteral reimplantation for the Taguchi and Lich-Gregoir techniques. MATERIALS AND METHODS We recorded all urological and anastomotic complications that developed from the date of transplantation through December 31, 2001. The cutoff date for transplantation was August 30, 2000. The urological complications evaluated included complicated hematuria, urinary fistula, ureteral stenosis, symptomatic vesicoureteral reflux and operative time. The chi-square test was done to compare the proportion of complications in the groups and the Mann Whitney test was used to compare the duration of ureteral reimplantation. RESULTS Of the 575 transplants evaluated 416 and 159 were performed via the Lich-Gregoir and Taguchi techniques, respectively. The incidence of anastomotic complications was 10.7%. Complications in the Lich-Gregoir group included fistula in 4.7% of cases, stenosis in 4.1%, symptomatic vesicoureteral reflux in 1.9% and complicated hematuria in 0.5%. Complications in the Taguchi group included urinary fistula in 6.3% of cases, stenosis in 2.5% and complicated hematuria in 2.5%. Symptomatic reflux was not observed in this group. There was a higher proportion of hematuria at the limit of statistical significance in the Taguchi group (p = 0.05). There were a higher number of urological complications in transplants from live donors in the Lich-Gregoir group (p = 0.01), mostly involving fistula (p = 0.05). There were no significant differences in the groups in overall complications. Average operative time for the Taguchi and Lich-Gregoir techniques was 14.2 and 29 minutes, respectively. This difference was significant (p = 0.02). CONCLUSIONS In the sample studied Taguchi ureterocystoneostomy proved to be a more rapid method without increasing the incidence of urological or anastomotic complications. There were no cases of symptomatic reflux in the Taguchi group and select fistula cases could be managed conservatively. The Lich-Gregoir cohort was at greater risk for the urological complications of live donor transplantation. The Taguchi method has become the ureterovesical reimplantation technique of choice in our setting.

SIU/ICUD Consultation on Urethral Strictures: Anterior Urethra—Lichen Sclerosus

We reviewed the current literature on lichen sclerosus as it related to urethral stricture disease using MEDLINE and PubMed (U.S. National Library of Medicine, National Institutes of Health) up to the current time. We identified 65 reports, 40 of which were considered relevant and form the basis of this review. Lichen sclerosus is now the accepted term, and balanitis xerotica obliterans is no longer acceptable. This common chronic inflammatory skin condition, mainly affecting the genitalia, remains an enigma, with uncertain etiology, varied presentation, and multiple treatments. In the early stages of the condition, a short course of steroids may be beneficial for some patients. If persistent, patients need long-term surveillance because of the potential development of squamous cell carcinoma. If diagnosed early, lichen sclerosus can be controlled, preventing progression. But once the disease has progressed, it is very difficult to treat. Surgical treatment by circumcision can be curative if the disease is treated early when still localized. Once progression to urethral involvement has occurred, treatment is much more difficult. Meatal stenosis alone is likely to require meatotomy or meatoplasty. Treatment of the involved urethra requires urethroplasty. Single-stage and multiple-stage procedures using oral mucosa have both been reported to give acceptable results, but the use of skin, genital or nongenital, is not recommended, because being skin, it remains prone to lichen sclerosus. With extensive disease, affecting the full length of the urethra, consideration should be given to perineal urethrostomy. A significant number of patients may prefer this simpler option.

Long-term follow-up for reconstruction of strictures of the fossa navicularis with a single technique

In a paper from the USA the authors describe their experience with the ventral transverse skin island flap elevated on a dartos fascia flap for reconstructing strictures of the fossa navicularis. They found it to be effective, with good functional and aesthetic results.

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.

Rectourethral Fistulas Secondary to Prostate Cancer Treatment: Management and Outcomes from a Multi-Institutional Combined Experience

Purpose: Rectourethral fistula is a known complication of prostate cancer treatment. Reports in the literature on rectourethral fistula repair technique and outcomes are limited to single institution series. We examined the variations in technique and outcomes of rectourethral fistula repair in a multi‐institutional setting. Materials and Methods: We retrospectively identified patients who underwent rectourethral fistula repair after prostate cancer treatment at 1 of 4 large volume reconstructive urology centers, including University of California‐San Francisco, University College London Hospitals, Lahey Clinic and Devine‐Jordan Center for Reconstructive Surgery, in a 15‐year period. We examined the types of prostate cancer treatment, technical aspects of rectourethral fistula repair and outcomes. Results: After prostate cancer treatment 201 patients underwent rectourethral fistula repair. The fistula developed in 97 men (48.2%) after radical prostatectomy alone and in 104 (51.8%) who received a form of energy ablation. In the ablation group 84% of patients underwent bowel diversion before rectourethral fistula repair compared to 65% in the prostatectomy group. An interposition flap or graft was placed in 91% and 92% of the 2 groups, respectively. Concomitant bladder neck contracture or urethral stricture developed in 26% of patients in the ablation group and in 14% in the prostatectomy group. Postoperatively the rates of urinary incontinence and complications were higher in the energy ablation group at 35% and 25% vs 16% and 11%, respectively. The ultimate success rate of fistula repair in the energy ablation and radical prostatectomy groups was 87% and 99% with 92% overall success. Conclusions: Rectourethral fistulas due to prostate cancer therapy can be reconstructed successfully in a high percent of patients. This avoids permanent urinary diversion in these complex cases.

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.

Urethroplasty after urethral urolume stent: an international multicenter experience

OBJECTIVE To evaluate the outcomes and factors affecting success of urethroplasty in patients with stricture recurrence after Urolume urethral stent. MATERIAL AND METHODS This is a retrospective international multicenter study on patients treated with urethral reconstruction after Urolume stent. Stricture and stent length, time between urethral stent insertion and urethroplasty, age, mode of stent retrieval, type of urethroplasty, complications and baseline, and posturethroplasty voiding parameters were analyzed. Successful outcome was defined as standard voiding, without need of any postoperative adjunctive procedure. RESULTS Sixty-three patients were included. Stent was removed at urethroplasty in 61 patients. Reconstruction technique was excision and primary anastomosis in 14 (22.2%), dorsal onlay buccal mucosa graft (BMG) in 9 (14.3%), ventral onlay BMG in 6 (9.5%), dorsolateral onlay BMG in 9 (14.3%), ventral onlay plus dorsal inlay BMG in 3 (4.8%), augmented anastomosis in 5 (7.9%), pedicled flap urethroplasty in 6 (9.5%), 2-stage procedure in 4 (6.4%), and perineal urethrostomy in 7(11.1%). Success rate was 81% at a mean 59.7 ± 63.4 months. Dilatation or internal urethrotomy was performed in 10 (15.9%) and redo-urethroplasty in 5 (7.9%). Total International Prostate Symptom Score, quality of life, urine maximum flow, and postvoid residual significantly improved (P <.0001). Complications occurred in 8 (12.7%), all Clavien-Dindo ≤2. Disease-free survival rate after reconstruction was 88.1%, 79.5%, and 76.7% at 1, 3, and 5 years, respectively. Explant of individual strands followed by onlay BMG is the most common approach and was significantly advantageous over the other techniques (P = .018). CONCLUSION Urethroplasty in patients with Urolume urethral stents is a viable option of reconstruction with a high success rate and very acceptable complication rate. Numerous techniques are viable; however, urethral preservation, tine-by-tine stent extraction, and use of BMG augmentation produced significantly better outcomes.

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.