Urethral Plate Research Articles

TOOme: A novel computational framework to infer cancer tissue-of-origin by integrating both gene mutation and expression.

3591 Background: Metastatic cancers require further diagnosis to determine their primary tumor sites. However, the tissue-of-origin for around 5% tumors could not be identified by routine medical diagnosis according. With the development of machine learning techniques and the accumulation of big cancer data from TCGA and GEO, it is now feasible to predict cancer tissue-of-origin by computational tools. Methods: Developed a computational framework to infer tumor tissue-o. Results: Applied TOOme to the TCGA data containing 7,008 non-metastatic samples across 20 solid tumors including BLCA, BRCA, CESC, COAD, GBM and so on. 74 genes by gene expression profile and 6 genes by gene mutation are selected by the random forest process, which can be divided into two categories: (1) cancer type specific genes, which are highly expressed or mutated only in one specific cancer and (2) those expressed or mutated in several cancers with different levels of expression or mutation rates. Function analysis indicates that the selected genes are significantly enriched in gland development, urogenital system development, hormone metabolic process, thyroid hormone generation prostate hormone generation and so on. According to the multiple-label classification method, random forest performs the best with a 10-fold cross-validation prediction accuracy of 96%. We also use the 19 metastatic samples from TCGA and 256 cancer samples downloaded from GEO as independent testing data, for which TOOme achieves a prediction accuracy of 89%. The cross-validation validation accuracy is better than those using gene expression (i.e., 95%) and gene mutation (83%) alone. Conclusions: TOOme provides a quick yet accurate alternative to traditional medical methods in inferring cancer tissue-of-origin. In addition, the methods combining somatic mutation and gene expressions outperform those using gene expression or mutation alone.

TOOme: A Novel Computational Framework to Infer Cancer Tissue-of-Origin by Integrating Both Gene Mutation and Expression.

Metastatic cancers require further diagnosis to determine their primary tumor sites. However, the tissue-of-origin for around 5% tumors could not be identified by routine medical diagnosis according to a statistics in the United States. With the development of machine learning techniques and the accumulation of big cancer data from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO), it is now feasible to predict cancer tissue-of-origin by computational tools. Metastatic tumor inherits characteristics from its tissue-of-origin, and both gene expression profile and somatic mutation have tissue specificity. Thus, we developed a computational framework to infer tumor tissue-of-origin by integrating both gene mutation and expression (TOOme). Specifically, we first perform feature selection on both gene expressions and mutations by a random forest method. The selected features are then used to build up a multi-label classification model to infer cancer tissue-of-origin. We adopt a few popular multiple-label classification methods, which are compared by the 10-fold cross validation process. We applied TOOme to the TCGA data containing 7,008 non-metastatic samples across 20 solid tumors. Seventy four genes by gene expression profile and six genes by gene mutation are selected by the random forest process, which can be divided into two categories: (1) cancer type specific genes and (2) those expressed or mutated in several cancers with different levels of expression or mutation rates. Function analysis indicates that the selected genes are significantly enriched in gland development, urogenital system development, hormone metabolic process, thyroid hormone generation prostate hormone generation and so on. According to the multiple-label classification method, random forest performs the best with a 10-fold cross-validation prediction accuracy of 96%. We also use the 19 metastatic samples from TCGA and 256 cancer samples downloaded from GEO as independent testing data, for which TOOme achieves a prediction accuracy of 89%. The cross-validation validation accuracy is better than those using gene expression (i.e., 95%) and gene mutation (53%) alone. In conclusion, TOOme provides a quick yet accurate alternative to traditional medical methods in inferring cancer tissue-of-origin. In addition, the methods combining somatic mutation and gene expressions outperform those using gene expression or mutation alone.

Cosmetic and functional outcome for the use of stitch by stitch technique in hypospadias surgery; results of 235 patients

One of the essential goals of hypospadias surgery is to create a cosmetically and functionally accepted penis with a near-normal looking glans and external meatus. We developed our technique stitch by stitch to allow glans closure in a conical manner with centrally located external urethral meatus in hypospadias repair using onlay flap. A total of 235 hypospadias male patients (0.5-30 years old) were included in the study. All of them treated by flap urethroplasty techniques and meatoglanuloplasty using stitch by stitch technique. Operative technique (described in details by illustrations); starts with penile degloving, preparation of the flap (Site of hypospadic meatus is determined after degloving). Creation of a narrow strip of the urethral plate with wide glanular wings is done using bilateral incisions which are extended to the tip of the glans. The width of the urethral plate is about 3mm then we suture the flap to the narrow urethral plate in two layers in continuous manner using vicryl 6/0 over a suitable plastic catheter. Triangular (V shape) area of the distal part of the flap is excised at the midline. After this we anastomose the flap to the tip of the glans. The glans appears opened in the midline as inverted V shape. Closure of the glans is finished in the midline using three mattress interrupted sutures with another three simple stitches are used in between. From February 2007 to December 2016; 235 hypospadias patients fulfilled criteria and were included in our prospective cohort study table (1). The meatoplasty technique and stitch-by-stitch glans closure were used in all patients. Excellent results were achieved with an overall degree of satisfaction of 87% in patients older than six years (based on the Pediatric Penile Perception Score), and 84% in patients younger than six years. The complication rate was low at 8.5% and was related to a failure of the flap technique. Many surgical techniques have been described for glans closure and meatoplasty with variable outcomes, but none of them fits all patients with hypospadias; each procedure has its limitations and demands specific selection criteria. Limitations of this study come from a relatively short follow-up, and a single surgeon experience that needs to be reproduced by other surgeons. Meatoglanuloplasty using stitch-by-stitch technique provides satisfactory cosmetic and functional results in hypospadias patients.

Outcomes of preputioplasty in patients undergoing TIP urethroplasty (tubularization of incised urethral plate) for distal and mid penile hypospadias

Preputioplasty as a part of hypospadias repair restores the normal appearance of phallus, which is especially important in distal and mid penile hypospadias. However possibility of its inherent complications such as iatrogenic phimosis or preputial breakdown are the cause of controversy and reluctance regarding this procedure.This study evaluates the results of preputial reconstruction with TIP urethroplasty in distal and mid penile hypospadias repair and analyses if preputioplasty may be offered to these patients. In this prospective observational study, 48 cases of distal and mid penile hypospadias underwent TIP urethroplasty and preputioplasty and results were assessed at 2 weeks, 3 months and 6 months. Major complications included preputial dehiscence, tight prepuce (iatrogenic phimosis) and minor complications included ventral tethering, persistent dorsal whorls and redundant prepuce. Data was analysed with Microsoft Excel spreadsheet where descriptive statistics were obtained. Preputioplasty was performed in 48 children with a mean age of 5.1 years. Preputioplasty dehiscence was seen in three (6%) patients, which gave an appearance of irregular prepuce on 6m follow up. Two patients (4%) were confirmed to have preputial tightness at 3 months but this resolved conservatively in one patient and only one patient (2%) required circumcision for a tight prepuce. Minor complications included ventral tethering, persistence of dorsal whorls and redundant prepuce. Ventral tethering was present in 3 patients (6.25%). Redundant prepuce was observed in 2 patients (4.16%). Additionally, unsightly dorsal whorls were found to be persistent in 2 children (4.16%). None of these patients opted for circumcision. The rest of the children had a cosmetically and functionally normal prepuce. Two patients (4%) developed urethrocutaneous fistula at 3 months' follow-up. Preputial reconstruction is feasible with a good cosmetic outcome and minimal complications in patients of distal and mid penile hypospadias undergoing TIP urethroplasty. Mild preputial tightness evolves over time and resolves with conservative measures. In patients with very prominent dorsal whorls and underlying bulky tissues the preputioplasty does not appear to be of satisfactory cosmesis. To help the patient and parents take a well informed decision, it would be useful to explain all possible major and minor foreskin complications, and their rectification.

Urogenital Abnormalities in Adenosine Deaminase Deficiency

BackgroundImproved survival in ADA-SCID patients is revealing new aspects of the systemic disorder. Although increasing numbers of reports describe the systemic manifestations of adenosine deaminase deficiency, currently there are no studies in the literature evaluating genital development and pubertal progress in these patients.MethodsWe collected retrospective data on urogenital system and pubertal development of 86 ADA-SCID patients followed in the period 2000–2017 at the Great Ormond Street Hospital (UK) and 5 centers in Italy. In particular, we recorded clinical history and visits, and routine blood tests and ultrasound scans were performed as part of patients’ follow-up.Results and DiscussionWe found a higher frequency of congenital and acquired undescended testes compared with healthy children (congenital, 22% in our sample, 0.5–4% described in healthy children; acquired, 16% in our sample, 1–3% in healthy children), mostly requiring orchidopexy. No urogenital abnormalities were noted in females. Spontaneous pubertal development occurred in the majority of female and male patients with a few cases of precocious or delayed puberty; no patient presented high FSH values. Neither ADA-SCID nor treatment performed (PEG-ADA, BMT, or GT) affected pubertal development or gonadic function.ConclusionIn summary, this report describes a high prevalence of cryptorchidism in a cohort of male ADA-SCID patients which could represent an additional systemic manifestation of ADA-SCID. Considering the impact urogenital and pubertal abnormalities can have on patients’ quality of life, we feel it is essential to include urogenital evaluation in ADA-SCID patients to detect any abnormalities, initiate early treatment, and prevent long-term complications.

Evaluation of double-folded meatal-based flap (modified Mathieu) in redo circumcised distal penile hypospadias: a prospective multicenter study

BackgroundSometimes it becomes a dilemma to repair a failed circumcised distal penile hypospadias with partial or complete wound dehiscence. In many of these cases, redo operations need a graft or a flap. The aim of this study is to evaluate the double-folded meatal-based flap in redo circumcised hypospadias with shallow urethral plate and a small glans penis.ResultsFrom September 2015 to August 2018, we prospectively studied the double-folded meatal-based flap in 56 failed circumcised distal hypospadias without penile curvature with shallow urethral plate and a small glans penis. Distally folded Mathieu flap was done. Forty-seven cases only had completed the study. We had 19 patients with distal penile hypospadias, 19 with sub-coronal hypospadias, and 9 with coronal hypospadias. Median operative time was 50 (range 40–80 min). The median length of the double-folded flap was 14 (range 10–18 mm). The median follow-up was 12 (range 1–33 months). The success of the operation means that there is an absence of any complications. Our success rate was 73%. We had 8 patients with meatal retraction, one fistula, and one patient with wound disruption. Only 3 patients (6.4%) needed re-operation: one case with meatal retraction, another with fistula, and a third with complete wound disruption.ConclusionDistally folded meatal-based flap is an additional option in redo circumcised hypospadias with shallow urethral plate, small glans penis, and pliable anterior penile skin with a considerable high percent of meatal recession.

V09-11 WATCH SHAPED BUCCAL MUCOSA GRAFT FOR SIMULTANEOUS CORRECTION OF SEVERE CHORDEE AND URETHROPLASTY AS A ONE STAGE REPAIR OF SCROTAL HYPOSPADIAS

You have accessJournal of UrologyPediatrics (V09)1 Apr 2020V09-11 WATCH SHAPED BUCCAL MUCOSA GRAFT FOR SIMULTANEOUS CORRECTION OF SEVERE CHORDEE AND URETHROPLASTY AS A ONE STAGE REPAIR OF SCROTAL HYPOSPADIAS Miroslav Djordjevic*, Abdulmuttalip Simsek, Marta Bizic, Borko Stojanovic, Joshua Roth, and Rajveer Purohit Miroslav Djordjevic*Miroslav Djordjevic* More articles by this author , Abdulmuttalip SimsekAbdulmuttalip Simsek More articles by this author , Marta BizicMarta Bizic More articles by this author , Borko StojanovicBorko Stojanovic More articles by this author , Joshua RothJoshua Roth More articles by this author , and Rajveer PurohitRajveer Purohit More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000923.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Severe hypospadias repair still presents a great challenge. We evaluated a novel approach of using a specially shaped buccal mucosa graft for simultaneous ventral tunica grafting and new urethral plate creation in combination with a longitudinal dorsal island skin flap for a one-stage repair of severe hypospadias. METHODS: A 14-month-old boy underwent scrotal hypospadias repair. The short and non-elastic urethral plate is divided. Buccal mucosa graft is harvested from the inner cheek, and designed in a special “watch” shape, with the spherical part in the middle and two rectangular parts on both sides. The tunica albuginea is opened ventrally for penile straightening and grafted to the spherical part of the "watch-shaped" buccal mucosa with 6-8 “U-shape” stitches. The rectangular parts are fixed to the tip of the glans distally and native urethral meatus proximally. A longitudinal dorsal skin flap is harvested, button-holed ventrally and joined with the buccal graft. Penile skin reconstruction is performed using available penile skin. RESULTS: Good appearance of the penis is achieved without residual chordee, urethral fistula or stricture. CONCLUSIONS: A watch shaped buccal mucosa graft for simultaneous curvature correction and urethroplasty could be a good choice for single stage repair of scrotal hypospadias with severe chordee. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e836-e836 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Miroslav Djordjevic* More articles by this author Abdulmuttalip Simsek More articles by this author Marta Bizic More articles by this author Borko Stojanovic More articles by this author Joshua Roth More articles by this author Rajveer Purohit More articles by this author Expand All Advertisement PDF downloadLoading ...

Possible pharmaceutical effect and active components in different parts of Eucommia ulmoides based on network pharmacology

The difference in pharmacological activities and active components between leaves, barks and flowers of Eucommia ulmoides(EU) are still unclear. However, clarifying the differences in pharmacological effects of different parts of EU is of great significance for the development of EU products, and their corresponding active components provide basis for quality control of different parts of EU. Based on the chemical compositions of different parts of EU, integrated strategy of target prediction and target analysis of the compounds was used to investigate the difference in the pharmacological effects of leaves, barks and followers. The "component-target-function" association network was constructed to mine the specific material basis corresponding to specific efficacy of different parts of EU. In this study, the author found that EU may have the activities of anti-oxidation, neuromodulation, blood pressure regulation, myo-cardial expansion, and anti-apoptosis according to target prediction and function analysis. However, the effects of different parts of EU were different. Leaves were involved in the process of bone development such as osteoblast differentiation and bone mineralization in a specific way. In addition, the leaves may affect the process of bone development by regulating the metabolism of vitamin D and affecting the absorption of calcium. Leaves may also specifically act on estrogen and estradiol response processes where estrogen receptors were involved. Regarding its protective function for the liver, leaves may play a role by regulating vitamin A-related pathways. As compared with leaves, the specific pharmacological effects of barks may be related to the development of the urinary system. Flowers specifically participate in functions related to pain sensation, glutamate signaling pathway, and excitatory postsynaptic potential. Based on the hie-rarchical network of "component-target-pathway", we further found that specific activities of different parts of EU were inseparable from its specific chemical compositions. Phenylpropanoids, terpenoids and rings, iridoids, flavonoids and other components which are specific in leaves can target the specific effects of leaves, while the flavonoids in barks and the quinones in flowers may be the material basis for their respective specific effects. The prediction of the activities of different parts of EU provides a new basis for the focuses and differences in subsequent Eucommia product development. At the same time, the material basis research based on differential efficacy also provides a basis for the quality control of Eucommia differentiated products.

Usual and Unexpected Variations in the Veins of the Posterior Abdomen: A Case Study

Two venous system components comprise the drainage of the posterior abdominal cavity. One component drains blood from the visceral derivatives of the urogenital ridge (e.g., kidneys, gonads) directly to the inferior vena cava (IVC). The other venous system collects blood from the body wall and drains into the azygos system through the subcostal vein, ascending lumbar vein, and lower posterior intercostal veins. Veins, and especially the azygos system, are notoriously variable. Much of this variability arises from the complex embryological development of the caval venous system in the thoracic and abdominopelvic cavities; but the formation of venous anastomoses representing multiple routes of drainage from a single region also contribute to the variability of veins.During routine dissection of the abdomen of a male cadaver (Caucasian, 67 years), the right testicular vein demonstrated multiple anatomical variations. An anomalous vein arising from several small tributaries at the lateral end of the 11th and 12th ribs was discovered during the dissection. This vein crossed the posterior abdominal wall inferomedially to drain into the right testicular vein. Further exploratory dissection revealed direct communication between the anomalous vein and the right 11th posterior intercostal vein, which could be traced from the origination of the anomalous vein to the connection with the azygos vein at the appropriate vertebral level. The anomalous vein represents an unusual route for collateral venous circulation between the azygos system and the caval system in the abdomen via the right 11th posterior intercostal vein. Additionally, the right testicular vein drained into the right renal vein instead of directly draining into the IVC. No other notable variations were observed in the abdominal vasculature. The left testicular vein, left renal vein, left posterior intercostal veins, and left subcostal vein all demonstrated typical merging patterns. Accompanying renal, testicular, and posterior intercostal arteries on the right side also appeared to have normal branching patterns.

V07-07 REVISION VAGINOPLASTY WITH ROBOTIC ASSISTANCE FOR NEOVAGINAL OBLITERATION SECONDARY TO RECURRENT RECTO-NEOVAGINAL FISTULA

You have accessJournal of UrologyLower-Tract Reconstruction II: ED/Infertility & Transgender Surgery (V07)1 Apr 2020V07-07 REVISION VAGINOPLASTY WITH ROBOTIC ASSISTANCE FOR NEOVAGINAL OBLITERATION SECONDARY TO RECURRENT RECTO-NEOVAGINAL FISTULA Alexandr Pinkhasov*, Kathryn Scott, Prashant Upadhyaya, Gennady Bratslavsky, and Dmitriy Nikolavsky Alexandr Pinkhasov*Alexandr Pinkhasov* More articles by this author , Kathryn ScottKathryn Scott More articles by this author , Prashant UpadhyayaPrashant Upadhyaya More articles by this author , Gennady BratslavskyGennady Bratslavsky More articles by this author , and Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000897.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To describe a case of neovagina revision following vaginal stenosis and complete obliteration in a patient 1 year post gender affirmation surgery. METHODS: The patient was a 23 year old transgender female who underwent combined penile and urethral inversion vaginoplasty in 2017. The initial postoperative course was complicated by unrecognized rectovaginal fistula formation. She subsequently underwent multiple repairs which impaired her ability to perform vaginal dilation. Dilations were stopped with eventual development of vaginal stenosis and ultimately obliteration. The patient underwent reconstruction with a combined perineal and robotic approach. The surgical steps included: 1) dissection of the urethral plate to be used in later neovaginal creation 2) robotic pelvic dissection; a plane between the prostate and rectum was developed for implantation of the neo-vagina 3) revision urethroplasty and meatal repositioning 4) creation of neovagina from local flaps; the ventral plate of the penile urethra was used to construct the anterior vaginal wall while the posterior was composed of excess scrotal skin in combination with perineal flaps 5) robotic fixation of neovagina. The reconstructed neo-vagina was inverted into the pelvis where robotic assisted dissection had developed a cavity. The neovagina was secured to the perivesical and peritoneal tissues. The patient underwent revision clitoroplasty and labioplasty for esthetic complaints. RESULTS: The patient was discharged on postoperative day 1 and vaginal packing removed on day 7. She was followed with regular exams and questionnaires. At two month follow-up she was performing vaginal dilations without difficulty or pain and by six months she was found to have a vaingal depth of 12 cm. On global response assessment survey she rated herself as “markedly improved” CONCLUSIONS: Revision vaginoplasty with neo-vaginal reconstruction may be used to correct complications related to prior fistula and/or cavity obliteration. A combined perineal and robotic approach is recommended to allow for careful dissection in a previously operated field. Source of Funding: N/A © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e645-e645 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexandr Pinkhasov* More articles by this author Kathryn Scott More articles by this author Prashant Upadhyaya More articles by this author Gennady Bratslavsky More articles by this author Dmitriy Nikolavsky More articles by this author Expand All Advertisement PDF downloadLoading ...

V06-04 NEW SURGICAL TECHNIQUE: INTRAURETHRAL TUBE IN TUBE PEDICLED PREPUTIAL FLAP FOR OBLITERATIVE STRICTURES

You have accessJournal of UrologyLower-Tract Reconstruction I: Sling/ Sphincter/ Penile & Urethral Reconstruction (V06)1 Apr 2020V06-04 NEW SURGICAL TECHNIQUE: INTRAURETHRAL TUBE IN TUBE PEDICLED PREPUTIAL FLAP FOR OBLITERATIVE STRICTURES Pankaj Joshi* and Sanjay Kulkarni Pankaj Joshi*Pankaj Joshi* More articles by this author and Sanjay KulkarniSanjay Kulkarni More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000885.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Management of Obliterative and recurrent long segment bulbar strictures is challenging. Few options exist such as double face urethroplasty or combined use of graft and flap. In majority of reported literature, the native urethra is excised and reconstruction is performed. This native urethra actually carries retrograde blood flow through bulbourethral arteries. We describe a new technique of preserving the native spongiosa and using it as cover for substitution decreasing the risk of diverticulum formation. METHODS: Ours is a tertiary care referral center for urethroplasty with experience of more than 4500 Urethroplasties in last 2 decades. This is a series of 3 patients operated between Jan 2019-March 2019.All had near Obliterative proximal bulbar stricture. Etiology was idiopathic in 1 patient and post TURP in 2 patients.2 patients had prior dorsal Onlay urethroplasties. RGU and MCU were performed. Perineal incision with ventral urethrotomy in proximal bulbar urethra was performed. The scarred urethral plate was excised. There was a gap of 3 cm between the healthy mucosal ends proximally and distally. Pedicled preputial flap was performed, transposed to perineum and tubularised over a 14 Fr Silicone catheter .The tube was anastomosed to the proximal urethral mucosa and then distally. The ventral urethrotomy which now had the spongiosa was closed over as a cover . RESULTS: Foleys catheter was kept for 6 weeks. On catheter removal, Uroflow was performed. Patients were followed up every 3 months with Uroflow, Ultrasound and urine culture .All 3 patients had good flow till last follow up.None of them developed infections.All complained of minimal post micturition dribbling. CONCLUSIONS: Obliterative redo urethral strictures merit reconstruction. Proximal post TURP strictures are not recommended to be treated with dorsal approach. Urethral substitution would require urethra transection, compromising the blood flow. This is a novel intraurethral tube in tube, flap technique which is vascular preserving and useful for management for such subset of patients. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e557-e557 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pankaj Joshi* More articles by this author Sanjay Kulkarni More articles by this author Expand All Advertisement PDF downloadLoading ...

V07-06 PROSTATO-NEOVAGINAL FISTULA REPAIR IN A PATIENT WITH PRIOR TRANSURETHRAL RESECTION OF THE PROSTATE

You have accessJournal of UrologyLower-Tract Reconstruction II: ED/Infertility & Transgender Surgery (V07)1 Apr 2020V07-06 PROSTATO-NEOVAGINAL FISTULA REPAIR IN A PATIENT WITH PRIOR TRANSURETHRAL RESECTION OF THE PROSTATE Rebecca Sager*, Daniela Kaefer, Natasha Ginzburg, and Dmitriy Nikolavsky Rebecca Sager*Rebecca Sager* More articles by this author , Daniela KaeferDaniela Kaefer More articles by this author , Natasha GinzburgNatasha Ginzburg More articles by this author , and Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000897.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Vaginoplasties for gender affirmation are becoming increasingly common and are reported to carry a risk of serious urological complications such as urethro-neovaginal fistulae. Our objective was to demonstrate a technique for repair of prostatic urethro-neovaginal fistula in a transgender female with prior transurethral resection of the prostate (TURP). METHODS: A 65-year-old transgender female presented with a complaint of severe incontinence and was diagnosed with a prostato-neovaginal fistula. She had undergone TURP for symptomatic benign prostatic hyperplasia (BPH) prior to penile inversion vaginoplasty at another institution. Following vaginoplasty, she had severe incontinence of urine after the initial vaginal packing removal. Cystoscopy and vaginoscopy identified fistulae from the urethra, just proximal to the verumontanum, to the neovagina. The options for repair were considered ensuring that the neovagina remained patent. Surgical technique: The urethra was dissected laterally away from neovagina, and the prostatic and membranous urethral plate was incised dorsally. An Asopa-type dorsal inlay urethroplasty with buccal mucosa graft was performed. The lateral urethral edges were rotated ventrally, approximated and the adjacent tissue flaps were brought over in layers to cover ventral urethral anastomosis. A 16 French urethral catheter and vaginal packing were left in place at the conclusion of the case. Patient was followed with imaging, cystoscopy and questionnaires. RESULTS: Voiding cystourethrogram was performed 3 weeks post-operatively with no evidence of fistula. On follow up visits at 4- and 8-months patient reported no recurrent incontinence, no difficulty with vaginal dilations or penetrative vaginal intercourse. Cystoscopy and pelvic exam at the 8-months follow-up demonstrated no evidence of fistula or stricture and no stress incontinence with cough or Valsalva. CONCLUSIONS: Surgical treatment of BPH by TURP prior to gender affirmation surgery in transgender female patients may lead to complicated fistulae in a setting of incompetent bladder neck. The close proximity of the neovaginal dissection to a thinned prostate capsule and external sphincter may predispose this group of patients to fistula formation and incontinence. Traditional interposition flaps such as gracilis could create significant bulk compromising the neovaginal space. Asopa-type urethroplasty with dorsal inlay of buccal mucosa graft and ventral urethral closure can be used for a novel application in repair of complex prostato-neovaginal fistula. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e644-e645 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rebecca Sager* More articles by this author Daniela Kaefer More articles by this author Natasha Ginzburg More articles by this author Dmitriy Nikolavsky More articles by this author Expand All Advertisement PDF downloadLoading ...

V07-05 GENDER-AFFIRMING METOIDIOPLASTY

You have accessJournal of UrologyLower-Tract Reconstruction II: ED/Infertility & Transgender Surgery (V07)1 Apr 2020V07-05 GENDER-AFFIRMING METOIDIOPLASTY Geolani Dy*, Miroslav Djordjevic, Kamran Sajadi, and Daniel Dugi Geolani Dy*Geolani Dy* More articles by this author , Miroslav DjordjevicMiroslav Djordjevic More articles by this author , Kamran SajadiKamran Sajadi More articles by this author , and Daniel DugiDaniel Dugi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000897.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Metoidioplasty involves release of clitoral attachments and local flap mobilization to create a small neophallus. Often combined with urethral lengthening, scrotoplasty and vaginectomy, this procedure may serve individuals who desire masculine-appearing genitalia and potential to stand to urinate while avoiding morbidity of an extra-genital flap-based phalloplasty. We describe our surgical approach and considerations for metoidioplasty. METHODS: Our metoidioplasty technique follows the Belgrade approach, utilizing overlapping labia minora flaps for ventral urethral reconstruction. Vaginectomy involves excision of all vaginal mucosa and colpocleisis, preserving an anterior vaginal wall flap for urethroplasty. After clitoral degloving, release of the suspensory ligament provides phallic length. Division of the urethral plate further detethers the phallus but leaves a dorsal urethral defect, to be reconstructed with a buccal mucosa or genital skin graft. The anterior vaginal wall flap is sutured to a labia minora flap to form the ventral urethra. Creation of a 16-French urethra and neomeatus precludes lengthening to the glans tip, but may produce a lower urethral complication rate in the long-term compared with more narrow reconstructions. The contralateral labia minora flap is used for ventral coverage of neophallus. Dorsal shaft skin reconstruction may be required. Two scrotoplasty options are described: the Belgrade technique, incorporating testicular implants during metoidioplasty; and the Ghent technique, our preferred approach, which involves supero-medial rotation of labia majora skin flaps to create an anterior scrotum. Perineorrhaphy creates a flat perineum. A second stage scrotoplasty with testicular implants V-Y scrotal advancement is offered 3 months later. RESULTS: The patient depicted in our video underwent metoidioplasty with urethral lengthening via buccal mucosa graft with ventral labia minora flap onlay, vaginectomy and first stage scrotoplasty. He had an improvement in phallic shaft length from 7 to 9.5 cm. There were no intraoperative or post-operative complications at 3 months follow-up. The patient is able to stand to void. CONCLUSIONS: Metoidioplasty is a gender affirming operation that offers preservation of erogenous sensation and potential to stand to void via a small neophallus. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e644-e644 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Geolani Dy* More articles by this author Miroslav Djordjevic More articles by this author Kamran Sajadi More articles by this author Daniel Dugi More articles by this author Expand All Advertisement PDF downloadLoading ...

MP65-16 CREATION OF A STANDARDIZED HYPOSPADIAS TEMPLATE IN THE ELECTRONIC MEDICAL RECORD

You have accessJournal of UrologyPediatrics: Hypospadias and Penile Surgery (MP65)1 Apr 2020MP65-16 CREATION OF A STANDARDIZED HYPOSPADIAS TEMPLATE IN THE ELECTRONIC MEDICAL RECORD Christopher Long*, Luis Braga, John Wiener, Mark Zaontz, and Melise Keays Christopher Long*Christopher Long* More articles by this author , Luis BragaLuis Braga More articles by this author , John WienerJohn Wiener More articles by this author , Mark ZaontzMark Zaontz More articles by this author , and Melise KeaysMelise Keays More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000940.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The lack of standardized reporting in hypospadias limits quality improvement and comparative effectiveness research. Variability in surgical decision making and reported complication rates in hypospadias surgery warrants further study to improve care delivery outcomes. Barriers to collaboration include small patient number, single institution efforts, and variability in patient assessment and reporting. Our goal was to create a document that could be shared across institutions, standardizing the documentation process. METHODS: A review of currently existing hypospadias scoring systems, data collection forms from existing registries (INSPIRE, HOLD) and expert opinion identified various datapoints for documentation. Expert feedback was obtained to determine necessary elements for surgical billing, a complete operative note and data elements for hypospadias reporting. Collaboration with an electronic health record (EHR) vendor established reportable data elements. A standardized clinical documentation form was created for preoperative measurements, intra-operative details and post-operative follow-up was created. RESULTS: An EHR standardized document was created for both documentation and research purposes (Figure 1). The operative note includes the type of repair, the planned intervention, type of anesthesia. The initial operative assessment includes the location of the urethral meatus, associated scrotal anomalies, the presence and degree of penile curvature, and the quality of the urethral plate. Specifics for orthoplasty, glansplasty, and urethroplasty are captured. Further granular details such as suture utilization, use of barrier layers, and duration of stent placement amongst others are also included, if the user elects to utilize them. The follow up note includes both functional and cosmetic assessment, reporting complications in a standardized fashion. CONCLUSIONS: This template standardizes the documentation of both intraoperative and follow up patients with hypospadias; it serves the dual purpose of clinical documentation and quality reporting. Furthermore, this will facilitate collaboration across institutions to improve the quality of the urologic literature. We present this work to foster broad utilization across centers. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e979-e980 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Long* More articles by this author Luis Braga More articles by this author John Wiener More articles by this author Mark Zaontz More articles by this author Melise Keays More articles by this author Expand All Advertisement PDF downloadLoading ...

MP65-14 FREE GRAFT VERSUS TUNNELED FLAP RECONSTRUCTION FOR STAGED PROXIMAL HYPOSPADIAS REPAIR

You have accessJournal of UrologyPediatrics: Hypospadias and Penile Surgery (MP65)1 Apr 2020MP65-14 FREE GRAFT VERSUS TUNNELED FLAP RECONSTRUCTION FOR STAGED PROXIMAL HYPOSPADIAS REPAIR Poone Shoureshi*, Casey Seideman, Aaron Bayne, and J. Christopher Austin Poone Shoureshi*Poone Shoureshi* More articles by this author , Casey SeidemanCasey Seideman More articles by this author , Aaron BayneAaron Bayne More articles by this author , and J. Christopher AustinJ. Christopher Austin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000940.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The optimal technique for correction of severe hypospadias remains highly debated, with varied complication rates. At our institution, patients with severe hypospadias have been managed with two-stage free graft and tunneled flap urethral reconstruction procedures. We present the results of these techniques at our institution. METHODS: We performed a cohort analysis examining all patients who underwent consecutive, two-stage hypospadias repair with either a preputial tunneled flap or free graft between May 2010 and August 2018. The tunneled flap technique involves correction of chordee with urethral plate division and primary glans reconstruction to create a normal appearing conical shaped glans. Then a buttonhole transfer of prepuce to the ventrum is done to complete the first stage. During the second stage the ventral prepuce is tubularized and then tunneled through the glans to an orthotopic location. Free graft procedures were performed with preputial grafts or buccal mucosa. RESULTS: Of 33 patients, 17 underwent tunneled flap and 16 free graft repair. The median time to follow up after the second stage procedure was 39.8 months (range 10.8 - 81.2) in the flap patients and 16.4 months (range 5.5 - 44.5) in graft patients. The median time to presentation of a complication postoperatively was 3.9 months (range 0.43 – 36.5) in the flap group and 0.56 (range 0.49 – 8.2). In the flap group, 11 patients required another intervention, and of those, 6 required more than one operation. In the graft group, 1 patient required an additional procedure. Flap patients were more likely to be re-operated on (64.7% versus 6.3%, p<0.001). There was no significant difference in post-operative complications between cohorts (64.7% of the buttonhole patients experienced complications versus 31.3% in the free graft patients, p =0.055). There was no significant difference between cohorts in regards to patient age, preoperative testosterone administration, postoperative meatus location, and degree of chordee. None of the pre-operative factors were independently associated with the probability of developing complications using the logistic regression model. There was a significant difference in the proportion of tunneled flaps performed by two attending physicians (35.3%) and the proportion of free grafts performed by two attending physicians (75%), p=0.0221. CONCLUSIONS: Free graft reconstruction is significantly associated with lower re-operation rates compared to tunneled flap repair. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e978-e979 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Poone Shoureshi* More articles by this author Casey Seideman More articles by this author Aaron Bayne More articles by this author J. Christopher Austin More articles by this author Expand All Advertisement PDF downloadLoading ...

Description of a new diminutive Hyloxalus (Anura: Dendrobatidae: Hyloxalinae)from the Magdalena Valley of Colombia.

Using different sources of evidence (i.e., integrative taxonomy), we describe a new species of Hyloxalus, Hyloxalus arliensis sp. nov. The new species occurs in the middle Magdalena River valley on slopes between the Cordillera Central and Cordillera Oriental of the Andes of Colombia. Previously, the new species was referred to as Hyloxalus "Ibagué" but was not formally described. Phylogenetic re-analyses of 2440 base pairs (bp) of mitochondrial DNA (mtDNA), revealed the species to be a sister taxon of H. lehmanni, within a monophyletic clade also comprising H. delatorreae lineage 1, H. pulchellus and H. vertebralis. The adult males of H. arliensis sp. nov. have a pale arm gland, which differentiates it from all other species of the genus, except for H. saltarius. The new species also differs from other species of Hyloxalus by its smaller size, disc on Finger III not expanded, toes unwebbed, dorsolateral stripe absent, oblique lateral stripe present, white spots on ventrolateral flanks in life and cloacal tubercles absent. The advertisement call consists of long trains of a single note repeated at a rate of 89-132 notes/min with a dominant frequency ranging from 4808-6387 Hz. The new species is a tiny frog that inhabits the sheltered areas around streams in sub-Andean forests. Aspects of its natural history are described.

Masculinizing genital gender-affirming surgery: metoidioplasty and urethral lengthening.

Metoidioplasty denotes the creation of a neophallus out of the hormonally hypertrophied clitoris. Construction of an esthetically acceptable male-like genitalia while enabling micturition in standing position are the primary goals. Herein, we aim to review the literature regarding masculinizing gender-affirming genital surgery in the form of metoidioplasty, focusing on the steps related to urethral lengthening and reconstruction, and describe the authors' preferred surgical technique. Clitoral release, division of the urethral plate, native urethral lengthening with anterior vaginal wall flap, and neourethral tubularization using a combination of buccal mucosa graft and labia minora flap(s) seem to provide the best result in terms of urinary outcomes. This is reflected in a greater urethral length, higher probability of standing micturition, and lower incidence of fistula. Urethral complications, which can be encountered in up to 15% of the patients, may necessitate additional procedures. Some of the studies have reported successful penetrative intercourse following metoidioplasty. Case series about different metoidioplasty techniques do not allow head-to-head comparison due to non-standardized reporting and outcome assessment. Metoidioplasty can be offered to transgender men with sufficiently hypertrophied clitoris who wish to avoid a complicated, multistage, flap-based total phalloplasty, or for those individuals considering phalloplasty at a later date.

Spongioplasty with Dartos Flap Coverage in the Snodgrass Technique of Hypospadias Repair

Objective: The aim of the study is to evaluate the role of spongiosal tissue with dartos flap coverage for preventing Urethrocutaneous Fistula (UCF) formation in the Snodgrass technique.&#x0D; Materials and Methods: It is a prospective study, performed on 35 patients of mid penile and distal hypospadias aged 15 months to 144 months who underwent urethroplasty in the Snodgrass technique using spongiosal tissue and dartos flap for neourethral coverage.&#x0D; Results: Among 35 patients, Age ranged from 15 months to 144 months (mean 85.94 months). Chordee was corrected by penile degloving alone in 11 patients, partial mobilization of urethral plate with spongiosum in 20 patients and 4 patients required dorsal plication. Glans groove was deep in 19 patients, shallow in 13 patients and no groove noticed in 3 patients. Sixteen patients had narrow urethral plate (&lt;8mm) and 19 patients had adequate urethral plate (&gt;8mm). Urethrocutaneous Fistula (UCF) was encountered in five patients (14.28%), meatal stenosis in two patients (5.71%), and partial glanular dehiscence in one patient.&#x0D; Conclusions: Approximation of spongiosal tissue along with dartos flap as the intermediate layer for neourethral coverage reduces fistula formation.&#x0D; J Bangladesh Coll Phys Surg 2020; 38(2): 64-67

Dorsal oral mucosa graft in combination with ventral penile flap as an alternative to repair obliterative stenosis of the anterior urethra in a single surgical time.

ABSTRACTPurpose:Obliterative urethral stenosis is a type of urethral lesion that compromises the whole corpus spongiosum's circumference. We present our experience in resolving complex long segment urethral obliteration in a single procedure using a combination of dorsal onlay oral mucosa graft (OMG) and ventral fasciocutaneous penile skin flap.Materials and methods:A prospectively maintained database was reviewed, which included data of men presenting long, obliterative strictures. Patients were excluded if they were lost to follow-up before one year. Failure was defined as need for further urethral instrumentation.The surgical technique used consisted on the fixation of OMG to the tunica albuginea of the corpus cavernosum, thus creating a new urethral plate. Penile or foreskin flaps were employed to complete the ventral aspect. Postoperative follow-up was done with a voiding cystourethrography at week 3.Results:A total of 21 patients were included with a median age of 49 years. Mean follow-up was 25 months. Failure was found for 3 patients (2 of them needing dilations and only one required a new urethral reconstruction).Conclusion:Single stage combination of dorsal OMG with ventral fasciocutaneous penile flap showed good results for selected patients affected with obliterative urethral stenosis.

Гистологическое исследование уретральной площадки: поиск оптимального пластического материала для хирургического лечения гипоспадии у детей

to study the microstructure of the urethral plate in patients with a proximal form of hypospadias to justify the use of tissues from the ventral penile surface when creating an artificial urethra. A histological study of surgical specimens from 10 patients with proximal hypospadias was carried out. The urethral plate, a strip of tissue from the ectopic external urethral orifice located in the penoscrotal angle, to the coronary sulcus, was completely excised and processed by various techniques. A staining with hematoxylin and eosin, picrofuchsin according to Van Gieson, as well as immunohistochemical typing of CD 34, collagen (type I, III, and IV), fibronectin, and smooth myocytes using alpha-smooth muscle actin was performed. All elements which are present in a healthy urethra, such as epithelial cells, blood vessels, normal collagen fibers, smooth muscle cells and complexes of glands, were found in the microstructure of the urethral plate. The cytoarchitectonic features of the ventral penile tissues are similar to the microstructure of the healthy urethra, which provides a rationale to consider the urethral plate as a material with optimal bioresistant properties for urethroplasty.