Penile Skin Research Articles

(452) Glans Necrosis is Not a Risk for Simple Inflatable Penile Prosthesis Insertion Performed via Subcoronal Incision

Abstract Introduction Some studies have questioned subcoronal incision via IPP as a risk factor for glans ischemia or necrosis. We analyzed the largest ever reported series of IPP via subcoronal incision. Objective To report complications related with subcoronal incision for IPP placement Methods We studied 898 men who had subcoronal IPP placement from 5/2015-3/2022 by single surgeon. 817 were first-time patients under local anesthesia, with 81 revisions under spinal anesthesia including 707 circumcised and 181 uncircumcised subjects. Most (76%) uncircumcised men underwent coincident circumcision; the remainder refused. Implants were Coloplast Titan (489) and AMS 700 (329) in 329 (36.6%) diabetics and 38 (4%) Peyronie’s. We report postoperative occurrence of device infections and glans/penile skin problems. Results Mean follow up was 47.3 months (3-81 months). Modeling (64%) and corporal relaxing incisions (36%) straightened the Peyronie’s patients. Transient distal penile skin edema which resolved within 2 to 4 months was noted in 673 cases (74.9%). Edema developed in 68.3% previously circumcised patients, 100% of concomitant circumcised patients and 96.2% of patients who had refused circumcision. One previously circumcised patient experienced prolonged edema of 7 months. Five previously circumcised patients (0.5%) developed partial distal penile skin necrosis on the proximal side of the subcoronal incision (Figure-1) with all but one healing without grafting. The other patient sustained necrotic wound dehiscence which led to device infection and removal. There were zero cases of glans ischemia or necrosis. Only 2 patients became infected (0.2%). Conclusions Subcoronal incision for simple IPP placement or revision is not an independent risk factor for glans ischemia or necrosis. Most postoperative patients do experience transient distal penile skin edema without glans involvement which heals without sequelae regardless of circumcision status. Very rarely (0.5%) penile skin loss may occur. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, International Medical Devices, Rigicon, Uramix.

(538) Penile Enlargement for Patient with Buried Penis: Pubic Dermolipectomy, Scrotoplasty and Mons Pubis Reconstruction

Abstract Introduction Acquired buried penis is a common condition in obese patients. Abnormal excess fat accumulation under the pubic skin leads to the partially or completely disappearance of the penis. This condition is related to voiding difficulties and sexual dysfunction. The goal of surgical treatment is to expose full penile lengthy by excising the adipose pubic tissue and part of excess pubic skin. Objective The aim of this kind of surgery is to make possible to have a normal sexual life to obese patients with buried penis. Methods We performed this technique for buried penis in 25 patients aged from 18 to 72 y (mean 48). Preoperatively, the patient is marked for the procedure in the standing position. Two transversal incisions are made on the pubis and joined laterally on both sides towards anterior iliac spines with the care taken to avoid the formation of "dog ears". The suprapubic fat is removed. Following the inner surface of the Scarpas fascia, the fat is also removed from the penoscrotal angle and from the scrotum as much as possible leaving exposed funiculus and testis on both sides. Suspensory ligament of the penis was incised. Penile skin redistribution leads to a better organ exposure. Postoperative vacuum erectile device was used in order to prevent penile retraction. Results Follow up was at 6 months. Early postoperative complications were hematoma (7pts), penile skin edema (5pts), seroma (5pts), wound infection (5pts), penile shaft retraction (3pts). Majority of pts (22pts) were satisfied good aesthetical and functional outcome. Conclusions Pubic dermolipectomy is a safe procedure with satisfactory results to treat men with buried penis. Surgical exposition of the penile shaft was accomplished in all patients. Disclosure No

(283) Managing Patient Pain Expectations in Buried Penis Repair: An Opportunity for Quality Improvement

Abstract Introduction Buried penis repairs are complex cases often requiring collaboration between urology and plastic surgery. These surgeries are often extensive, can require split thickness skin grafting (STSG) of the penile shaft, negative pressure wound vac, and have high incidence of wound complications. There are no studies that evaluate perioperative pain in patients undergoing buried penis repair. Objective In the ongoing opioid epidemic, we aim to evaluate patient risk factors and peri-operative elements that can minimize opioid use in buried penis repair. Methods A retrospective chart review of patients who underwent buried penis repair from 7/2012 to 7/2021 was performed. Patient demographics, comorbidities and perioperative data were collected, including history of chronic pain, indications, intraoperative findings, perioperative pain control, and 30-day post-operative encounters. The state’s prescription monitoring program was used to verify use of prescription pain medications prior to surgery, at discharge, and refills, collected as Morphine Equivalent Dose (MED). Results A total of 63 patients were included in analysis. Mean age was 55.9 ± 14.4 with a mean pre-op BMI of 41.99 ± 9.17. 75% required a STSG on the penile shaft. The median discharge MED (dMED) was 150, ranging from 0 to 450 MED. 36.5% required opioid refills within 30 days of surgery. This cohort was further separated into two groups: patients who were discharged with < 150 MED (A) vs ≥ 150 MED (B), based on the median dMED. Three patients were excluded: two were on home opioids, one discharged on benzodiazepines. There were no differences in age, pre-op BMI, medical comorbidities (CAD, PVD, HTN, DM, psychiatric history) or history of chronic pain between the cohorts. Surgery for improvement of hygiene was more likely to have higher dMED, 40.7% (A) vs 69.7% (B), p=0.017. Other surgical indications (sexual health, voiding) showed no difference. Prior surgeries (urethral procedures, circumcision) were statistically more likely to require higher dMED, 48.1% (A) vs 72.7% (B), p=0.033. If a penile skin graft was required, there was no difference in graft size and dMED. Twenty-six patients had a hospital managed wound vac, while 19 patients had home wound vacs, but there was no difference in dMED. Although there was no standardized hospital pain regimen, patients on scheduled acetaminophen were more likely to have a lower dMED, 70.3%(A) vs 42.4% (B), p=0.021. 40.7% (A) vs 36.4% (B) of patients required opioid refills within 30 days of surgery, showing no statistical significance. Conclusions For patients who are embarking on buried penis repair, providers can pre-operatively set pain control expectations, especially for those who require repair for hygiene purposes or have had prior urologic reconstructive surgery. In the perioperative setting, this data supports the use of non-opioids, specifically scheduled acetaminophen, to minimize opioid prescribing at discharge. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific

(286) Goldmember: A Novel Approach to Remove Entrapped Metal Rings Around a Penis

Abstract Introduction Penile strangulation with metal objects is a rare urologic emergency that can present considerable challenges. The treatment approach can vary depending on the type of constricting device, degree of injury, and available equipment. Prior medical reports document the use of various instruments such as bolt cutters, oscillating saws, and power drills. Our case demonstrates a safe and reproducible means to remove metal rings entrapped around a penis using the Midas Rex® drill. Objective To describe a novel treatment approach in penile strangulation with the use of the Midas Rex® drill. Methods A 70-year-old male with a history of paranoid schizophrenia presented to our institution’s emergency department with urinary retention and penile pain due to the placement of five rings onto the penis two weeks prior. On exam, he had swelling of the glans and skin necrosis underneath the rings (Figure 1). After initial bedside attempts to remove the rings proved unsuccessful, he was promptly taken to the operating room. Further attempts to remove the rings using orthopedic pin cutters were also unsuccessful. Next, the Midas Rex® drill (Figure 2a) was used to cut each ring into two segments. The penis was protected from traumatic and thermal injury with careful retraction and continuous irrigation (Figure 2b). All five rings were successfully removed without sustaining iatrogenic injuries (Figure 2c). The injuries were limited to pre-existing superficial wounds of the penile skin (Figure 3a). A cystoscopy was performed and did not reveal any evidence of urethral injury. A suprapubic catheter (SPC) was placed to allow for urethral rest with 1,200 ml of urine drained. Postoperatively, the patient was stable and was transferred to the inpatient psychiatric unit the next day. After adjustment of his psychiatric medications and six days of observation, he was discharged. At his two-week urology follow-up, he had near-complete healing of the penile skin (Figure 3b). His SPC was also removed with low post-void residual noted. Results We present a case where mechanical methods could not be used to remove entrapped metal rings around a penis. In cases requiring the use of electrical tools, it is of utmost importance to protect the penis from iatrogenic injuries. Although the use of non-medical devices such as electric saws have been described in penile strangulation, they can often be bulky. Also, in several reports these devices have caused thermal injuries, leading to urethral strictures and urethrocutaneous fistulae. We were able to use the Midas Rex® drill, an instrument typically used in neurosurgical and orthopedic procedures, with excellent results. By using the diamond-tipped metal cutter attachment and powering the drill with compressed nitrogen set at 120 psi, all five metal rings were safely removed in under 30 minutes. Conclusions Penile strangulation represents a rare urologic entity requiring prompt removal of constricting devices to avoid ischemic complications. From our experience, we demonstrated that the Midas Rex® drill can be safely and expeditiously used to remove metal rings entrapped around a penis with minimal risk of iatrogenic injury. Disclosure No

(112) An Experimental Animal Study of the Histopathological Effect of Collagen Fleece (TachoSil) Patch of Tunica Albuginea Defects Associated with Penile Surgery

Abstract Introduction A penile tunica defect may arise during penile prosthesis surgery or reconstruction of the penis in patients with Peyronie’s disease. Collagen fleece (TachoSil) was recently reported in penile surgery to cover the tunica defect with reported clinical success. However, it is not known what the histological outcomes of these grafts are in the penis. Objective We study the novel application of TachoSil graft in an experimental animal model. We looked at the regeneration of tunica albuginea, development of inflammation and fibrosis, and histopathological effect on the underlying cavernous tissue. Methods Seven adult male Sprague Dawley rats were used. All procedures were carried out under general inhalation anesthesia. The penis was degloved through a circumferential subcoronal incision. A longitudinal 1x10 mm defect was created at the base of the lateral aspect of the penis. A TachoSil patch (Takeda, Japan) was applied to the defect in six rats and Surgicel (Ethicon) in one. The penile skin covering is then restored and fixed with interrupted 5-6 zero absorbable sutures. At two months, the rat penis was evaluated for excision. Euthanasia was carried out with an overdose of inhalation anesthesia and chest opening. The excised penis was examined by hematoxylin and eosin and trichrome stains. Results At the time of surgery, the rats’ weight was 390 gm (SD 33.8). All rats with TachoSil showed normal-looking penis at two months with complete healing, no scaring, tethering, or gross inflammatory features. The penis of three rats with a Tachosil patch was harvested at two months postoperatively. It showed histopathology of fibrosis, chronic inflammation, and foreign body giant cell reaction at the site of the patch. There was no generation of a new tunica albuginea, no new vascularity or distinct fibrous layer development. The underlying corpus cavernous tissue was not affected by any inflammatory or pathological reaction. One rat died on the 6th postoperative day. Postmortem showed massive gastrointestinal bleeding, intraperitoneal hemorrhage, and punctate hemorrhages of the parenchyma of both suprarenal glands, both kidneys, and the liver. A clinical diagnosis of DIC was made. Histopathology of the penis, however, did not show micro thrombosis. The fifth rat with a Surgicel patch showed immediate hematoma of the penis controlled by compression. After two months, during harvesting of the penis, large pockets of pus were seen spreading from the site of the patch to surrounding structures. Histopathology showed chronic inflammation and fibrosis extending into the corpus cavernosum. The sixth and seventh rats showed normal penis external appearance at two months and were left surviving for harvest at four months. Conclusions Tachosil patching of penile tunica albuginea defect forms a distinctive barrier against inflammation protecting the underlying corpus cavernosum. However, no regeneration of tunica defect is observed at two months. DIC is a potential complication of systemic absorption of TachoSil. Disclosure No

(140) Penile Length and Girth Restoration in Mb Peyronie: Less Invasive Approach for Complex Composite Graft Corporplasty and Implantation of Inflatable Penile Prosthesis

Abstract Introduction Peyronie's disease (PD) is a fibrotic disorder of the tunica albuginea. It is both a physically and psychologically devastating disorder that causes penile deformity, curvature, narrowing and shortening, which eventually compromise sexual function. Objective The presented technique is a less invasive approach that gives few complications, has a natural cosmetic outcome with preserved preputium, and high patient satisfaction. Methods In the period between December 2017 and May 2022, 65pts aged 33y to 78y underwent complex corporoplasty with inflatable penile prosthesis implantation. Mean penile curvature was 70 o (60 o -95 o ). Average penile shortening was 3.2cm (1 - 5.5cm), and girth narrowing 2.5cm (0 - 4cm). The surgical approach was thru penos-crotal incision, followed by direct dissection of NVB from tunica albuginea, penile eversion, composite corporoplasty (for transversal grafting 0.5mm thick porcine dermal graft, and for longitudinal graft composite semi-resorbable soft mash), and 3-piece inflatable penile prosthesis implantation. Postoperative vacuum drainage and compressive dressing were left in place for one week. Results Follow-up was 2-58 months (mean 21). Penile shape (corrected curvature, length and girth) was restored in all patients. In the first 4 weeks postoperatively 12pts had mild scrotal oedema; 8pts developed mild scrotal haematoma; 7pts developed penile skin oedema; 5pts had a transitory loss of sensitivity. All patients 5 weeks postoperatively started with sexual intercourse. All patients 12 weeks after surgery reported satisfactory aesthetical and functional results with no visible scaring related to surgery. Five pts (12-23 months after surgery) had prosthesis malfunction that needed reimplantation of the prosthesis. Conclusions Penile eversion thru peno-scrotal incision with preserving the prepuce for complex reconstructive surgery of PD is safe and gives the natural aesthetic appearance and good functional result with low complication rate. The high satisfaction rate for the patients is the most important aspect of this surgical method. Disclosure No

Outcome of Urethroplasty in Management of Urethral Stricture: Experience at Institute of Kidney Diseases Hayatabad Peshawar

Objective: To determine the frequency of successful outcomes of urethroplasty in the management of urethral stricture Methods: It is a descriptive study, conducted in the department of Urology at the Institute of Kidney diseases Peshawar from April 2016 to December 2019. A total number of 85 patients for urethroplasty were included in the study by non-probability convenient sampling. The entire pre-operative, per-operative, and postoperative data were collected on structured proforma and analyzed on SPSS®, version 20.0. Results: The mean age of the patient in this study was 41 years. Regarding etiology, External trauma was the major cause in the form of road traffic accidents in 38.82% while straddle urethral injury in 29.41% of patients, other less frequent causes included iatrogenic urethral trauma and infective stricture. The bulbar urethral stricture was found in 55.29% of cases, with proximal penile and bulboperineal accounting for 23.52% and 21.17% respectively. Significant past surgical history found was suprapubic catheterization in 100%, a failed primary attempt of internal optical urethrotomy (IOU) in 29.41%, multiple recurrences in 48.23%, and re-do urethroplasty in 10.58% of cases. The most common procedure performed was end-to-end anastomotic urethroplasty in 81%, other procedures included penile flap urethroplasty, pull-through procedure, and 10.58% of cases required pubectomy. Urethroplasty was found highly successful in 94% of mean follow-ups 15 months. The cause of failure was wound infection in 1, UTI in 2, and necrosis of penile skin flap in 2 patients. Conclusion: Our initial results conclude that anastomotic urethroplasty is an effective and mainstay treatment modality in the management of urethral stricture disease. It bears less rate of recurrence of urethral stricture. Keywords: Urethroplasty, urethro stricture, Recurrence

MP02-01 CADAVERIC PENILE DISSECTION AND ITS IMPACT ON LIVE DONOR PENILE TRANSPLANTATION: A PRELIMINARY STUDY

You have accessJournal of UrologyCME1 Apr 2023MP02-01 CADAVERIC PENILE DISSECTION AND ITS IMPACT ON LIVE DONOR PENILE TRANSPLANTATION: A PRELIMINARY STUDY Borko Stojanovic, Bojana Radnic, Marta Bizic, Milenko Bogdanovic, Sinisa Ducic, Vesna Popovic, Tatjana Atanasijevic, and Miroslav Djordjevic Borko StojanovicBorko Stojanovic More articles by this author , Bojana RadnicBojana Radnic More articles by this author , Marta BizicMarta Bizic More articles by this author , Milenko BogdanovicMilenko Bogdanovic More articles by this author , Sinisa DucicSinisa Ducic More articles by this author , Vesna PopovicVesna Popovic More articles by this author , Tatjana AtanasijevicTatjana Atanasijevic More articles by this author , and Miroslav DjordjevicMiroslav Djordjevic More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003213.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penile transplantation presents an ideal treatment for penile agenesis, traumatic penile amputation, penile cancer or gender dysphoria in transmen. Until now, all four reported cases underwent cadaveric penile transplantation. We evaluated possibilities for using all penile entities after their removal in transfemale gender affirming surgery for live donor penile transplantation. Main goal of this cadaveric study was to develop techniques for anatomical harvesting of the penile entities (corpora cavernosa with distal urethra and glans) that could be used for safe and successful donor penile transplantation. METHODS: Between January and September 2022, penile dissection was performed in 18 male cadavers, aged from 19 to 51 years (mean 38.5 years). Dissection was based on penile disassembly principles: corpora cavernosa with urethra, glans with neurovascular bundle and penile skin. Penile skin with small piece of the glans and proximal urethra were separated as a tissue for creating the female genitalia. This way completely preserved cavernosal bodies, distal urethra and largest part of the glans were precisely measured with associated blood vessels and nerves. RESULTS: Mean penile length was 10.5 cm (from 6 to 13 cm) in flaccid and 15 cm (from 12 to 18 cm) in stretched state, and mean circumference 8 cm (from 7 to 9 cm). Neurovascular bundle had regular anatomy in 16 cases, while in remaining 2 anatomical variations were detected: single penile artery in one and a common trunk of both penile arteries in another case. Mean diameters of deep dorsal vein, right and left left artery were measured 2.9 mm, 2.5 mm and 2.2 mm, respectively. Penile nerves were found in all cases with anatomical distribution. A circumflex branches and perforators of the blood vessels were detected in all cases. Mean length and girth of cavernosal bodies were 20 cm (from 18 to 24 cm), and 7.4 cm (from 6.5 to 11 cm), respectively. Both crural arteries are identified in all cases. Mean length of the distal urethra was 11.4 cm (from 9.5 to 14 cm) without registered anomalies. The mean volume of the remaining glans after creation of the neoclitoris was 87% (from 85 to 90%). All dissections were finished successfully, and all entities were joined again in all cadavers. CONCLUSIONS: Preliminary results of cadaveric penile dissection confirm feasibility of using all remaining entities such as corpora cavernosa, minimally reduced glans, distal urethra and preserved neurovascular elements during transfemale gender affirming surgery for possible penile transplantation. Surgical technique is suggested and will be established with further research. Source of Funding: Science Fund of the Republic of Serbia, Project IDEAS © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e10 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Borko Stojanovic More articles by this author Bojana Radnic More articles by this author Marta Bizic More articles by this author Milenko Bogdanovic More articles by this author Sinisa Ducic More articles by this author Vesna Popovic More articles by this author Tatjana Atanasijevic More articles by this author Miroslav Djordjevic More articles by this author Expand All Advertisement PDF downloadLoading ...

MP62-09 GLANS NECROSIS IS NOT A RISK FOR SIMPLE INFLATABLE PENILE PROSTHESIS INSERTION PERFORMED VIA SUBCORONAL INCISION

You have accessJournal of UrologyCME1 Apr 2023MP62-09 GLANS NECROSIS IS NOT A RISK FOR SIMPLE INFLATABLE PENILE PROSTHESIS INSERTION PERFORMED VIA SUBCORONAL INCISION Sung Hun Park and Steven Wilson Sung Hun ParkSung Hun Park More articles by this author and Steven WilsonSteven Wilson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Some studies have questioned subcoronal incision for IPP as a risk factor for glans ischemia or necrosis.1 We analyzed the largest ever reported series of IPP via subcoronal incision. METHODS: We studied 898 men who had subcoronal IPP placement from 5/2015-3/2022 by single surgeon after ethical committee approval. 817 were first-time patients, with 81 revisions including 707 circumcised and 181 uncircumcised subjects. Most (76%) uncircumcised men underwent coincident circumcision; the remainder refused. Implants were Coloplast Titan (489) and AMS 700 (329) under local anesthesia in 329(36.6%) diabetics and 38(4%) Peyronie’s. We report postoperative occurrence of device infections and glans/penile skin problems. RESULTS: Mean follow up was 47.3 months (3-81 months). Modeling (64%) and corporal relaxing incisions (36%) straightened the Peyronie’s patients. Transient distal penile skin edema which resolved within 2 to 4 months was noted in 673 cases (74.9%). Edema developed in 68.3% previously circumcised patients, 100% of concomitant circumcised patients and 96.2% of patients who had refused circumcision. One previously circumcised patient experienced prolonged edema of 7 months. Five previously circumcised patients (0.5%) developed partial distal penile skin necrosis on the proximal side of the subcoronal incision with all but one healing without grafting. (see below) The other patient sustained necrotic wound dehiscence which led to device infection and removal. There were zero cases of glans ischemia or necrosis. Only 2 patients became infected (0.2%). CONCLUSIONS: Subcoronal incision for simple IPP placement or revision is not an independent risk factor for glans ischemia or necrosis. Most postoperative patients do experience transient distal penile skin edema without glans involvement which heals without sequelae regardless of circumcision status. Very rarely (0.5%) penile skin loss may occur. Reference: 1. Wilson SK et al. Glans Necrosis Following Penile Prosthesis Implantation: Prevention and Treatment Suggestions. Urology 2017; 107:144-148. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e864 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sung Hun Park More articles by this author Steven Wilson More articles by this author Expand All Advertisement PDF downloadLoading ...

V11-01 DEEP DORSAL VEIN BED PLICATION FOR VENTRAL PENILE CURVATURE

You have accessJournal of UrologyCME1 Apr 2023V11-01 DEEP DORSAL VEIN BED PLICATION FOR VENTRAL PENILE CURVATURE Pedro Caetano Edler Zandoná, Guilherme Garcia Barros, Igor Valente Coimbra, Plinio Moreira De Góes, Eduardo Zinoni Silva Pato, William Carlos Nahas, Bruno Chiesa Gouveia Nascimento, and Jorge Hallak Pedro Caetano Edler ZandonáPedro Caetano Edler Zandoná More articles by this author , Guilherme Garcia BarrosGuilherme Garcia Barros More articles by this author , Igor Valente CoimbraIgor Valente Coimbra More articles by this author , Plinio Moreira De GóesPlinio Moreira De Góes More articles by this author , Eduardo Zinoni Silva PatoEduardo Zinoni Silva Pato More articles by this author , William Carlos NahasWilliam Carlos Nahas More articles by this author , Bruno Chiesa Gouveia NascimentoBruno Chiesa Gouveia Nascimento More articles by this author , and Jorge HallakJorge Hallak More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003337.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Either Congenital Penile Curvature or Peyronie’s Disease may cause severe ventral curvature. Historically, surgical techniques for this type of deformities were associated with longer operative time and greater patient dissatisfaction, mainly due to neurovascular bundle (NVB) dissection [1]. Previous studies described a midline dorsal plication technique in pediatric patients, allowing for an effective correction without requiring NVB manipulation [2-5]. Neuroanatomical studies have demonstrated the distribution of nerve fibers and identified the 12 o'clock position as the only nerve-free position [2]. Finally, in 2021, Bagnara et al published the description of the Giammusso corporoplasty in adults [6]. We aim to demonstrate with this video article the step by step of this previously published technique for ventral penile curvature correction. METHODS: This video article is a compilation of images of three surgeries performed for ventral penile curvature utilizing an adaptation of the Giammusso Corporoplasty technique. In the main video, the procedure was performed for a 26-year old male with a 62-degree ventral congenital penile curvature. Supplementary photographs of other two cases were added to the video: a 77-year old male with a 68-degree Peyronie’s ventral curvature and a 29-year old male with a 28-degree ventral congenital penile curvature. In all cases, a subcoronal incision was performed, and penile skin and Dartos’ fascia were degloved. The point of maximum curvature was identified after a saline induced artificial erection, Buck’s fascia was incised, and deep dorsal vein and its branches were then dissected and ligated. Differently from the Giammusso technique, we did not perform a corporoplasty, but a simple plication as described by Akdemir et al [5]. This latter technique however spares the deep dorsal vein. For the plication, after planning and marking their sites with Allys clamp and artificial erection confirming functional alignment, we utilized 3 inverted non-absorbable 2-0 coated polyester sutures for each plication site. Circumcision was performed for penile shaft closure. RESULTS: The three patients shown in this video obtained functional penile alignment, and no change in glans sensation. No severe adverse event was observed, with one patient developing a small penile hematoma managed conservatively. CONCLUSIONS: This video article describes Deep Dorsal Vein Bed Plication, a feasible and effective technique for ventral penile curvature treatment, which avoids NVB dissection and its associated risks such as glans hypoesthesia and glans necrosis. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e999 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pedro Caetano Edler Zandoná More articles by this author Guilherme Garcia Barros More articles by this author Igor Valente Coimbra More articles by this author Plinio Moreira De Góes More articles by this author Eduardo Zinoni Silva Pato More articles by this author William Carlos Nahas More articles by this author Bruno Chiesa Gouveia Nascimento More articles by this author Jorge Hallak More articles by this author Expand All Advertisement PDF downloadLoading ...

V09-03 GENDER-AFFIRMING CLITOROPLASTY: TWO VERSIONS AND RATIONALE FOR CHOICE

You have accessJournal of UrologyCME1 Apr 2023V09-03 GENDER-AFFIRMING CLITOROPLASTY: TWO VERSIONS AND RATIONALE FOR CHOICE Michele Fascelli, Geolani Dy, Blair Peters, and Daniel Dugi Michele FascelliMichele Fascelli More articles by this author , Geolani DyGeolani Dy More articles by this author , Blair PetersBlair Peters More articles by this author , and Daniel DugiDaniel Dugi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We present two techniques for creating the neoclitoris in gender-affirming vaginoplasty and vulvoplasty, preputial skin flap clitoroplasty and urethral flap clitoroplasty. METHODS: The technique to be used is chosen prior to skin incision. After penile disassembly, the the glans is reconstructed to form the clitoris, based on the corona. The tissue used to construct the clitoral hood and labia minora differs by technique, and the decision to use one technique or the other is based on patient anatomy. RESULTS: We demonstrate two techniques and their post-operative results. We chose the preputial skin clitoroplasty for all uncircumcised patients and patients with adequate penile skin, both distal to and proximal to the circumcision scar. We chose the urethral flap clitoroplasty technique for circumcised patients with penile skin insufficient for the preputial skin technique. CONCLUSIONS: These two techniques for clitoroplasty provide surgical options adaptable to individual anatomy. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e837 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michele Fascelli More articles by this author Geolani Dy More articles by this author Blair Peters More articles by this author Daniel Dugi More articles by this author Expand All Advertisement PDF downloadLoading ...

MP02-12 A NOVEL SURGICAL TECHNIQUE TO CREATE A NATURAL-APPEARING RECESSED VAGINAL INTROITUS WITH GENDER-AFFIRMING SHALLOW-DEPTH VAGINOPLASTY

You have accessJournal of UrologyCME1 Apr 2023MP02-12 A NOVEL SURGICAL TECHNIQUE TO CREATE A NATURAL-APPEARING RECESSED VAGINAL INTROITUS WITH GENDER-AFFIRMING SHALLOW-DEPTH VAGINOPLASTY Jenna Stelmar, Shannon Smith, Nance Yuan, Michael Zaliznyak, Sandeep Sandhu, and Maurice Garcia Jenna StelmarJenna Stelmar More articles by this author , Shannon SmithShannon Smith More articles by this author , Nance YuanNance Yuan More articles by this author , Michael ZaliznyakMichael Zaliznyak More articles by this author , Sandeep SandhuSandeep Sandhu More articles by this author , and Maurice GarciaMaurice Garcia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003213.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A key genital gender affirming surgery (gGAS) option for transfeminine patients is vaginoplasty without creation of a vaginal canal, commonly referred to as ‘shallow-depth vaginoplasty' (SDV), which is an alternative to full-depth vaginoplasty (FDV). Together with the advantages of SDV (lower complications, no need for dilation/douching), achieving “normal appearing” anatomy is typically important for patients. However, no surgical technique for how to create a recessed vaginal introitus has been published. We aim to: 1. Assess patient decision-making priorities when choosing SDV over FDV; and 2. Describe a novel surgical technique to create a recessed vaginal introitus regardless of penile shaft length and 3. Patients’ perception of how it compares to a cis-gender vulva. METHODS: Of the 110 patients who underwent primary feminizing gGAS at our institution between 4/2017 and 7/2022, 35 (32%) underwent SDV and were emailed a link to an anonymous, electronic Qualtrics® survey querying decision-making and satisfaction.Our technique is described. RESULTS: Prioritites: Achieving external appearance “comparable to” a cis-vagina was the second-highest ranked priority for patients (after “elimination of male genital anatomy”) (Figure 1a) Surgical Technique: To achieve a recessed skin-lined introitus, we place gathering sutures to create a “dimple” on the penile or scrotal skin to be used, and then tether this dimple to two structures: the tendon of the Bulbospongiosus muscle, and diffuse perineal body tissue behind the urethral bulb. (Figure 1, b-d) Attractiveness: When asked how patients perceive their vagina compared to a cisgender woman’s of similar age and weight, 3/29 (10%) reported they “do not know what a cisgender woman’s vagina looks like” and were excluded from further analyses. The remaining 19/26 (73%) reported their vagina was “similar in appearance” and 7/26 (27%) “somewhat similar in appearance.” 21/26 (81%) found their vagina to be “similarly attractive”; 3/26 (10%) “more attractive”; and 2/26 (8%) “less attractive” than a cis-gender woman’s vagina. CONCLUSIONS: For women to choose SDV, it is essential that the cosmetic appearance of the vulva be as indistinguishable as possible from a cis-gender woman’s vulva. The surgical technique presented appears to offer this. Source of Funding: Richard Onofrio, MD Research Grant to the CSMC Transgender Surgery & Health Program © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e15 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jenna Stelmar More articles by this author Shannon Smith More articles by this author Nance Yuan More articles by this author Michael Zaliznyak More articles by this author Sandeep Sandhu More articles by this author Maurice Garcia More articles by this author Expand All Advertisement PDF downloadLoading ...

MP60-16 DORSAL/ DORSO-LATERAL ONLAY BUCCAL MUCOSAL GRAFT VERSUS VENTRAL ONLAY LOCAL PENILE SKIN FLAP IN COMPLEX ANTERIOR URETHRAL STRICTURES; A PROSPECTIVE RANDOMIZED STUDY

You have accessJournal of UrologyCME1 Apr 2023MP60-16 DORSAL/ DORSO-LATERAL ONLAY BUCCAL MUCOSAL GRAFT VERSUS VENTRAL ONLAY LOCAL PENILE SKIN FLAP IN COMPLEX ANTERIOR URETHRAL STRICTURES; A PROSPECTIVE RANDOMIZED STUDY Ahmed Tawakol, Mohammed Abdel-Rassoul, Mohamed Abdelwahab, Mohamed Elghoneimy, Ahmed Y. Abdelaziz, Ahmed Rammah, Mohamed Elgammal, and Amr Elkady Ahmed TawakolAhmed Tawakol More articles by this author , Mohammed Abdel-RassoulMohammed Abdel-Rassoul More articles by this author , Mohamed AbdelwahabMohamed Abdelwahab More articles by this author , Mohamed ElghoneimyMohamed Elghoneimy More articles by this author , Ahmed Y. AbdelazizAhmed Y. Abdelaziz More articles by this author , Ahmed RammahAhmed Rammah More articles by this author , Mohamed ElgammalMohamed Elgammal More articles by this author , and Amr ElkadyAmr Elkady More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003318.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Anterior urethral stricture is a challenging disease. Multiplicity of surgical techniques denotes that none is ideal. Our aim is to compare the use of buccal mucosal grafts (BG) versus local penile skin flaps (PF) in patients with complex anterior urethral strictures regarding success rates and complications. METHODS: A total of 34 adult patients with complex anterior urethral stricture were included. A complex anterior urethral stricture was defined as a stricture length of>2 cm and/or previous failed procedures, including urethral dilatation, internal optical urethrotomy and urethroplasty. We randomized patients to undergo either buccal mucosa dorsal/ dorso-lateral onlay graft or ventral onlay local penile skin flap urethroplasty. We compared operative time, estimated blood loss, complications, and succcess rates in both groups. Successful treatment outcome was defined as no further treatment of the urethral stricture required after urethroplasty and peak flow rate>15 ml/s. RESULTS: Mean follow up was 22.3 months in BG group vs 18.9 months in PF group. The site of the stricture, the median stricture length (40 mm in BG group Vs. 50 mm in PF group) and mean operative time were not statistically different between the two groups. Estimated blood loss was higher in PF group (median 400 ml and 300 ml in PF and BG group respectively, p=0.003); statistically significant but clinically insignificant.Two patients (11.8%) in each group developed wound infection. In PF group, one patient (5.9%) had urinary fistula, and one patient (5.9%) presented by mild ventral chordee post operatively. The success rates in the buccal mucosal and penile flap groups were similar (88.2%). CONCLUSIONS: Dorsal/ dorso-lateral onlay buccal mucosal graft and ventral onlay penile skin flap urethroplasty provided similar success rates. Complications were higher in the penile skin flap group. Both techniques can be used for the treatment of complex anterior urethral strictures with good outcome based on the surgeon's expertise. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e849 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Tawakol More articles by this author Mohammed Abdel-Rassoul More articles by this author Mohamed Abdelwahab More articles by this author Mohamed Elghoneimy More articles by this author Ahmed Y. Abdelaziz More articles by this author Ahmed Rammah More articles by this author Mohamed Elgammal More articles by this author Amr Elkady More articles by this author Expand All Advertisement PDF downloadLoading ...

The Role of Tissue Expanders in the Reconstruction of Proximal Hypospadias

OBJECTIVETo report the technique and outcomes of tissue expansion (TE) for generating additional penile skin for urethroplasty and/or skin coverage during primary or redo hypospadias repair in penoscrotal transposition (PST) patients with a proximal hypospadias. METHODSProximal hypospadias and PST patients with a lack of penile skin, congenitally or after failed repair, who underwent TE assisted reconstruction were reviewed. TE were placed under the penile shaft and expanded skin was used for tubularized incised plate repair. Success was defined as urethral advancement to the corona or more distal with tension free skin coverage. RESULTSA total of 24 patients underwent reconstruction including 16 as part of primary repair and for redo repairs in 8. Nine patients experienced expander extrusion and posturethroplasty complications occurred in 43.8% of primary repairs and 75.0% of redo repairs; a urethrocutaneous fistula was most common (n = 8). Overall, success was achieved in 87.5% of patients with postoperative meatal locations almost all coronal (45.8%) or glanular (50.0%). CONCLUSIONProximal hypospadias reconstruction is challenging, and complications are not infrequent. TE is a useful alternative for complex patients with a skin paucity such that cutaneous coverage would be difficult following urethroplasty. Although the complication rate was 43.8% for primary repair, TE generated sufficient residual skin for success after additional reconstruction. For redo repair early use is most beneficial as there is more expandable skin. The pseudocapsules provide vascularized coverage to reinforce the urethra while there is sufficient skin to minimize the need for a skin graft for penile coverage.

Clinical Classification of Urethrocutaneous Fistulas Developing after Hypospadias Repair.

Background Clinical classification of the urethrocutaneous fistulas (UCFs) was designed to help the surgeons in (1) categorizing the fistulas, (2) selecting appropriate treatments, (3) keeping record at presentation and discharge, and (4) transferring information while referring a patient with recurrent fistula to a higher center. Methods This retrospective study comprised of 68 patients with UCFs who reported in the "Hypospadias and VVFs Clinic" between 2004 and 2016. The study was performed to determine the incidence or etiology of the UCFs. It was rather performed to classify fistulas into different categories depending on the number of fistulas: A (5 fistulas), B (16 fistulas), C-a (28 fistulas), C-b (4 fistulas), D (4 fistulas), and E (11 fistulas). Category A fistulas healed conservatively. Category B fistulas underwent transection of the fistula tracts (tractotomy), purse-string closure, or multilayered closure (fistulorrhaphy). Category C-a fistulas were reenforced by preputial or penile skin flaps or waterproofing flaps. Category C-b fistulas underwent re-tubularization of their neourethral plates and eccentric closure of peno-preputial skin. The urethral plates of category D fistulas were re-tubularized after 3 to 6 months and cover was provided by the Cecil-Culp procedure. Category E fistulas had associated hairy urethra, stricture distal urethra, stricture with diverticulum, perifistular scar-induced chordee, long narrow urethral plate, balanitis xerotica obliterans (BXO), and short reconstructed neourethra. Accordingly, appropriate corrective measures were taken. Miscellaneous category F was excluded from the study. Results Except for one in category D, none of the patients had any recurrence of fistula. One patient of category E had residual diverticulum. Conclusion The designed clinical classification of UCFs is simple. Treatment was in accordance with reconstructive ladder wherein complexity of treatment paralleled with increasing complexity of fistulas.

Early Syphilis Presenting as Thickened Penile Plaques With an Embedded Recurrent Ulcer (Chancre Redux): A Case Report

Introduction: The manifestations of syphilis are varied, and serology can establish the diagnosis early, especially in rare cases. We report a case of chancre redux (a rare recurrence of primary syphilis), which was embedded within a secondary syphilitic penile skin plaque. There were missed opportunities at earlier diagnosis as serology for syphilis was not ordered. Case presentation: A 56-year-old man presented with thickened penile plaques for five months. He reported a small penile ulcer approximately one month prior. There was no history of other skin lesions or rash. However, clinically there was an asymptomatic, indurated ulcer embedded within a plaque which was swab-positive for syphilis by PCR. A punch biopsy of a plaque was spirochaete-positive using an immunoperoxidase stain. The patient’s lesions resolved three weeks after treatment with intramuscular benzathine penicillin. Discussion: Uncommonly reported even in the preantibiotic era, chancre redux is now rare. The ulcer usually recurs at or near the site of the original chancre, and has similar morphological features. The skin lesions of secondary syphilis can exhibit remarkable morphological variety. The most common skin manifestation, a generalized macular rash, was not present at any time in this case. Rather, there were only a couple of nonspecific penile plaques. If biopsy is performed, histologic findings are variable, though typically the inflammatory infiltrate includes plasma cells. A special immunoperoxidase stain can highlight spirochaetes in biopsy sections. Conclusion: This case highlights the importance of considering syphilis in the differential diagnosis of persistent, atypical penile lesions and underscores the need for appropriate serological testing in such instances.

Fournier’s gangrene reconstruction: A 10-year retrospective analysis of practice at Guys and St Thomas’s NHS Foundation Trust

Fournier's gangrene is a rare and potentially fatal condition that affects the external genitalia and perineum as a necrotizing soft-tissue infection. It is equally prevalent in men and women and although there are many ways to manage the condition, it must be done so effectively because there is a chance that life-threatening complications could develop. This retrospective study set out to fill any knowledge gaps, compare reconstructive options to those described in the literature, and promote reflection on current management. Between January 2010 and January 2020, all perineal debridement operation notes were examined. The primary conclusions were that a large majority of defects could be repaired using split skin grafts to reduce surgical time and donor site morbidity. To avoid secondary contracture and the need for revision surgery, full-thickness skin grafts should be used whenever possible to treat penile defects.

Efficacy and safety evaluation of the scrotal skin transfer method in the treatment of pediatric concealed penis: a six-month follow-up data.

Pediatric concealed penis affects penis development and the psychological health of the children. Current surgical methods tend to retain too much of the inner foreskin plate, resulting in unsatisfactory appearance and postoperative complications. We aimed to investigate the efficacy and safety of a new surgical intervention method using a scrotal skin transfer instead of the external foreskin plate to treat pediatric concealed penis. Sixty children (aged between 3 and 9 years and 3 months) diagnosed with concealed penis admitted to our hospital between June 2020 and June 2022 were included. All patients were randomly divided into Improve group (n=30, treated with the new surgical intervention method of scrotal skin transfer) and General group (n=30, treated with traditional Shiraki procedure). The pre-operative and post-operative penis length were collected. A follow-up of 6 months was conducted in all patients. Postoperative penile appearance, penile skin color difference, and satisfaction with the penile appearance were used to evaluate the efficacy of surgery, and the postoperative complications (penile retraction, skin edema and incision infection) were collected to observe the safety of treatment. The post-operative penis length of Improve group was significantly increased compared with General group. The penile skin color was consistent, the penile scrotal angle and the penile pubic angle were formed naturally, and the penis was completely exposed in Improve group. During 6 months' follow-up, the patients in the improvement group did not have infection, penile retraction and skin color difference, and 2 patients had edema. The complication rate in the Improve group was lower than that in the General group. The scrotal skin transfer method shows remarkable efficacy and safety without apparent complications and results in a penis that is fully exposed and aesthetically pleasing.

Robotic Tubularized Peritoneal Vaginoplasty

Introduction: For transfeminine patients desiring penetrative intercourse, several surgical reconstructive options exist including penile inversion vaginoplasty, peritoneal vaginoplasty, and sigmoid vaginoplasty. Penile inversion vaginoplasty requires preoperative laser hair removal that can be time consuming and costly. Sigmoid vaginoplasty requires bowel harvest and some patients are bothered by excess mucus secretion and odor. Peritoneal vaginoplasty, though without known long-term outcomes, foregoes the need for bowel harvest and preoperative laser hair removal. We present the first video of a robotic tubularized peritoneal vaginoplasty (RATPV) with penile skin inversion. Materials and Methods: We retrospectively reviewed all patients who underwent gender-affirming RATPV at our institution (July 2020–July 2022). Patient demographics, intraoperative details, and postoperative outcomes are described. RATPV involves dissecting and tubularizing a single anterior peritoneal flap (lateral borders: vas deferens, inferior border: retrovesical pouch). The distal end of the tubularized peritoneal flap is then anastomosed to the inverted nonhair bearing penile shaft skin. Results: In 33 patients, median age was 26 years old (interquartile range [IQR]: 24–37) and body mass index was 26 kg/m2 (IQR: 23–32). Median operative time was 406 minutes (IQR: 370–434) and robotic console time was 177 minutes (IQR: 154–220). Intraoperatively, median vaginal depth was 17 cm and diameter was 3+ cm. Median length of stay was 7 days. One-third (15) of patients had a complication within 30 days (40% Clavien–Dindo I, 60% Clavien II). There were no complications related to the robotic reconstruction. Conclusions: RATPV is a safe and effective option for individuals seeking gender-affirming vaginoplasty that obviates the need for laser hair removal before surgery. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No commercial associations occurred during the last 3 years that might create a conflict of interest with this video. Runtime of video: 5 mins 6 secs

Alternative surgical management of penile siliconoma using partial degloving and resurfacing

Siliconoma represents an inflammatory tissue response to extravasated silicone. Penile enhancing silicone injections have been described for over 50 years. Most of the publications report complications including negative effects on penile appearance and function which require corrective procedures. Penile circumferential skin and siliconoma excision with skin grafting has been described in multiple case reports and series as an effective and feasible option to remove the silicone and achieve good esthetic results. We describe a simple and feasible single stage procedure removing the siliconoma with adjacent non-viable skin while preserving 50% of healthy penile skin and resurfacing the defect with a split-thickness skin graft to treat a long-term complication of penile silicone injection associated with recurrent infections and a chronic skin ulceration. Partial excision of the affected penile skin and sili-conoma with defect resurfacing with a split-thickness skin graft is a feasible with good functional and cosmetic outcomes.