Penile Urethra Research Articles

V1-10 IS CONTINENCE POSSIBLE IN PATIENTS WITH DOUBLE BLOCK AT BLADDER NECK -PROSTATE AND MEMBRANO -BULBAR URETHRA AFTER PELVIC FRACTURE URETHRAL INJURY?

You have accessJournal of UrologyReconstruction Lower Tract (I)1 Apr 2017V1-10 IS CONTINENCE POSSIBLE IN PATIENTS WITH DOUBLE BLOCK AT BLADDER NECK -PROSTATE AND MEMBRANO -BULBAR URETHRA AFTER PELVIC FRACTURE URETHRAL INJURY? Pankaj Joshi, Devang Desai, Sandesh Surana, Hazem Orabi, Craig Hunter, and Sanjay Kulkarni Pankaj JoshiPankaj Joshi More articles by this author , Devang DesaiDevang Desai More articles by this author , Sandesh SuranaSandesh Surana More articles by this author , Hazem OrabiHazem Orabi More articles by this author , Craig HunterCraig Hunter More articles by this author , and Sanjay KulkarniSanjay Kulkarni More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.242AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Rarely, pelvic fracture urethral injury can cause simultaneous transection of bladder neck and membrano-bulbar junction. Mundy reported sequestration of prostate. In another report, they found 85% of patients of PFUI have functioning external urethral sphincter mechanism after successful anastomotic repair. This information helped in our development of a new technique for repair in such cases to preserve continence. METHODS We present a retrospective review of 8 patients .Preoperative evaluation requires MCU and RGU. Urethroscopy evaluates the membrano-bulbar obliteration. Antegrade cystoscopy confirms the bladder neck obliteration. Pelvic MRI is also obtained to check for the prostate. Perineal incision- bulbar urethra is mobilized and transected proximally. Suprapubic incision- posterior pubectomy is performed. An endoscope passed through SPC tract and blocked bladder neck area is opened from outside. Semen collected in the sequestrated prostatic urethra is aspirated with needle over which prostatic urethra is opened .A 6Fr endoscope is passed through the prostatic urethra distally to visualize the membranous urethra. The membranous urethra is opened perfectly under vision as distally as possible. Excision of the scar at the apex of membranous urethra is kept to minimum to preserve continence. Bulbo-Membranous Anastomosis (BMA) and bladder neck–prostatic anastomosis is performed . RESULTS Mean age 14 (5 to 36) yrs ,mean follow up 26 (14 to 72) months .Initial 2 adults are 100% incontinent . We then modified our technique of identifying membranous urethra through intraprostatic scopy and bulbo membranous anastomosis. The video is of an adult who underwent transpubic urethroplasty at age 7 for double block. As prostatic urethra was rudimentary bulbo vesical anastomosis was performed. He presented at age 18 years with pain after ejaculation. He was reoperated using our modified technique.1 adult and all 5 children were approached through the above improved technique. 2 (40%) children required redo surgery with for revision of the bladder neck anastomosis. as we had tried narrow anastomosis to help continence. All children are continent and have good flow, 2 have occasional nocturnal dribbling. CONCLUSIONS Double transection with injury at membrano-bulbar and prostate bladder neck junction requires two separate anastomoses to be performed. Postoperative continence is possible .Our step wise technique improved continence rates to ensure proper preservation of the external sphincter. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e70-e71 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Pankaj Joshi More articles by this author Devang Desai More articles by this author Sandesh Surana More articles by this author Hazem Orabi More articles by this author Craig Hunter More articles by this author Sanjay Kulkarni More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD29-02 OUTCOMES OF URETHROPLASTY TO TREAT STRICTURES ARISING FROM ARTIFICIAL URINARY SPHINCTER (AUS) EROSIONS AND RATES OF SUBSEQUENT AUS REIMPLANTATION

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II1 Apr 2017PD29-02 OUTCOMES OF URETHROPLASTY TO TREAT STRICTURES ARISING FROM ARTIFICIAL URINARY SPHINCTER (AUS) EROSIONS AND RATES OF SUBSEQUENT AUS REIMPLANTATION Sorena Keihani, Jason C. Chandrapal, Andrew C. Peterson, Joshua A. Broghammer, Nathan Chertack, Sean P. Elliott, Keith F. Rourke, Nejd F. Alsikafi, Jill C. Buckley, Thomas G. Smith, Bryan B. Voelzke, Lee C. Zhao, William O. Brant, and Jeremy B. Myers Sorena KeihaniSorena Keihani More articles by this author , Jason C. ChandrapalJason C. Chandrapal More articles by this author , Andrew C. PetersonAndrew C. Peterson More articles by this author , Joshua A. BroghammerJoshua A. Broghammer More articles by this author , Nathan ChertackNathan Chertack More articles by this author , Sean P. ElliottSean P. Elliott More articles by this author , Keith F. RourkeKeith F. Rourke More articles by this author , Nejd F. AlsikafiNejd F. Alsikafi More articles by this author , Jill C. BuckleyJill C. Buckley More articles by this author , Thomas G. SmithThomas G. Smith More articles by this author , Bryan B. VoelzkeBryan B. Voelzke More articles by this author , Lee C. ZhaoLee C. Zhao More articles by this author , William O. BrantWilliam O. Brant More articles by this author , and Jeremy B. MyersJeremy B. Myers More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1354AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urethral stricture can result after AUS cuff erosion. There is limited data describing the success of urethroplasty and the rate of AUS reimplantation in these patients. We hypothesized that urethroplasty and AUS reimplantation was feasible in most men. METHODS From 2009-2016, we identified patients from Trauma and Urologic Reconstruction Network of Surgeons (TURNS) database, as well as the Cleveland Clinic, Duke University, and University of Alberta. We included patients with a history of urethral stricture arising from AUS erosion who underwent urethroplasty ± subsequent AUS reimplantation. Information was gathered on demographics, initial AUS placement, stricture and urethroplasty specifics, AUS reimplantation, and outcomes. In results analysis we included men with follow up of > 3 months. RESULTS 31 men were identified. Mean age was 73.2 y (SD: 7.0). Radical prostatectomy was the etiology of incontinence in 87%, with 33% having radiation therapy. Prior to urethroplasty, patients had a median of 3 (range: 2-9) urethral operations. Mean duration of initial AUS was 43.4 months (SD: 39.9, range: 1-144) prior to erosion. Mean stricture length was 1.7 cm (SD: 0.8, range 0.5-4.5) found within the bulbar urethra in all cases (9 proximal, 16 middle, 6 distal). Anastomotic (28) and buccal graft substitution (3) urethroplasty were performed. 3/28 patients who had a urethrogram post-operatively had contrast extravasation; all resolved with observation. Post-operative complications included: wound infection (3), and myocardial infarction (1). 29 men had follow up > 3 months. Follow up cystoscopy was performed in 28 patients at a median of 4.5 months (range 2-42) and showed no recurrences. Overall mean follow up was 28.2 months (SD: 16.2, range 6.5-71). Two men had stricture recurrence, but these occurred after AUS reimplantation and repeat erosion. In 27 men (87%), AUS was replaced at mean of 6.2 months (SD: 2.6, range 3-13) after urethroplasty, with either transcorporal placement (18) or standard technique (9). 25 men had follow-up > 3 months after AUS (mean 23.1 months, SD: 15.1, range 4-57); operative complications occurred in 11/25 patients (44%) and included: pump migration (2), sub-cuff atrophy (3), and erosion (6). The 19 men with AUS remaining reported ≤1 pad per day leakage. CONCLUSIONS In patients with urethral stricture after AUS erosion, urethroplasty is very successful and AUS reimplantation rates are high. However, AUS reimplantation after urethroplasty has a high erosion rate even in the short-term. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e572 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Sorena Keihani More articles by this author Jason C. Chandrapal More articles by this author Andrew C. Peterson More articles by this author Joshua A. Broghammer More articles by this author Nathan Chertack More articles by this author Sean P. Elliott More articles by this author Keith F. Rourke More articles by this author Nejd F. Alsikafi More articles by this author Jill C. Buckley More articles by this author Thomas G. Smith More articles by this author Bryan B. Voelzke More articles by this author Lee C. Zhao More articles by this author William O. Brant More articles by this author Jeremy B. Myers More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V1-04 RECONSTRUCTION OF BULBO-MEMBRANOUS URETHRAL STRENOSIS AFTER SURGERY FOR BENIGN PROSTATIC HYPERPLASIA WITH PRESERVATION OF CONTINENCE

You have accessJournal of UrologyReconstruction Lower Tract (I)1 Apr 2017V1-04 RECONSTRUCTION OF BULBO-MEMBRANOUS URETHRAL STRENOSIS AFTER SURGERY FOR BENIGN PROSTATIC HYPERPLASIA WITH PRESERVATION OF CONTINENCE Cristina Baeza, Reynaldo Gomez, Rodrigo Campos, and Laura Velarde Cristina BaezaCristina Baeza More articles by this author , Reynaldo GomezReynaldo Gomez More articles by this author , Rodrigo CamposRodrigo Campos More articles by this author , and Laura VelardeLaura Velarde More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.236AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Bulbo-membranous urethral stenosis after surgery for benign prostate hyperplasia (BPH) are challenging because the internal sphincter has been removed and continence depends on the function of the external sphincter, which is located just at the site of the stenosis; any attempt for reconstruction may jeopardize continence. Anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue. We developed a novel technique performing a meticulous dissection of this sheath to separate the muscle from the urethral wall, thus performing an intra-sphincteric anastomosis without disturbing the sphincteric function METHODS A 67 year old patient underwent a transvesical simple prostatectomy for BPH. He developed an early bulbo-membranous stenosis managed initially with repeated dilation until he went into complete retention needing a suprapubic tube. The bulbar urethra is exposed through a vertical perineal incision with splitting of the bulbo-spongiosum muscle and then separated from the corpus cavernosum. Opening of the perineal membrane and splitting of the intercrural space in the midline, provides access to the dorsal aspect of the bulbo-membranous junction. The bulb is then mobilized to the left side, without detachment from the perineal body and the bulbar vessels are retracted. The sheath of the membranous urethra is now opened circumferentially at the bulbo-membranous junction, carefully reflecting the circular muscle fibers of the external sphincter until exposure of the urethral wall is obtained and the connecting tissue plane is identified. Gentle blunt proximal dissection along this plane allows separating the muscle away from the urethra towards the prostatic apex until healthy urethra is found to perform the bulbo-prostatic anastomosis, which is completed with a standard parachute technique. Finally the sphincteric muscle ring is anchored to the anastomosis with interrupted absorbable stitches RESULTS The patient was discharged on PO day 3 and the urethral catheter was removed at 3 weeks. He recovered normal continent micturition and is voiding symptoms free at 3 months of follow-up CONCLUSIONS Excision and bulbo-prostatic anastomosis with sphincter sparing for bulbo-membranous stenosis after BPH surgery is feasible and safe. Our technique allows repairing the urethra preserving continence and to our knowledge it has not been described before. A larger series and reproduction in other centers are needed to validate this technique © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e68-e69 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Cristina Baeza More articles by this author Reynaldo Gomez More articles by this author Rodrigo Campos More articles by this author Laura Velarde More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD63-12 EXCISION AND PRIMARY ANASTOMOSIS RECONSTRUCTION FOR TRAUMATIC STRICTURES OF THE PENILE URETHRA

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) II1 Apr 2017PD63-12 EXCISION AND PRIMARY ANASTOMOSIS RECONSTRUCTION FOR TRAUMATIC STRICTURES OF THE PENILE URETHRA Boyd Viers, Billy Cordon, Travis Pagliara, Jeremy Scott, Noel Armenakas, and Allen Morey Boyd ViersBoyd Viers More articles by this author , Billy CordonBilly Cordon More articles by this author , Travis PagliaraTravis Pagliara More articles by this author , Jeremy ScottJeremy Scott More articles by this author , Noel ArmenakasNoel Armenakas More articles by this author , and Allen MoreyAllen Morey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2936AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Anastomotic urethroplasty has long been recognized as a reliable method of reconstruction for focal, severe bulbar urethral strictures. The role of excision and primary anastomosis (EPA) is less well defined for penile urethral strictures due to concerns for potential compromise of sexual function. We report a multi-institutional experience with functional outcomes among men undergoing EPA of pendulous urethral strictures. METHODS A retrospective review was conducted of over 2000 urethroplasty patients from two tertiary referral centers from 1995-2016. We identified 13 men treated with EPA for isolated penile urethral strictures, with radiographically confirmed location between the penoscrotal junction and urethral meatus. Clinical characteristics and outcomes are described. Validated questionnaires were utilized to evaluate overall improvement (PGI-I), urinary bother (I-PSS), sexual function (IIEF-5), as well as symptoms related to penile curvature (PDQ). RESULTS Among the 13 men who underwent EPA for penile urethral strictures, strictures were focal (median length 1cm, IQR 1-1.4) and median follow-up was 31 months (IQR 5-110). Only 1/12 (8%) men experienced a treatment failure requiring further instrumentation. None reported new onset penile curvature or curvature related bother (PDQ) following treatment. The majority of men had stricture etiology reported as trauma (10/13, 77%), of which 4 had a history of urethral disruption secondary to penile fracture and 6 iatrogenic trauma. Median patient age was 51 years (IQR 30-60); and 8/12 (67%) had normal preoperative erectile function. After stricture treatment, 75% of men reported a significant global improvement in condition (PGI-I). Sexually active men reported normal erectile function (median IIEF 21 (IQR 19-25), and the majority had only mild urinary bother (median IPSS 4 (IQR 2-14)). The single treatment failure had a history of hypospadias with multiple prior procedures who now requires intermittent catheterization. CONCLUSIONS Among selected patients with focal traumatic strictures involving the penile urethra, EPA appears to be highly effective with negligible impairment of erectile function. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1259 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Boyd Viers More articles by this author Billy Cordon More articles by this author Travis Pagliara More articles by this author Jeremy Scott More articles by this author Noel Armenakas More articles by this author Allen Morey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V1-07 CLAMPO-TRACTOR. A NOVEL SELF RETAINING CLAMP RETRACTOR FOR PENILE URETHRAL RECONSTRUCTION: IMPROVING SURGEON ERGONOMICS

You have accessJournal of UrologyReconstruction Lower Tract (I)1 Apr 2017V1-07 CLAMPO-TRACTOR. A NOVEL SELF RETAINING CLAMP RETRACTOR FOR PENILE URETHRAL RECONSTRUCTION: IMPROVING SURGEON ERGONOMICS Pankaj Joshi and Sanjay Kulkarni Pankaj JoshiPankaj Joshi More articles by this author and Sanjay KulkarniSanjay Kulkarni More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.239AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Constant, steady retraction and exposure are important for penile surgery - including hypospadias repair, urethral reconstruction, and correction of penile curvature. We set out to develop a retractor that would improve surgeon and assistant ergonomics and provide compression at the base of the penis to reduce blood loss. We describe this novel self-retaining penile retractor and our initial experience in its use. METHODS This retractor is made of medical grade stainless steel. It has three components – a fixed hemostatic clamp attached to a scale, with also houses an artery forceps. This forceps moves along the scale to adjust the traction on the penis. The clamp is flat and compressive. The arms are non-traumatic and do not cause circumferential constriction. A stay suture taken through the glans is engaged by the artery forceps, and the height adjusted according to the penile length. The retractor has been used by reconstructive urologists in India, Turkey, Australia, Kuwait, Indonesia, and the United States of America. RESULTS A total of 37 reconstructive cases were performed using this penile retractor (23 redo hypospadias repairs, 7 complex penile urethroplasties, 4 penile urethrocutaneous fistula repairs, and 3 surgeries for correction of Peyronie's disease). For each case, surgeons were asked to score the retractor on a 4 point scale: 1. Extremely Non satisfactory, 2. Not Satisfactory, 3. Satisfactory, 4. Extremely Satisfactory. The average score was 3.65. Advantages noted were ease of application, reduction of assistant fatigue, stable operative exposure and non-traumatic tissue compression conferring a bloodless field. There were no complications attributable to the device. The main limitation is that it cannot be used for hypospadias proximal to the penoscrotal junction. This retractor is inexpensive, durable and easy to sterilize and can be used on adult and pediatric patients alike. CONCLUSIONS In our experience this retractor has high utility in reconstruction of the penis and penile urethra. It affords improved ergonomics for the surgeon and assistant, which results in shorter operative times and reduced blood loss while avoiding tissue damage. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e69-e70 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Pankaj Joshi More articles by this author Sanjay Kulkarni More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP36-13 CHANGES IN NOCTURNAL BLADDER DIARY PARAMETERS IN MEN AFTER URETHROPLASTY FOR ANTERIOR URETHRAL STRICTURES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) I1 Apr 2017MP36-13 CHANGES IN NOCTURNAL BLADDER DIARY PARAMETERS IN MEN AFTER URETHROPLASTY FOR ANTERIOR URETHRAL STRICTURES Rajveer Purohit, Jyoti D. Chouhan, frank copeli, Dennis Robins, Andrew Tam, and Jeffrey P Weiss Rajveer PurohitRajveer Purohit More articles by this author , Jyoti D. ChouhanJyoti D. Chouhan More articles by this author , frank copelifrank copeli More articles by this author , Dennis RobinsDennis Robins More articles by this author , Andrew TamAndrew Tam More articles by this author , and Jeffrey P WeissJeffrey P Weiss More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1124AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We evaluated changes in nocturnal voiding patterns of men before and after anterior urethroplasty for urethral stricture disease using a pre-operative and post-operative 24 hour bladder diary. METHODS This was a retrospective study of men undergoing anterior urethroplasty for urethral stricture who completed a pre-operative and post-operative 24 hour bladder diary. Diaries done anytime prior to surgery and at least 1 month after surgery were included. Patients recorded the volume, time of void and degree of urgency of voids. Paired t-tests were performed on nocturnal voiding variables. RESULTS 18 men had preoperative and post-operative 24 hour bladder diaries. The mean age was 45.4 years (median 46.5,range, 26-70). 13 strictures were bulbar (72.2%), 4 pendulous-bulbar (22.2%), and 1 in the penile urethra (5.6%). Type of surgery included 6 (33%) buccal mucosa onlay grafts (5 dorsal, 1 ventral), augmented anastomotic repair, (n=2, 11.1%), and excision and primary anastomosis (n=10, 55.6%). Mean days from surgery to first post-operative 24 hour bladder diary was 287.5 days (median 109, range, 32-1116). Maximum voided volume increased after surgery (p = 0.02). Overall, nocturnal voiding parameters improved after urethroplasty and trended towards significance primarily by increases in functional bladder capacity measured by the maximum voided volume (mean preop 333ml, post-op 406.6, p=0.02), number of nightly voids (mean 1.8 to 1.2, p=0.07), and the nocturnal bladder capacity index (mean 1.2 to 0.8, p=0.13) and the correlation of the degree of urgency with the voided volume (Spearman's rho mean 0.5 to 0.6, p=0.09). Urethroplasty did not improve nocturnal voiding parameters by changes in urine production as measured by changes in the 24 hour voided volume, nocturnal urine volume, the nocturnal urine production rate or the nocturnal polyuria index. CONCLUSIONS Anterior urethral reconstruction improves nocturnal voiding parameters by improving functional bladder capacity. The maximum voided volume, actual night time voids, nocturnal bladder capacity index and Spearman's rho most significantly improved. This is the first study evaluating changes in nocturnal voiding function after urethroplasty. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e470-e471 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Rajveer Purohit More articles by this author Jyoti D. Chouhan More articles by this author frank copeli More articles by this author Dennis Robins More articles by this author Andrew Tam More articles by this author Jeffrey P Weiss More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP79-09 TITLE: ROBOT ASSISTED PENILE INVERSION VAGINOPLASTY A DESCRIPTION OF A NOVEL TECHNIQUE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) I1 Apr 2017MP79-09 TITLE: ROBOT ASSISTED PENILE INVERSION VAGINOPLASTY A DESCRIPTION OF A NOVEL TECHNIQUE Brenton Armstrong, Aaron Weinberg, Kiranpreet Khurana, Jamie Levine, and Lee Zhao Brenton ArmstrongBrenton Armstrong More articles by this author , Aaron WeinbergAaron Weinberg More articles by this author , Kiranpreet KhuranaKiranpreet Khurana More articles by this author , Jamie LevineJamie Levine More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2493AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Gender confirmation surgery represents an essential component in the management of gender identity disorder. The perineal dissection and creation of the neovaginal canal is the most challenging aspect of the penile inversion vaginoplasty (PiV) and poor visualization can lead to surgical complications. An incomplete dissection also results in a foreshortened neovagina, increased risk for vaginal stenosis and need for excessive postoperative dilations. Here we present the results of our first 15 patients performed at our intuition utilizing our robot assisted PiV (RAPiV). METHODS 15 transgender patients who were already living as females presented to our institution from 1/2016 to 10/2016, and underwent our previously defined RAPiV. Briefly, the RAPiv is performed in the low lithotomy position and the penis is degloved through a circumcision incision. An additional perineal incision is made to the bulbar urethra. The dissected penis, urethra, neurovascular bundle, glans and corpora are delivered through the perineal incision (Figure 1a). We spare the dorsal aspect of the tunica of the corpora cavernosa to reduce risk of glans necrosis. Four robotic ports were placed and the abdomen was insufflated (1b) and robot docked. Denonviller's fascia is opened (1c) and the abdominal dissection is continued to the peritoneal one (1d), the neovagina is passed into robotic field (1e) and pexed to the anterior reflection of the posterior peritoneum (1f). The peritoneal reflection is then closed (1g). We then complete the labioplasty and clitoroplasty. RESULTS The average operative time for RAPiV was 5.8 hours (5-7), 8/15 (53%) required mobilization of additional tissue flaps (4/15, 27%) or underwent concomitant abdominoplasty and skin graft harvest (4/15 27%) to supplement penile skin. EBL was 386cc (100-600) and LOS was 3.7 (2-6). Average postoperative vaginal depth was 11.3cm (10.2-12.7). Two patients had complications, 1 dehiscence of labioplasty treated with conservative therapy and 1 had loss of neovagina depth and distal urethral stenosis secondary to wound infection requiring debridement. CONCLUSIONS We have performed 15 cases utilizing our novel method for robot assisted penile inversion vaginoplasty. Under direct visualization the neovaginal canal is created. This technique achieves maximal vaginal length in a reproducible manner. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1075-e1076 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Brenton Armstrong More articles by this author Aaron Weinberg More articles by this author Kiranpreet Khurana More articles by this author Jamie Levine More articles by this author Lee Zhao More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V5-07 PERINEAL ARTIFICIAL URINARY SPHINCTER (AUS) WITH HIGH SUBMUSCULAR (HSM) PLACEMENT OF PRESSURE REGULATING BALLOON (PRB)

You have accessJournal of UrologyBPH and Voiding Dysfunction1 Apr 2017V5-07 PERINEAL ARTIFICIAL URINARY SPHINCTER (AUS) WITH HIGH SUBMUSCULAR (HSM) PLACEMENT OF PRESSURE REGULATING BALLOON (PRB) Billy Cordon and Allen Morey Billy CordonBilly Cordon More articles by this author and Allen MoreyAllen Morey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1412AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In patients undergoing Artificial Urinary Sphincter (AUS) placement, with a history of major pelvic surgery, avoidance of the Space of Retzius with traditional placement of the Pressure Regulating Balloon (PRB) may be beneficial. This video presents perineal AUS placement with high submuscular placement (HSM) of the PRB. METHODS A perineal incision provides excellent exposure of the bulbar urethra for proximal bulbar urethral cuff placement. Via a separate 2cm high scrotal incision the external inguinal ring is identified. A pediatric Deaver is placed within the superficial ring and blunt finger dissection used above the transversalis fascia develops a space below the rectus that accommodates the PRB. Using one's index finger the PRB is then easily placed in the HSM space without any additional instrumentation. Finally through this same incision a subdartos pouch is created for pump placement. The AUS is cycled and deactivated and the wound is closed in multiple layers. RESULTS There is no difference in revision rates between HSM PRB placement versus Space of Retzius placement. CONCLUSIONS HSM placement of the PRB at the time of AUS implantation avoids the Space of Retzius with associated potential bladder, bowel, or vascular injury and/or complications. HSM placement avoids peritoneal placement post-robotic prostatectomy. HSM placement is safe, effective, can easily be learned and implemented, and may be used with concomitant IPP placement. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e601 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Billy Cordon More articles by this author Allen Morey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

P-01-055 Penile fracture with complete urethral rupture in 29 years old male. Primary delayed surgical repair

Penile fracture is often accompanied by various forms of urethral trauma. Even though the gold standard is immediate surgical repair, delayed repair is possible and has comparable outcome when performed in specialized centres. Our goal is to present the surgical repair of a fractured penis with complete urethral rupture, 7 days after the trauma occurred. A 29 years old male was admitted to the Urological department with 7 days history of sudden cracking sound followed by severe pain and swallowing of the penis, which occurred during sexual intercourse. The patient was first admitted to another hospital where a suprapubic catheter was placed following unsuccessful placement of a Foley catheter. The patient had severe contusion localized in penile shaft, clearly contained by Buck’s fascia. Ultrasound evaluation revealed a discontinuation of tunica albuginea and blurring of the surrounding tissues, due to a hematoma. The patient underwent an urethrography where a mass extravasation of the contrast mean was demonstrated. Therefore he was lead to the operating theater where he underwent penis deglovement. After the hematoma was removed, a complete urethral disruption was revealed, at the level of penile urethra, along with tunica’s albuginea of both corpora cavernosa. What followed was suturing of tunica’s disruption and repairing of the urethral defect using buccal mucosa after the positioning of a 16 Fr Foley catheter.

The role of male slings in post prostatectomy incontinence: ICI-RS 2015.

Post prostatectomy stress urinary incontinence can significantly impact on quality of life and is bothersome for patients. The artificial urinary sphincter is still considered the gold standard surgical treatment. Male slings are an alternative surgical option and several designs are currently available. This review will focus on efficacy, adverse events, and mechanism of action of male slings. The context of this review was a proposal at the ICI-RS meeting 2015. Following synthesis of the evidence we address the question: does it matter how male slings work? The proposal lecture was reviewed and a comprehensive review of the literature undertaken utilising the PubMed database. Male slings can be broadly divided into adjustable retropubic and suburethral transobturator slings. Male slings are efficacious and can improve quality of life. Adjustable retropubic slings appear to be compressive but studies suggest efficacy can be achieved without voiding dysfunction. Transobturator slings work by urethral compression and/or re-locating the urethral bulb. There is a recognized failure rate in all sling types and most studies suggest radiotherapy as a risk factor for failure. Adjustable slings have the ability to be altered to optimize continence or to prevent retention of urine. However, there appears to be a higher explantation rate in some of these systems. It is important to understand how male slings work and by doing so we are more reliably able to choose the appropriate sling, predict outcomes, and as a result counsel patients. Suggestions for future research are proposed.

Urethral reconstruction with autologous urine-derived stem cells seeded in three-dimensional porous small intestinal submucosa in a rabbit model

BackgroundUrethral reconstruction is one of the great surgical challenges for urologists. A cell-based tissue-engineered urethra may be an alternative for patients who have complicated long strictures and need urethral reconstruction. Here, we demonstrated the feasibility of using autologous urine-derived stem cells (USCs) seeded on small intestinal submucosa (SIS) to repair a urethral defect in a rabbit model.MethodsAutologous USCs were obtained and characterized, and their capacity to differentiate into urothelial cells (UCs) and smooth muscle cells (SMCs) was tested. Then, USCs were labeled with PKH67, seeded on SIS, and transplanted to repair a urethral defect. The urethral defect model was surgically established in New Zealand white male rabbits. A ventral urethral gap was created, and the urethral mucosa was completely removed, with a mean rabbit penile urethra length of 2 cm. The urethral mucosal defect was repaired with a SIS scaffold (control group: SIS with no USCs; experimental group: autologous USC-seeded SIS; n = 12 for each group). A series of tests, including a retrograde urethrogram, histological analysis, and immunofluorescence, was undertaken 2, 3, 4, and 12 weeks after the operation to evaluate the effect of the autologous USCs on urethral reconstruction.ResultsAutologous USCs could be easily collected and induced to differentiate into UCs and SMCs. In addition, the urethral caliber, speed of urothelial regeneration, content of smooth muscle, and vessel density were significantly improved in the group with autologous USC-seeded SIS. Moreover, inflammatory cell infiltration and fibrosis were found in the control group with only SIS, but not in the experimental autologous USC-seeded SIS group. Furthermore, immunofluorescence staining demonstrated that the transplanted USCs differentiated into UCs and SMCs in vivo.ConclusionsAutologous USCs can be used as an alternative cell source for cell-based tissue engineering for urethral reconstruction.

Use of a fibrovascular tube in creation of neo-urethra during penile reconstruction

There are several techniques employed in the surgical treatment of total or partial penile reconstruction, hypospadias surgery, and urethral stricture. Urethral reconstruction is performed in different ways applying these techniques. We evaluated use of a fibrovascular sheath to create a neo-urethra formed around a silicon tube. We used nine male New Zealand rabbits for this study. In the first step, we placed a silicone tube under the skin in the lower abdomen of the rabbits and waited for the formation of a fibrovascular sheath to totally surround the tube. In the second step, the silicone tube was removed and the formed fibrovascular sheath was anastomosed with penile urethra over a silicone 8F Foley catheter. Ten days after the second step, the silicone Foley catheter was removed. Twenty days after the second step, we evaluated the newly created neo-urethra with a retrograde urethrogram. Thirty days after the second step, the rabbits were sacrificed and the bladder, urethra, and neo-urethra were removed for histopathological examination. Six of the rabbits completed the study. After the first operation, in the third month, formation of the fibrovascular sheath was observed around the silicon tube. After anastomosis and removal of the silicon Foley catheter, urine was seen to pass through the neo-urethral meatus. Urethrocystography showed that the neo-urethra and penile urethra were aligned and urine flow was regular. Histopathological evaluation showed that the structural integrity of the newly formed urethra was comparable with the structure of the regular urethra (Table) and the calibration did not change over time, although the newly formed urethra was not covered with uroepithelium. In this study, we achieved promising results with use of a newly formed fibrovascular sheath as a neo-urethra.

Routine Urethrography After Buccal Graft Bulbar Urethroplasty: The Impact of Initial Urethral Leak on Surgical Success

To determine the long-term impact of extravasation at initial post-urethroplasty urethrogram, we present a novel classification system and report the association of leak severity with outcome. A total of 91 patients underwent buccal graft urethroplasties of the bulbar urethra from 2007 to 2015. Median time to urethrogram was 23 days. All leaks were characterized by length and width. Cutoffs for length and width were calculated using receiver operating characteristic curves. Each urethrogram was graded 0-3 (0 = no leak) with 1 point given for any leak, length ≥1.03 cm, and width ≥0.32 cm. Failure was stricture recurrence on cystoscopy. One-year failures were compared using Fisher test. Kaplan-Meier curves were constructed to measure the impact of variables on recurrence. Mean age was 46.1 years. Of 91 urethroplasties, 31 had extravasation on initial imaging. With median follow-up of 11 months, 15 patients had stricture recurrence, 6 of whom had leak on initial urethrogram. For patients with at least 1 year of follow-up, there was no difference at 1 year for failures, as to any leak (P = .220), length (P = 1.000), width (P = 1.000), or grade (P = .823). Grade 3 was associated with higher failure rates compared with grades ≤2 using Kaplan-Meier curves (P = .031), with the curves significantly diverging around the 1-year mark. Similarly, length ≥1.03 cm was associated with higher failure rates compared with <1.03 cm beyond 1 year (P = .044). Although there is no indication that leaks at 3 weeks are associated with short-term failure, leak length and width appear to be a predictor of longer term recurrence (>1 year).

Our experience with progressive perineal urethroplasty and anastomotic urethroplasty in post-traumatic urethral strictures in pediatric patients

Background: Confined perineum and elevated prostate and bladder in children make management of post-traumatic stricture in children technically difficult.Methods: A retrospective study of patients from 2007 till September 2016 was conducted. 15 pediatric patients with a mean age of 7.3 years presented with post traumatic urethral stricture or distraction defect. 11 patients had pelvic fracture urethral distraction defect (PFUDD) and underwent PPU. Four had bulbar stricture caused by straddle injury and underwent EEU. Post operatively patients were evaluated using uroflowmetry at 3, 6 and 12 months. Maximum velocity of less than 10 ml/s and symptoms of straining was considered as recurrence and such cases were evaluated further with MCU, RGU and cystoscopy.Results: Mean stricture length was of 2.3 cm and was at bulbo-membranous junction in 11 and in proximal bulbar urethra in 4. Of the 11 PPUs, crural separation was done in nine and inferior pubectomy in six patients. Transpubic approach was required in one patient. Gracilis flap was placed in one patient as an onlay over anastomotic urethroplasty. Of the 11 PPUs, 2 patients and 1 of 4 EEU patients had recurrence. All recurrent strictures were &lt;1.5 cm long and at the site of the anastomosis. Two patients were managed with anastomotic urethroplasty. The remaining one patient could be managed with laser visual internal urethrotomy.Conclusions: PPU and EEU are treatment of choice in paediatric patients with PFUDD and proximal bulbar strictures respectively. Both are technically feasible, have good outcome and have an acceptable morbidity.

Experimental investigation of the structural behavior of equine urethra

Background and objectiveAn integrated experimental and computational investigation was developed aiming to provide a methodology for characterizing the structural response of the urethral duct. The investigation provides information that are suitable for the actual comprehension of lower urinary tract mechanical functionality and the optimal design of prosthetic devices. MethodsExperimental activity entailed the execution of inflation tests performed on segments of horse penile urethras from both proximal and distal regions. Inflation tests were developed imposing different volumes. Each test was performed according to a two-step procedure. The tubular segment was inflated almost instantaneously during the first step, while volume was held constant for about 300s to allow the development of relaxation processes during the second step. Tests performed on the same specimen were interspersed by 600s of rest to allow the recovery of the specimen mechanical condition. Results from experimental activities were statistically analyzed and processed by means of a specific mechanical model. Such computational model was developed with the purpose of interpreting the general pressure-volume-time response of biologic tubular structures. The model includes parameters that interpret the elastic and viscous behavior of hollow structures, directly correlated with the results from the experimental activities. ResultsPost-processing of experimental data provided information about the non-linear elastic and time-dependent behavior of the urethral duct. In detail, statistically representative pressure-volume and pressure relaxation curves were identified, and summarized by structural parameters. Considering elastic properties, initial stiffness ranged between 0.677 ± 0.026kPa and 0.262 ± 0.006kPa moving from proximal to distal region of penile urethra. Viscous parameters showed typical values of soft biological tissues, as τ1=0.153±0.018s, τ2=17.458 ± 1.644s and τ1=0.201 ± 0.085, τ2= 8.514 ± 1.379s for proximal and distal regions respectively. DiscussionA general procedure for the mechanical characterization of the urethral duct has been provided. The proposed methodology allows identifying mechanical parameters that properly express the mechanical behavior of the biological tube. The approach is especially suitable for evaluating the influence of degenerative phenomena on the lower urinary tract mechanical functionality. The information are mandatory for the optimal design of potential surgical procedures and devices.

Analyse des taux de succès des urétroplasties pour sténoses de l’urètre bulbaire chez l’homme adulte : revue systématique de la littérature

The aim of this review of literature was to evaluate the success rates of different techniques of urethroplasty for strictures of the bulbar urethra. We performed a systematic review of the MEDLINE literature from 2004 to 2015 following the PRISMA's statement recommendations. Key words were: urethroplasty, urethral reconstruction, onlay, graft, urethral stricture. Inclusion criteria were original articles describing the results of urethroplasty for bulbar urethral stricture in an adult male population. A minimum follow-up of 24 months was required. From 891 articles of the literature, 20 are studied in this review. Only 3 studies were prospective. The success rate of anastomotic urethroplasty varied from 68.7 to 98.8% for strictures from 1 to 3.5cm, from 60 to 96.9% for augmented urethroplasty performed for strictures from 4.2 to 4.7cm. Substitution urethroplasty with grafts presented from 75 to 89.8% of success for strictures from 2.6 and 4.36cm. Overall, 19/20 studies used buccal mucosal graft. The success rate of urethroplasty for bulbar urethral stricture is high; the surgical technique should be adapted to the length of the stricture.

Treatment of long anterior urethral stricture associated to lichen sclerosus

IntroductionPanurethral stricture associated with lichen sclerosus is a therapeutic challenge. We present the analysis of our results using two urethroplasty techniques based on oral mucosa graft. Material and methodRetrospective study in patients with long anterior urethral stricture (>8cm) associated with lichen sclerosus. Patients received urethroplasty with oral mucosa graft technique according Kulkarni (n=25) or two-step Johanson–Bracka urethroplasty (n=15). Demographics, operative time, complications (Clavien–Dindo), hospital stay, days with catheter, EAV postoperative pain, failure rate, need for retreatment and functional data including IPSS, QoL, Qmax, post void residual (PVR) are evaluated. ResultsIn all cases there was involvement of glandular and penile urethra, and in 75% of bulbar urethra. A single graft was used in 22.5%, two in 72.5% and three in 5%. Patients treated at a single step were younger (p=0.007). Although the length of the stenosis was equivalent in both techniques (p=0.96), relapse and complication rates were higher in two-step surgery (p=0.05 and p=0.03; respectively) and so was operative time (p<0.0001) and overall stay (p=0.0002). There were no differences in preoperative IPSS, QoL, Qmax or PVR, neither in postoperative values of IPSS or Qmax; but there was a difference in QoL (p=0.006) and PVR (p=0.03) favoring single-step urethroplasty. VAS pain on postoperative day 1 was also lower in Kulkarni urethroplasty than in the first step of Johanson–Bracka technique (p<0.0001). ConclusionsIn patients with lichen sclerosus and long anterior urethral stricture Kulkarni urethroplasty provides more efficient and better patient reported outcomes than Johanson–Bracka urethroplasty. It also prevents cosmetic, sexual and voiding temporary deterioration inherent to 2-step surgery.

Eruption of blood: Arteriovenous malformation of the penile urethra

While arteriovenous malformations (AVMs) are a common congenital or post-traumatic abnormality, male genital AVMs are rare and have been described in the scrotum or penis in pediatric patients.1,2 We describe a 34-year-old male presenting with recurrent spontaneous penile urethral bleeding found to have an AVM of the penile urethra. While angiography has traditionally been helpful, magnetic resonance imaging (MRI) can aid in the diagnosis and characterization of these lesions.3 Each case of male genital AVM provides a unique challenge to manage depending on the presenting complaint, as there are no guidelines to direct treatment.4.

Incidence of Urethral Stricture in Patients with Adult Acquired Buried Penis.

Introduction. Concealed-buried penis is an acquired condition associated with obesity, challenging to both manage and repair. Urethral stricture is a more common disorder with multiple etiologies. Lichen sclerosus is a significant known cause of urethral stricture, implicated in up to 30%. We hypothesize that patients with buried penis have a higher rate of urethral stricture and lichen sclerosus than the general population. Methods. We retrospectively reviewed a single surgeon's (CM) case logs for patients presenting with a buried penis. All patients were evaluated for urethral stricture with cystoscopy or retrograde urethrogram either prior to or at the time of repair for buried penis. Those that had surgical repair or biopsy were reviewed for presence of lichen sclerosus. Results. 39 patients met inclusion criteria. Of these, 13 (33%) had associated stricture disease. The location of the strictures was bulbar urethra (38%), penile urethra (15%), and meatus or fossa navicularis (62%). Five patients had lichen sclerosus and urethral stricture disease, while 3 had lichen sclerosus without stricture. 11/13 stricture patients were treated. Six underwent dilation, 3 underwent meatotomy, and 2 underwent urethroplasty. No significant recurrences of stricture were seen. Conclusion. Patients with a concealed penis are more likely than the general population to have a urethral stricture and/or LS. Patients presenting with concealed penis should also be evaluated for a urethral stricture.

Urethral strictures after bipolar transurethral resection of prostate may be linked to slow resection rate.

PurposeThis study aimed to determine the urethral stricture (US) rate and identify clinical and surgical risk factors associated with US occurrence after transurethral resection of the prostate using the bipolar Gyrus PlasmaKinetic Tissue Management System (PK-TURP).Materials and MethodsThis was an age-matched case-control study of US occurrence after PK-TURP. Retrospective data were collected from the hospital records of patients who had a minimum of 36 months of follow-up information. Among the data collected for analysis were prostate-specific antigen level, estimated prostate weight, the amount of prostate resected, operative time, history of urinary tract infection, previous transurethral resection of the prostate, and whether the PK-TURP was combined with other endourological procedures. The resection rate was calculated from the collected data. Univariate and multivariate analyses were performed to identify clinical and surgical risk factors related to US formation.ResultsA total of 373 patients underwent PK-TURP between 2003 and 2009. There were 13 cases of US (3.5%), and most of them (10 of 13, 76.9%) presented within 24 months of surgery. Most of the US cases (11 of 13, 84.6%) occurred at the bulbar urethra. Multivariable logistic regression analyses identified slow resection rate as the only risk factor significantly associated with US occurrence.ConclusionsThe US rate of 3.5% after PK-TURP in this study is comparable to contemporary series. A slow resection rate seems to be related to US occurrence. This should be confirmed by further studies; meanwhile, we must be mindful of this possibility when operating with the PK-TURP system.