Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis.

PURPOSE: The treatment of urethral stenosis after a combination of prostatectomy and radiation therapy for prostate cancer is understudied. We evaluate the clinical and patient-related outcomes after dorsal onlay buccal mucosal graft urethroplasty (D-BMGU) in men who underwent prostatectomy and radiation therapy. MATERIALS AND METHODS: A multi-institutional, retrospective review of men with vesicourethral anastomotic stenosis or bulbomembranous urethral stricture disease after radical prostatectomy and radiation therapy from 8 institutions between 2013 to 2021 was performed. The primary outcomes were stenosis recurrence and development of de novo stress urinary incontinence. Secondary outcomes were surgical complications, changes in voiding, and patient-reported satisfaction. RESULTS: Forty-five men were treated with D-BMGU for stenosis following prostatectomy and radiation. There was a total of 7 recurrences. Median follow-up in patients without recurrence was 21 months (IQR 12-24). There were no incidents of de novo incontinence, 28 patients were incontinent pre- and postoperatively, and of the 6 patients managed with suprapubic catheter preoperatively, 4 were continent after repair. Following repair, men had significant improvement in postvoid residual, uroflow, International Prostate Symptom Score, and International Prostate Symptom Score quality-of-life domain. Overall satisfaction was +2 or better in 86.6% of men on the Global Response Assessment. CONCLUSIONS: D-BMGU is a safe, feasible, and effective technique in patients with urethral stenosis after a combination of prostatectomy and radiation therapy. Although our findings suggest this technique may result in lower rates of de novo urinary incontinence compared to conventional urethral transection and excision techniques, head-to-head comparisons are needed.

Urinary Reconstruction in Genital Gender-Affirming Surgery: Checking Our Surgical Complication Blind Spots.

BACKGROUND: Urologic complications in genital gender-affirming surgery are imperfectly measured, with existing evidence limited by "blind spots" that will not be resolved through implementation of patient-reported outcomes alone. Some blind spots are expected in a surgical field with rapidly expanding techniques, and they may be exacerbated by factors related to transgender health. METHODS: The authors provide a narrative review of systematic reviews published in the past decade to describe the current options for genital gender-affirming surgery and surgeon-reported complications, as well as contrasting peer-reviewed sources with data not reported by the primary surgeon. In combination with expert opinion, these findings help estimate complication rates. RESULTS: Eight systematic reviews describe complications in patients undergoing vaginoplasty, including 5% to 16.3% mean incidence of meatal stenosis and 7% to 14.3% mean incidence of vaginal stenosis. Compared with surgeon-reported cohorts, patients undergoing vaginoplasty or vulvoplasty in other reports had higher rates of voiding dysfunction (47% to 66% versus 5.6% to 33%), incontinence (23% to 33% versus 4% to 19.3%), or misdirected urinary stream (33% to 55% versus 9.5% to 33%). Outcomes in six reviews of phalloplasty and metoidioplasty included urinary fistula (14% to 25%), urethral stricture or meatal stenosis (8% to 12.2%), and ability to stand to void (73% to 99%). Higher rates of fistula (39.5% to 56.4%) and stricture (31.8% to 65.5%) were observed in alternate cohorts, along with previously unreported complications such as vaginal remnant requiring reoperation. CONCLUSIONS: The literature does not completely describe urologic complications of genital gender-affirming surgery. In addition to standardized, robustly validated patient-reported outcome measures, future research on surgeon-reported complications would benefit from using the IDEAL (idea, development, exploration, assessment, and long-term study) framework for surgical innovation.

Complications after Prostate Cancer Treatment: Pathophysiology and Repair of Post-Radiation Urethral Stricture Disease.

Radiation therapy (RT) in the management of pelvic cancers remains a clinical challenge to urologists given the sequelae of urethral stricture disease secondary to fibrosis and vascular insults. The objective of this review is to understand the physiology of radiation-induced stricture disease and to educate urologists in clinical practice regarding future prospective options clinicians have to deal with this condition. The management of post-radiation urethral stricture consists of conservative, endoscopic, and primary reconstructive options. Endoscopic approaches remain an option, but with limited long-term success. Despite concerns with graft take, reconstructive options such as urethroplasties in this population with buccal grafts have shown long-term success rates ranging from 70 to 100%. Robotic reconstruction is augmenting previous options with faster recovery times. Radiation-induced stricture disease is challenging with multiple interventions available, but with successful outcomes demonstrated in various cohorts including urethroplasties with buccal grafts and robotic reconstruction.

Transurethral ventral inlay buccal mucosa graft urethroplasty: technique and intermediate outcomes.

OBJECTIVE: To outline our step-by-step surgical technique for a transurethral ventral buccal mucosa graft inlay urethroplasty to treat fossa navicularis and distal urethral strictures. METHODS: The transurethral ventral inlay urethroplasty is accomplished in four steps. First, after obtaining proper exposure the cicatrice is excised via a transurethral ventral urethrotomy until the lumen is at least 24fr. Second, double arm 6-0 polydioxanone suture is used to deliver the triangular buccal mucosal graft to the proximal extent of the urethrotomy and secured externally. Third, the graft is secured to the meatus with 5-0 polyglactin sutures and additional 6-0 double arm polydioxanone sutures are used to quilt the graft for spread fixation. Finally, a 16fr silicone catheter is placed. Patients are discharged the same day and return for void trial after one week. A retrospective, single institution review was conducted to include all patients who underwent this procedure with a minimum of 1 year follow-up. Patients were analyzed for recurrences, and pre- and post-operative urine flow rates, post void residuals, and patient questionnaires were also reviewed. RESULTS: 44 patients met our inclusion criteria. Median surgical time was 120 minutes. At a mean follow up of 36 months (IQR 22-50) 95% of patients are patent without additional interventions. The 2 patients that did have stricture recurrence were found to have urethral stenosis that extended more proximally, and both were successfully treated with a dorsal onlay buccal urethroplasty. There were significant improvements in urine flow rate, post void residuals, international prostate symptom score and quality of life scores post operatively. There was no difference in post operative sexual function scores. CONCLUSION: This minimally invasive transurethral ventral urethroplasty has excellent intermediate term outcomes in terms of traditional objective measures of urethroplasty success and patient reported outcomes.

How and why tobacco use affects reconstructive surgical practice: a contemporary narrative review.

Background and Objective: The overall negative impact of tobacco use on an individual's health has been well documented but the literature on tobacco's impact on post-surgical outcomes, specifically the outcomes after urologic surgery, is not as clear cut. The aim of this narrative review is to provide urologists with the information needed to have a nuanced pre-operative counseling conversation with patients about tobacco use. Here we combine publications on the histologic and physiologic changes induced by nicotine and tobacco use with publications from the wider surgical literature on post-operative outcomes in tobacco users. Methods: A literature search of PubMed, Google Scholar and Medline was performed using iterations of the following terms: tobacco, nicotine, changes, physiologic, histology, post-operative, and surgical. Non-English publications and abstracts were excluded. Inclusion required agreement from all authors and preference was given to human specimens over animal models for the basic science manuscripts and large database and meta-analyses over single institution experiences. Key Content and Findings: Tobacco use results in measurable changes in nearly every organ system in the body. While smokers have increased wound complications, there is no evidence that reconstructive surgery using grafts or flaps fail more frequently in tobacco users. Smokers have an increased risk of respiratory complications following endotracheal intubation. Conclusions: Surgeries should not be canceled due to a patient's inability to cease tobacco use. Urologists and patients should engage in joint decision making regarding the timing and pursuit of elective operations.

Evaluation and management of urologic complications following transmasculine genital reconstructive surgery.

AIMS: Transmasculine genital reconstructive surgery involves the creation of a neourethra by way of metoidioplasty or phalloplasty. We aim to describe approaches in identifying complications associated with these procedures as well as the various reparative techniques that can be utilized to reestablish the neourethral tract. METHODS: We prepared a guide to diagnostic and procedural interventions for urologic complications following transmasculine genital reconstructive surgery based on our clinical experience as well as those of our colleagues. We reviewed all current peer-reviewed publications based on this topic. RESULTS: These procedures have a considerable revision rate for urologic complications, which include urethrocutaneous fistulae, persistent vaginal remnant, and urethral strictures. These complications often present simultaneously and require appropriate workup and treatment. CONCLUSIONS: Several reconstructive techniques can be employed to restore the neourethral tract, as we describe in detail.

Pain management strategies in urethral reconstruction: a narrative review.

Background and Objective: Few investigations explore pain recovery comprehensively following urethral reconstruction, and understanding pain pathways that lead to discomfort following reconstruction has posed challenges. Options for pain control aside from opioids continue to be in the early forms of investigation, and remain an important strategy to combat the well-documented burden of the opioid epidemic. We conduct a detailed assessment of pain pathways in patients undergoing urethral reconstruction and further outline non-narcotic based pain management strategies in those undergoing urethroplasty. Methods: We performed a literature review to describe pain pathways involved in urethral reconstruction with buccal graft, and postoperative pain recovery. We searched for pain management techniques performed by fields similar to urology, and those being utilized in urethroplasty with buccal graft. Key Content and Findings: Innervation of the penoscrotal areas and mouth are well-defined, but understanding postoperative pain after urethroplasty remains a challenge. Preventative analgesia, nerve blocks, and multimodal analgesia have been employed by colorectal and gynecological surgeons. Urologists have utilized similar techniques for patients undergoing urethral reconstruction with buccal graft. Conclusions: Few investigations explore pain recovery comprehensively following urethral reconstruction, but we believe that utilizing a combination of preventative analgesia, nerve blocks, and multimodal analgesia will have acceptable outcomes in post-surgical patients undergoing recovery. Additional work is required to further explore how combined pain management strategies can optimally reduce postoperative pain.

Gender Affirmation Surgery, Transfeminine.

Feminizing genital surgery for transgender women is a feasible and fulfilling intervention in alleviating gender dysphoria. Several techniques in neovaginal creation can be offered, including vulvoplasty, penile skin inversion vaginoplasty, peritoneal vaginoplasty, and enteric vaginoplasty. Complication rates are low and often managed conservatively. Favorable sexual function outcomes indicate high satisfaction rates.

Evaluation of the Effect of Tobacco Use on Buccal Mucosa Graft Histology.

OBJECTIVE: To assess the effect of tobacco use on oral mucosal tissue harvested for urethroplasty. MATERIALS AND METHODS: Retrospective histologic and immunohistochemical (IHC) evaluation of available buccal mucosa tissue samples from patients that underwent buccal mucosa graft urethroplasty from 2018 to 2020. Patients were asked about tobacco use during pre-operative workup. Patients were counseled on and provided resources to aid in cessation of tobacco use, but surgical cases were not canceled or delayed if patients are unable cease all tobacco use. Patients that ceased use 3 months prior to surgery were considered former users. A single pathologist blinded to the smoking status evaluated the buccal mucosa specimens for histologic changes. Quantitative IHC for p75 and Sox2 were obtained. These investigative markers were selected due to their clear and direct involvement in oral mucosa's regenerative mechanism. Current tobacco users, former users and control patients were compared using ANOVA and Chi-square analyses. RESULTS: Study cohort was 16 current users, 16 former users, 32 controls. Demographics did not differ across the groups. Blinded histologic analysis between all groups found no differences. Pair-wise statistical analysis found greater collagen density in the control group compared to current users (P = .01). No differences were found between former and current users or former users and controls. IHC analysis did not demonstrate any difference in the amount or localization of epithelial stem cell markers. CONCLUSION: Our study of buccal mucosa did not find clear or clinically significant histologic or IHC differences between patients with or without a history of tobacco use.

Long-term outcomes from a multi-institutional experience with prefabricated composite gracilis-buccal mucosal flap for reconstruction of devastated urethras.

PURPOSE: Patients with devastated bulbar urethras have limited surgical options to restore normal upright voiding. We investigated the long-term feasibility of using two independently vascularized urethral hemi-plates lined with buccal mucosal graft (BMG) to treat these patients. METHODS: A multi-institutional retrospective review was conducted for patients that underwent this staged repair. In stage-1, the affected urethra is dissected and removed or prepared for a dorsal inlay augmentation. Two BMG segments are harvested; one graft is quilted on corpora cavernosa and urethra, creating an augmented perineal urethrostomy, and the other is quilted on the exposed distal gracilis muscle. Stage-2 utilizes the gracilis-BMG composite to recreate ventral bulbar urethra. The primary outcome measure was stricture recurrence. Secondary outcome measures included patient-reported outcome measures (PROMs). RESULTS: Five patients with mean age of 50 years (45-56) underwent staged repairs at two institutions between 7/2014 and 4/2016. All patients presented with suprapubic tubes and underwent at least one prior failed repair (1-9). Mean stricture length was 7.2 cm (5-9). Mean time between stage-1 and stage-2 repairs was 6.2 weeks (1-10). At a mean follow-up of 61 months (39-87), there were no recurrences. The mean uroflow was 20 cc/s (9-42) with a mean PVR of 59 cc (0-157). Four patients completed post-operative surveys; all reported at least a moderate improvement in their condition on Global Response Assessment (GRA), and a mean IPSS of 7.3 (0-26). CONCLUSIONS: Our bi-institutional case series demonstrates that this technique is a feasible option for devastated urethras with long-term durability.

Multi-institutional review of non-hypospadiac penile urethral stricture management and outcomes.

OBJECTIVES: Penile urethral stricture disease not associated with hypospadias is rare, and there is a wide range of commonly used surgical repair techniques for this disease. We sought to compile a multi-institutional database of patients who had surgical correction of strictures in the penile urethra not limited to the meatus, and who had no history of hypospadias, for analysis using the Trauma and Urologic Reconstructive Network of Surgeons length, urethral segment and etiology classification system. METHODS: A retrospective database from 13 institutions was compiled of patients who had undergone surgical correction of Trauma and Urologic Reconstructive Network of Surgeons length, urethral segment and etiology urethral stricture segments S2b/S2c and excluding E5, with a minimum follow-up time of 4 months. Failure was defined as cystoscopically confirmed recurrence of a stricture measuring less than 16-Fr. RESULTS: We analyzed 222 patients with a median age of 57 years and a follow-up of 49 months. The overall surgical success rate was 80.2%. On multivariate analysis, the two variables identified that were predictive of surgical success were stricture length ≤2 cm as well as use of a buccal mucosa graft as compared to use of a fasciocutaneous flap, which had success rates of 83% and 52%, respectively (P = 0.0004). No statistically significant differences were found based on incisional approach or surgical technique, nor were outcomes different based on etiology or preoperative patient demographics. CONCLUSIONS: Surgical repair of penile urethral strictures of non-hypospadiac origin have a favorable overall success rate, at 80.2%. Regardless of incisional approach or surgical technique, all operations appear to have similar outcomes other than repairs using fasciocutaneous flap, which were statistically less successful than those using buccal mucosa graft.

Staged Urethroplasty for Reconstruction of Long Complex Pendulous Strictures of a Neophallic Urethra.

BACKGROUND: Post-phalloplasty, patients may present with urologic complications, including strictures, urethrocutaneous fistulas and vaginal cavity remnants.1-3 OBJECTIVE: To demonstrate the feasibility of staged repairs for long complex neophallus strictures. METHODS: All post-phalloplasty patients who underwent pendulous (pars pendulans) or panurethral urethroplasty for strictures >7 cm were identified. In preparation for surgery patients were co-managed with their local providers, whenever possible, in treating symptomatic infections with culture-specific antibiotics, draining abscess and managing suprapubic catheters. During Stage-1, a ventral incision through the perineum and neophallus was created to expose remnants of the neo-urethral plate. Additional findings (fistula/remnant cavity) were treated at this stage if found, along with re-mobilization of a previously placed gracilis flap. The neourethral plate was augmented with buccal mucosal graft (BMG) with a goal of achieving an approximately 3-cm-wide plate. The lateral neourethral edges were sutured to the edges of the skin incision creating a temporary perineal urethrostomy. Stage-2 was performed in a delayed fashion and included mobilization and tubularization of the neourethra, with additional oral mucosa inlay (BMG or lingual), if needed, followed by a multi-layer closure. Postoperatively, patients were assessed in clinic when possible, or via telemedicine appointments for urethral patency, and queried using patient-reported outcome measures. Failures were defined as need for additional revisions or urethral instrumentation. RESULTS: Twenty-one patients presented between December 2013 and July 2021 with urinary obstruction due to long penile strictures. Seventeen patients, mean age 33 (22-58), elected to undergo staged reconstruction. Prior phalloplasty techniques included radial forearm flap phalloplasty in 15/17 and anterolateral thigh flap in 2/17. In 11/17 patients BMG was previously used during phalloplasty for urethral prelamination.4 Mean stricture length was 12 cm (7-17). Concurrent procedures during Stage-1 included re-harvesting BMG (11/17), gracilis flap re-mobilization (7/17) and redo-vaginectomy (5/17).5 During Stage-2, 14 patients (82%) required additional oral graft inlays: lingual 6/14 (including 2 bilateral), BMG 5/14 (including 1 bilateral) and lingual+BMG in 3/14. At a mean follow-up of 24 months (4-77), there were 2 failures (12%). Thirteen patients completed follow-up questionnaires and all reported upright voiding and at least a moderate improvement in their condition on Global Response Assessment: +3 (markedly improved) in 11/13 (85%), and +2 (moderately improved) in 2/13 (15%). CONCLUSION: A staged urethroplasty is a feasible option for transgender men with long complex penile strictures of the neophallus. This technique demonstrates promising early functional outcomes and high patient satisfaction.

Sexual Functioning of Transgender Females Post-Vaginoplasty: Evaluation, Outcomes and Treatment Strategies for Sexual Dysfunction.

INTRODUCTION: Transfeminine genital reconstructive surgery is an important part of gender affirmation for many transgender women. Sexual health post-vaginoplasty is an important aspect of quality of life that can have a significant impact on overall well-being. OBJECTIVES: The objective of this review is to provide a summary of the literature on the sexual outcomes of transgender females post-vaginoplasty and identify treatment strategies for those experiencing sexual dysfunction. METHODS: A literature review was conducted with a focus on sexual health outcomes in transgender females post-vaginoplasty as well as treatment options for sexual dysfunction. RESULTS: Penile inversion vaginoplasty with or without free skin grafts or local tissue flaps and intestinal vaginoplasty are the options available to patients interested in transfeminine genital reconstructive surgery with a neovagina. Sexual satisfaction post-vaginoplasty is high regardless of the vaginoplasty technique, however up to 29% of patients may be diagnosed with a sexual dysfunction due to associated distress with a sexual function disturbance. Hormone treatment, pelvic floor physical therapy, sex therapy, and sex surrogacy are treatment options for patients with sexual dysfunctions. CONCLUSION: Patient reported outcome measures appropriately validated for this patient population are necessary to better understand sexual function outcomes, sexual dysfunction and treatment options for post-vaginoplasty patients. Schardein JN, Nikolavsky D. Sexual Functioning of Transgender Females Post-Vaginoplasty: Evaluation, Outcomes and Treatment Strategies for Sexual Dysfunction. Sex Med Rev 2022;10:77-90.

A buccal mucosal graft subcoronal resurfacing technique to treat recurrent penile adhesions: the buccal belt.

OBJECTIVE: To outline our step-by-step surgical technique using a subcoronal buccal mucosal graft (BMG) resurfacing technique for the treatment of recurrent penile adhesions. METHODS: To perform the 'buccal belt' procedure a subcoronal circumferential segment of diseased skin was excised. An appropriately sized BMG was circumferentially secured subcoronally with a proximal and distal anastomosis to the edges of the wound. Quilting stitches were also placed to allow proper graft fixation. A petroleum jelly bolster was secured as a tie-over dressing. Patients were discharged with a Foley catheter and the bolster dressing in place. The bolster and Foley catheter were removed 7 days postoperatively. The patients were then seen for follow-up at 4- to 6-month intervals. A retrospective, international multi-institutional review was conducted to include all patients who underwent this procedure. Surgical complications, evidence of recurrence, and patient-reported outcome measures including visual analogue scale (VAS) and global response assessment (GRA) questionnaires were reviewed. RESULTS: Thirty-one men underwent the procedure across six institutions between March 2014 and September 2020. The mean (range) surgical time was 59 (25-95) min. At the mean (range) follow-up of 27 (4-79) months all patients reported resolution of presenting symptoms and no recurrence of adhesions. The mean VAS score was 8.9 and 9.0 for aesthetics and functional outcomes, respectively. On GRA, overall improvement was reported by all patients (61%, +3; 25%, +2; 14%, +1). CONCLUSION: There are limited options for the treatment of recurrent penile adhesions. A subcoronal BMG resurfacing is feasible, with no recurrence and overall high satisfaction seen in an initial patient cohort.

Multi-Institutional Study of Dorsal Onlay Urethroplasty of the Membranous Urethra after Endoscopic Prostate Procedures: Operative Results, Continence, Erectile Function and Patient Reported Outcomes.

(1) Background: To critically evaluate dorsal onlay buccal mucosal graft urethroplasty (DOBMGU) for posterior urethral stenosis repair following transurethral resection and other endoscopic prostate procedures. (2) Methods: A retrospective multi-institutional review of patients with membranous or bulbomembranous urethral stenosis for whom treatment with DOBMGU was conducted after receipt of prostate endoscopic procedures. Baseline data, peri-operative care, post-operative care and patient-reported outcomes were analyzed. The primary outcomes were procedural failure and development of de novo stress urinary incontinence (SUI). The secondary outcomes were changes in voiding, sexual function and patient satisfaction. (3) Results: A total of 107 men with a mean age of 69 ± 9.5 years and stenosis length of 3.5 ± 1.8 cm were included. Prior endoscopic procedures among participants were 47 patients (44%) with monopolar TURP, 33 (30.8%) with bipolar TURP, 16 (15%) with Greenlight laser, 9 (8.4%) with Holmium laser enucleation and 2 (1.9%) with bladder neck incision. At a mean follow-up time of 59.3 ± 45.1 months, stenosis recurred in 10 patients (9.35%). Multivariate analysis confirmed that postoperative complications (OR 12.5; p = 0.009), history of radiation (OR 8.3; p = 0.016) and ≥2 dilatations before urethroplasty (OR 8.3; p = 0.032) were independent predictors of recurrence. Only one patient (0.9%) developed de novo SUI. Patients experienced significant improvement in PVR (128 to 60 cc; p = 0.001), Uroflow (6.2 to 16.8 cc/s; p = 0.001), SHIM (11.5 to 11.7; p = 0.028), IPSS (20 to 7.7; p < 0.001) and QoL (4.4 to 1.7; p < 0.001), and 87 cases (81.3%) reported a GRA of + 2 or better. (4) Conclusions: DOBMGU is an effective and safe option for patients with posterior urethral stenosis following TURP and other prostate endoscopic procedures. This non-transecting approach minimizes external urinary sphincter manipulation, thus limiting postoperative risk of SUI or erectile dysfunction.

Histological Evaluation of Vaginal Cavity Remnants Excised During Neourethral Stricture Repair in Transgender Men.

OBJECTIVE: To determine the prevalence of patients who require vaginal cavity remnant excision and obliteration during neourethral stricture repair and to characterize the histological composition of the excised tissue. METHODS: A retrospective review was performed of all transgender men who underwent neourethral stricture repair. Preoperative imaging and operative reports were reviewed to determine the presence of a vaginal cavity remnant that was excised and obliterated during neourethral reconstruction. Pathology slides were reviewed by 2 pathologists to determine if there was presence of stratified squamous epithelium consistent with vaginal tissue within the vaginal cavity remnant. RESULTS: A total of 47 consecutive transgender men underwent neourethral stricture repair between January 2014 and December 2020. Of these, 18 patients (38%) with a mean age of 37 years (23-59) underwent excision and obliteration of a vaginal cavity remnant. Seventy eight percent (14/18) had a prior phalloplasty and 22% (4/18) had a prior metoidioplasty. Primary vaginectomy type was not associated with whether or not a patient had a vaginal cavity remnant (P = .12). Histological evaluation demonstrated the presence of vaginal epithelium in all vaginal cavity remnant specimens. CONCLUSION: A high percentage of transgender men with neourethral strictures present with vaginal cavity remnants despite prior vaginectomy. Pathological evaluation confirms that all vaginal cavity remnant specimens contain vaginal epithelium that was either incompletely excised or regenerated. While the implications of this residual vaginal epithelium require further investigation, total removal of vaginal tissue primarily or during reconstruction is important given the risk of associated symptoms.