Robotic Management of Complex Vesicourethral Anastomosis Stenosis With Transperineal Urethral Advancement: A Step-by-Step Technique.

BACKGROUND: Vesicourethral anastomosis stenosis (VUAS) refers to the diameter narrowing of a vesicourethral anastomosis (VUA). It is a known complication after radical prostatectomy that nowadays presents in less than 1% of these cases. When the lumen narrows sufficiently to impede urine flow, obstructive symptoms arise. While the incidence of VUAS used to be notably higher prior to the widespread use of the robotic approach, traditional procedures still fail in up to 42% of cases. Initial management typically involves endoscopic procedures, such as dilation, incision, or resection. If these approaches prove ineffective, VUA reconstruction is warranted. Following the resection of the unhealthy urethra, a potential drawback is the insufficient length of the healthy proximal urethral to reach the bladder without tension. In such cases, urinary diversion with an ileal conduit is an option. However, when the patient prefers to maintain an orthotopic urinary tract configuration, there is limited guidance in the literature regarding surgical techniques. OBJECTIVE: To outline the indications, describe the step-by-step technique, and evaluate the outcomes of transperineal urethral advancement to facilitate a tension-free VUA. MATERIALS: We first discuss the indications to identify which patients are candidates for this procedure. Then, a step-by-step description of the robotic VUA revision assisted by transperineal urethral mobilization is presented. Detailed steps and helpful hints are included. Finally, we outline the postoperative pathway and expected outcomes. RESULTS: This technique allows patients with VUAS to preserve the orthotopic configuration of the urinary tract when a tension-free anastomosis proves challenging. Although urinary incontinence is expected, an artificial urinary sphincter could be placed in the following months. CONCLUSION: The robotic management of complex vesicourethral anastomosis stenosis with transperineal urethral advancement is a feasible and safe procedure that requires the interdisciplinary management of robotic and reconstructive urologists.

A prospective cohort study of assisted bladder emptying following primary cloacal repair: The Children's National experience.

INTRODUCTION/BACKGROUND: Although the combination of bladder dysfunction and upper tract anomalies puts patient with cloaca at risk for renal disease, the rarity of this condition makes it difficult to study empirically. As a high-volume center, we uniquely capture bladder function outcomes following our growing number of cloacal repairs. OBJECTIVE: 1) Describe the rates of incomplete bladder emptying following primary cloacal repair (at 2-3 months after repair and last follow up), and 2) identify clinical factors associated with assisted bladder emptying. STUDY DESIGN: We performed a prospective cohort study of patients undergoing primary cloaca repair by our Children's National Colorectal Center team between 2020 and 2021. The primary outcome was assisted bladder emptying at 2-3 months postoperatively and last visit. Covariables included preoperative characteristics (cloacagram measurements), ARM complexity (moderate = common channel [CC] <3-cm, severe = CC ≥ 3-cm), vesicoureteral reflux (VUR) status, sacral ratio (good ≥0.7, intermediate 0.7-0.4, poor ≤0.4), spinal cord status, means of preoperative bladder emptying, and operative details (age at repair, repair type, & concomitant laparotomy). RESULTS: Eighteen participants were eligible. A majority had moderate cloaca (78%), VUR (67%), spinal cord abnormalities (89%), and good sacral ratios (56%). Preoperatively, 10 patients were diapered for urine and 8 had assisted bladder emptying. Surgical repairs were performed at a median age of 8 months (range 4-46). Nine (50%) patients underwent urogenital separation (UGS), eight (44%) total urogenital mobilization, and 1 (6%) perineal sparing posterior sagittal anorectoplasty with introitoplasty. Exploratory laparotomy was performed in 7 (39%) patients. At 2-3 months, 7 patients were voiding and 11 required assisted bladder emptying. Median length of long-term follow up was 12 months (range 5-25), and 8 patients were voiding and 10 required assisted bladder emptying. Postoperative need for assisted bladder emptying was significantly associated with assisted bladder emptying preoperatively, a shorter urethra and increasing common channel length, UGS and exploratory laparotomy. Spinal cord imaging findings were not associated. DISCUSSION: Bladder emptying following cloaca repair is likely a result of congenital function and surgical effects. Indeed, increasingly cloaca complexity requiring UGS and laparotomy was associated with both pre- and post-operative assisted bladder emptying. The lack of association with spinal cord imaging may reflect a divergence between anatomy and function. CONCLUSION: Approximately half of patients required assisted bladder emptying in this study. Associated factors included urethral and common channel length, the need for assisted bladder emptying preoperatively, the type of surgical approach and additional laparotomy. Being diapered with seemingly normal voiding prior to surgery did not guarantee normal bladder function postoperatively.

Could IVF replace reproductive surgery? No, reproductive surgery is still very much alive.

Could IVF replace reproductive surgery? The answer is no. Reproductive surgery still has a place, at least in some indications that will be explored in this contribution. While IVF can offer infertile couples the chance to have a healthy baby, it should be acknowledged that reproductive surgery can heal or harm the organs where reproduction takes place. This paper reviews different diseases and conditions with an impact on fertility, which may benefit from the technological innovations of recent decades, novel applications and the skill of reproductive surgeons. Reproductive surgery is certainly not dead. It lives on with the promise of restoring the functional anatomy to enhance the chances of pregnancy. It is our responsibility to train young residents adequately in this field to provide the right treatment at the right time.

Hypospadias surgery: understanding parental emotions, decisions and regrets.

This paper builds an argument about genital surgery in the context of medical treatment of children and young people with variations in sex characteristics. First, I set out what is known from existing research including psychological research, surgical follow-up studies and parental regret studies. Second, I present an analysis of surgeons' talk about children, young people and parents in relation to genital surgery. This paper focuses most specifically on hypospadias surgery, but the argumentation is relevant for other kinds of genital surgery carried out in the context of genital variations. The questions guiding this paper are: what research evidence supports hypospadias surgery and what research evidence brings this surgery into question? How might a new interpretation of the evidence, in light of psychosocial research and human rights concerns, contribute to a new perspective on elective genital surgery on minors with variations in sex characteristics? I draw out implications for clinicians supporting parents to decide whether a surgical pathway is the best option for their child.

Why do parents recommend clitoral surgery? Parental perception of the necessity, benefit, and cost of early childhood clitoral surgery for congenital adrenal hyperplasia (CAH).

Historically, medical management of Congenital Adrenal Hyperplasia (CAH) in girls typically involved feminising surgery, which meant reducing the size and/or visibility of the enlarged clitoris. This practice may have become less routine but remains a common response to genital differences associated with CAH. Parents typically give permission for the child to undergo surgery in early childhood and recommend other parents facing a similar situation do the same. The current report is based on a qualitative content analysis of interviews with sixteen parents whose daughters with CAH had undergone one of two forms of clitoral surgery. We observed that: (i) some parents were initially unconcerned about their child's genital presentation; (ii) in general, clitoral surgery was considered as a readily available and natural response to the child's bodily difference; (iii) the parents acknowledged that there would be some risk but anticipated various benefits; and (iv) there was an absence of ethical considerations when the parents evaluated the various effects of surgery afterwards. We conclude from our analysis that parents of girls with CAH may not receive psychologically and ethically informed counselling to encourage critical reflections prior to authorizing genital surgery.

Disorders of sex development: Challenges in a low-resource country.

AIM: We aimed to identify the challenges in the management of sexual development abnormalities in a low-resource country. METHODS: The study was retrospective from January 2000 to December 2017 based on patient records from two pediatric surgery departments. Epidemiological, clinical, paraclinical, treatment, and outcome data were studied. RESULTS: We collected data on 13 patients (average age = 7.95 years). The sex of rearing was as follows: three females (23%), 10 males (77%). Atypical genitalia other than hypospadias represented the reason for consultation in 92% of the cases. We could not find complete hormonal analyses; testosterone levels were studied in 69.23% of cases. We found the following disorders of sexual development (DSD): four patients with 46,XX karyotype (30.77%), eight patients with 46,XY karyotype (61.53%), and one patient with 46,XX/XY karyotype. Four patients had medical treatment only, four had surgical treatment only, and one patient had medical and surgical treatment. The medical treatment comprised topical administration of androgen. The surgical treatment consisted of feminizing genitoplasty for one patient and masculinizing genital surgeries for two patients. Six of the 13 patients were lost to follow-up. CONCLUSION: The socioeconomic difficulties of the population and the lack of access to basic diagnostic and paraclinical methods, coupled with the negative cultural representations of the pathology, constitute the challenges in the management of DSD in our practice.

History and future perspectives of male aesthetic genital surgery.

Since ancient times, men have tried to change the size and shape of their genitals. Bites from insects or poisonous snakes and weights were among the first methods used for this purpose. In the first half of the 1900s, the scientific push regarding male genital aesthetic surgery began. Scrotoplasty, penile suspensory ligament release, injection of hyaluronic acid as filler, use of several types of grafts, lipofilling, and liposuction are techniques currently used. The Penuma® implant has recently been described with promising results. We are living in the era of tailored surgery and regenerative medicine. Shortly the surgeons will have to know several surgical techniques and adapt them to the patient. New fillers with ideal characteristics, innovative prosthetic devices, and stem cells will probably be the protagonists of future aesthetic surgery. The main effort of the scientific community should be directed towards the design of new randomized controlled trials to increase the evidence on the efficacy and safety of the topic, with the ultimate aim of allowing clear recommendations from scientific societies.

Male esthetic genital surgery: recommendations and gaps to be filled.

The reason behind the spread of penis enlargement practices over time is rooted in the virility that the appearance of the genitals can give a man, as well as an altered perception of his own body. The approach should be to modulate the interventions on the real needs of patients, carefully evaluating the history, the psychological picture, and possible surgical advantages. The aim of this study was to shed light on cosmetic surgery of male genitalia through minimally invasive and more radical techniques, with the purpose of laying the foundation for possible indications and recommendations for the future. A non-systematic literature review using the PubMed and Scopus databases was conducted to retrieve papers written in English on cosmetic surgery of the penis published over the past 15 years. Papers discussing cosmetic surgery in patients with concomitant pathologies associated with sexual dysfunction were excluded. The main outcomes recorded were change in penile dimensions in term of length and girth and surgical complications.

Sexual function in adult females after feminizing genitoplasty for congenital adrenal hyperplasia.

OBJECTIVE: To investigate sexual function and subjective attitudes towards surgery in adult women after feminizing genitoplasty (FG) for congenital adrenal hyperplasia (CAH). MATERIALS AND METHODS: We retrospectively reviewed the medical files of patients who underwent FG from 1996 to 2018. Of those, patients older than 16 years of age were asked to answer non-standardized questions aiming at the awareness of genital surgery and standardized questionnaire evaluating sexual function (GRISS). The anonymized answers were compared to a control group of 50 healthy females. Student's t-test, Pearson's χ2 test, Fisher's exact test and Spearman's rank correlation coefficient were performed. A P-value less than 0.05 was considered significant. RESULTS: Out of 106 patients who underwent FG, 64 were included, 55 successfully contacted and 32, aged 17-40 years (median 25.5), answered the questionnaires (58% response rate). In all, 11 patients underwent historical clitorectomy in early childhood by a pediatric gynecologist before 1996 and pull-through vaginoplasty at puberty. A total of 21 patients underwent modern one- or two-staged FG. There were statistically significant differences between the CAH group and controls as to the proportion living in committed partnerships (28% and 84%, respectively; p = 0.0000), having sexual intercourse (41% and 92%, respectively; p = 0.0000) and having their own children (13% and 36%, respectively; p = 0.0369). The median overall GRISS score was 4 (range 1-7) in the CAH group compared to 1 (range 1-9) in the control group, with infrequency and vaginismus representing the least favorable subscales (median 5). In all, 81% of the women operated on for CAH would recommend such an operation to any other individual with CAH and 66% of them suggested the surgery should be performed in early childhood. DISCUSSION: By this study we have contributed to the debate over suggestions that FG may cause adverse effects on sexual life of the patients in adulthood, beside already published effects on their mental well-being and LUTS. Despite possible selection bias due to only 58% response rate the comparison with control group shows only a moderate sexual dysfunction and more significant impact on long-term partnership that might be caused by other factors related to CAH beside FG itself. CONCLUSIONS: Partnership, offspring, sexual frequency and function were impaired in adult females with CAH after FG. However, the median GRISS score was below the pathological level of 5.

Uretroplastia bulbar con injerto: Una actualización sobre las diferentes técnicas quirúrgicas / Graft Urethroplasty for Bulbar Strictures: An Update on the Different Surgical Techniques

En pacientes con estrechez uretral bulbar de una longitud mayor a 2 cm, que no sean candidatos a otras técnicas, se realiza uretroplastia con injerto. Actualmente se emplean diversas técnicas, cada una con ventajas y desventajas propias. Describir las ventajas y desventajas de las técnicas quirúrgicas empleadas actualmente en la uretroplastia con injerto, así como sus tasas de éxito. Se hizo una búsqueda en PubMed, ClinicalKey y en ScienceDirect, utilizando las palabras claves: "urethral stricture," "urethroplasty," "oral graft" y "flap." Se utilizaron los estudios más relevantes, tanto originales como revisiones sistemáticas y metaanálisis, en inglés y en español. Las diferentes técnicas quirúrgicas ofrecen ventajas y desventajas teóricas frente a las otras, aunque las tasas de éxito en todas es cercana al 90%, sin ser una francamente superior frente a las demás. La elección de la técnica quirúrgica a realizar depende de las preferencias y experiencia del cirujano, dado que la tasa de éxito para todas las técnicas es similar.

In patients with urethral stricture longer than 2 cm who are not candidates for other techniques, graft urethroplasty is the most performed surgery. Currently, several techniques are used, each with their own advantages and disadvantages. Describe the advantages and disadvantages of the surgical techniques currently used in graft urethroplasty, as well as their success rates. A search was made in PubMed, ClinicalKey and ScienceDirect, using the keywords: "urethral stenosis," "urethroplasty," "oral graft" and "flap." The most relevant original studies, systematic reviews and meta-analyzes were used, both in English and Spanish. The different surgical techniques offer theoretical advantages compared with the others, although the success rates in all are close to 90%, without being frankly superior compared with the others. The choice of the surgical technique to be performed depends on the preferences and experience of the surgeon, given that the success rate for all techniques is similar.

Surgical Practice in Girls with Congenital Adrenal Hyperplasia: An International Registry Study.

In this article international trends in surgical practice in girls with congenital adrenal hyperplasia (CAH) are evaluated. All cases that had been classified in the I-CAH/I-DSD registry as 46,XX CAH and who were born prior to 2017 were identified. Centers were approached to obtain information on surgical decision making. Of the 330 included participants, 208 (63.0%) presented within the first month of life, and 326 (98.8%) cases were assigned female. Genital surgery had been performed in 250 (75.8%). A total of 64.3, 89.2, and 96.8% of cases residing in Europe, South America and Asia, respectively, had at least one surgery. In a logistic regression model for the probability of surgery before the second birthday (early surgery) over time an increase of probability for early vaginal surgery could be identified, but not for clitoral surgery or both surgeries combined. Genitoplasty in girls with CAH remains controversial. This large international study provides a snapshot of current practice and reveals geographical and temporal differences. Fewer surgeries were reported for Europe, and there seems to be a significant trend towards aiming for vaginal surgery within the first 2 years of life.

[Feminizing genitoplasty for prepubertal children and teenagers female]. / Génitoplastie féminisante dans les anomalies du développement sexuel de l'enfant pré-pubère et de l'adolescente au Cameroun. À propos de 9 cas.

OBJECTIVE: The aim of this study was to report our experience after 10 years of practice of feminizing genitoplasty in prepubertal and adolescent patients with disorders of sex development (DSD) assigned females as females in a developing country. METHODOLOGY: This was a cross-sectional, descriptive and retrospective study over a period of 9 years. All pre-pubertal (8-12 years) and adolescent patients female sex assigned with DSD who had willfully consented to the surgery with their guardians and underwent feminizing genital surgery were enrolled in the study. Data collection included: age at presentation, precise diagnosis, surgical procedures, complications, cosmetic result and duration of follow-up. Each patient had a precise diagnosis and the surgery was planned after discussion with the multidisciplinary team. Cosmetic results were assessed based on: appearance of the clitoris and separation of the vaginal and urethral openings. RESULTS: Nine patients raised as females with a median age of 8 years (IR: 10.75) were recorded. Surgery was performed at a median age of 11 years (IR: 9.5). In this series, 6 had a 46, XY karyotype with varying diagnoses: partial androgen insensitivity syndrome (n=2); 5-alphareductase insufficiency (n=2); 17-ketoreductase insufficiency (n=2); gonadal dysgenesis with a mutation in the NR5A1 gene (n=2), 2 had ovostesticular DSD, (karyotypes 46, XX), and 1 had mixed gonadal dysgenesis (karyotype 45, X/46, XY). Partial or total gonad(s) removal in accordance with assigned gender was the most common associated procedure. It was bilateral in 7 cases and unilateral in 2 cases. Follow-up ranged from 3 months to 4.5 years (median: 26 months, IR:18.25). One patient had acute urinary retention in the early follow-up. No other complication such as incision bleeding was recorded. The cosmetic appearance of the external genitalia was satisfactory in all patients. CONCLUSION: Feminizing genital surgery in Cameroon remains a major challenge and should seldom be realized without a precise diagnosis. Late age at presentation is peculiar to our setting; however, it gives room for the patients' participation and input to decisions that will have a life-long personal impact on their lives in terms of psychosocial development and fertility. LEVEL OF EVIDENCE: 3.

Effects of patients' understanding and choice of surgical types on postoperative outcomes of Peyronie's disease: a single-center retrospective study of 108 patients.

Surgical correction can be considered for treating patients with a chronic phase of Peyronie's disease (PD) and persistent penile curvature. In clinical practice, some patients pay too much attention to surgical complications and refuse the recommended feasible surgical types. Meanwhile, they require operations according to their preferences. This study aimed to evaluate the effects of patients' own choice of surgical type on postoperative satisfaction. This retrospective study analyzed data from 108 patients with PD who underwent surgical correction according to doctors' recommendations or patients' own demands. The objective and subjective surgical outcomes were assessed. Patients' understanding of the disease was analyzed using a questionnaire survey. Objective measurements of surgical outcomes, including penile straightening, penile length, and sexual function, in patients who received the recommended surgery, were similar to those in patients who did not accept the recommended surgery. However, subjective evaluations, including erectile pain, discomfort because of nodules on the penis, and decreased sensitivity in the penis, were more obvious in patients who did not follow doctors' recommendations. In addition, a questionnaire survey showed that understanding PD and the purpose of surgery of patients who did not follow doctors' advice were inappropriate, as they did not conform to the principle of treatment. The present study showed that surgical correction seemed to be an objectively effective option in the management of patients in the stable chronic phase of PD. Low patient satisfaction might be related to patients' lack of correct understanding of the disease and its treatment strategy as well as unrealistic expectations.

Individualized care for patients with intersex (differences of sex development): part 4/5.Considering the Ifs, Whens, and Whats regarding sexual-reproductive system surgery.

Issues and concerns regarding surgery of the sexual-reproductive anatomy during infancy and early childhood are discussed using four actual examples. A case of a 46, XX infant with 21 hydroxylase deficiency congenital adrenal hyperplasia (CAH) with atypical (ambiguous) genitalia is discussed regarding timing and potential harms and benefits of surgery. We present the perspective of balancing the child's rights to bodily autonomy and right to an open future versus parents' decision making authority regarding what they perceive as their child's future best interests. The second case is a newborn with complete androgen insensitivity syndrome and we discuss the harms, benefits and timing of gonadectomy. The third case examines the physical and psychological impact of penile shaft hypospadias, raising the question of whether surgery is justified to prevent what may or may not be considered a permanent disability. The fourth case involves an adult woman with classic CAH, born with a urogenital sinus and clitoromegaly, who never had genital surgery and is now requesting vaginoplasty, but not clitoral reduction. The primary message of this article, as the previous articles in this series, is to encourage patient-family centered care that individualizes treatment guided by shared decision making.

Early Genital Surgery in Disorders/Differences of Sex Development: Patients' Perspectives.

Controversy continues over a proposed moratorium on elective genital surgery in childhood for disorders/differences of sex development (DSD). Empirical evidence on patient preference is needed to inform decision-making. We conducted a multicentre survey by cross-sectional questionnaire in 14 specialized clinics in six European countries. The sample comprised 459 individuals (≥ 16 years) with a DSD diagnosis, including individuals with congenital adrenal hyperplasia (CAH) (n = 192), XY DSD with prenatal androgen effect (A) (n = 150), and without (nA) (n = 117). Main outcome measures were level of agreement with given statements regarding genital surgery, including clitoris reduction, vaginoplasty, and hypospadias repair. A total of 66% of individuals with CAH and 60% of those with XY DSD-A thought that infancy or childhood were the appropriate age for genital surgery. Females with XY DSD were divided on this issue and tended to prefer vaginoplasty at a later age (XY DSD-A 39%, XY DSD-nA 32%). A total of 47% of males preferred early hypospadias surgery. Only 12% (CAH), 11% (XY DSD-A), and 21% (XY DSD-nA) thought they would have been better off without any surgery in childhood or adolescence. Individuals who had early genital surgery were more likely to approve of it. Outcome data failed to support a general moratorium on early elective genital surgery. Participant perspectives varied considerably by diagnostic category, gender, history of surgery, and contact with support groups. Case-by-case decision-making is better suited to grasping the ethical complexity of the issues at stake.Trial registration: German Clinical Trials Register DRKS00006072.