Development of male and female models of long urethral strictures in swine.

Background: Preclinical animal models which mimic the dimensions of long urethral strictures (>2 cm in length) encountered in the clinic are necessary to evaluate prospective graft designs for urethroplasty. The purpose of this study was to develop both male and female porcine models of long urethral strictures (∼4 cm in length) and characterize histological and functional outcomes of iatrogenic stricture formation between genders. Methods: Focal, partial thickness urethral injuries were created over 5-6 cm long segments in male and female swine (N = 4 per gender) via electrocoagulation and the degree of stricture formation was monitored for up to 6 weeks by urethroscopy and retrograde urethrography. Animals were sacrificed following stricture confirmation and histological, immunohistochemical, and histomorphometric analyses were performed on strictured and uninjured control urethral segments to profile wound healing responses. Results: Urethral stricture formation was detected in all female swine by 2 weeks and 100 % of male swine at 3.2 ± 1.8 weeks, post-operatively. The mean length of urethral strictures in both male and female swine was ∼4 cm. Substantial variations in the degree of stricture severity between sexes were observed with males exhibiting significant urethral stenosis and loss of α-smooth muscle actin+ smooth muscle bundles in comparison to controls, while females primarily displayed defects in pan-cytokeratin+ epithelia as well as functional urethral obstruction. Conclusions: Electrocoagulation injury is sufficient to produce long urethral strictures in male and female swine and the degree of stricture severity and nature of urethral obstruction was observed to be dependent on gender. Animal Protocol: AUP-19-150. Key message: Novel male and female models of long urethral strictures in swine were created to characterize histological and functional outcomes of iatrogenic stricture formation between genders.

Long-term follow-up suggests high satisfaction rates for bulbomembranous radiation-induced urethral stenoses treated with anastomotic urethroplasty.

PURPOSE: To analyze patients who underwent anastomotic urethroplasty for radiationinduced bulbomembranous urethral stricture/stenosis (RIS) due to prostate cancer treatment with up to 19 years of follow-up and assess long-term patient reported outcomes (PROMs). Long-term follow-up with the inclusion of urethroplasty specific PROMs is lacking in the available research. METHODS: Patients who underwent anastomotic urethroplasty for RIS were identified from 2002 to 2020. Inclusion criteria included completion of 4-month post-operative cystoscopy and PROMs including IPSS, SHIM, MSHQ-EF, 6Q-LUTS, and global satisfaction queries at 4 months. PROMs were assessed annually thereafter, and cystoscopy was performed for adverse change in PROMs or worsening uroflow/PVR parameters. PROMs were compared at pre-op, post-op, and most recent follow-up. RESULTS: 23 patients met inclusion criteria. Short-term anatomic success was 95.7%. At a mean follow-up of 73.1 months (9.1-228.9), one late recurrence occurred for an overall success of 91.3%. Significant and sustained objective improvement was identified in voiding scores, quality of life, and urethroplasty specific PROMs. Satisfaction was 91.3% despite sexual side effects, and 95.7% of patients stated they would have surgery again knowing their outcome at a mean of over 6 years' follow up. CONCLUSIONS: RIS are challenging problems, but durable symptomatic relief is achievable in well-selected patients. Patients with bulbomembranous RIS should be appropriately counseled regarding the risk of urinary incontinence and sexual side effects after anastomotic urethroplasty. However, long-term success is high, and overall QoL will have sustained subjective improvement in most cases.

Evaluation of silk fibroin-based urinary conduits in a porcine model of urinary diversion.

Background: The primary strategy for urinary diversion in radical cystectomy patients involves incorporation of autologous gastrointestinal conduits into the urinary tract which leads to deleterious consequences including chronic infections and metabolic abnormalities. This report investigates the efficacy of an acellular, tubular bi-layer silk fibroin (BLSF) graft to function as an alternative urinary conduit in a porcine model of urinary diversion. Materials and methods: Unilateral urinary diversion with stented BLSF conduits was executed in five adult female, Yucatan mini-swine over a 3 month period. Longitudinal imaging analyses including ultrasonography, retrograde ureteropyelography and video-endoscopy were carried out monthly. Histological, immunohistochemical (IHC), and histomorphometric assessments were performed on neoconduits at harvest. Results: All animals survived until scheduled euthanasia and displayed moderate hydronephrosis (Grades 1-3) in reconstructed collecting systems over the course of the study period. Stented BLSF constructs supported formation of vascularized, retroperitoneal tubes capable of facilitating external urinary drainage. By 3 months post-operative, neoconduits contained α-smooth muscle actin+ and SM22α+ smooth muscle as well as uroplakin 3A+ and pan-cytokeratin + urothelium. However, the degree of tissue regeneration in neotissues was significantly lower in comparison to ureteral controls as determined by histomorphometry. In addition, neoconduit stenting was necessary to prevent stomal occlusion. Conclusion: BLSF biomaterials represent emerging platforms for urinary conduit construction and may offer a functional replacement for conventional urinary diversion techniques following further optimization of mechanical properties and regenerative responses.

Characterization of a novel rabbit model of Peyronie's disease.

Peyronie's disease (PD) is a debilitating pathology which is associated with penile curvature and erectile dysfunction due to the formation of fibrotic plaques in the penile tunica albuginea. In the present study, we developed a novel rabbit model of PD via subtunical injection of recombinant transforming growth factor (TGF)-ß1 protein and characterized erectile function and histopathological endpoints following plaque formation. Ten adult male, New Zealand white rabbits were randomized into 3 experimental groups including nonsurgical controls (NSC, N = 3) and those receiving subtunical injections of vehicle (N = 3) or TGF-ß1 protein (0.5 µg/50 µl; N = 4). Following 1 month post-op, focal fibrous plaques composed of disorganized collagen type I and III bundles as well as fragmented elastin fibers at TGF-ß1 injection sites were observed in contrast to control groups. Cavernosometric and cavernosographic evaluations revealed no significant differences in maximum intracorporal pressures or substantial curvature during papaverine-induced erection in either the vehicle or TGF-ß1 cohorts. Immunohistochemical and histomorphometric analyses demonstrated significant increases in elastase 2B expression in TGF-ß1-induced plaques as well as significant declines in matrix metalloproteinase (MMP)-2 and -9 expression relative to control levels. Our results demonstrate that PD-like fibrotic plaques can be created in the rabbit penile tunica albuginea following TGF-ß1 injection.

Urethral Stricture/Stenosis as a Complication of High Intensity Focused Ultrasound of the Prostate (HIFU): What is the Overall Patient Experience?

OBJECTIVE: To analyze the location and management of urethral stricture/stenosis in patients treated with High-intensity focused ultrasound (HIFU) of the prostate as well as to describe patient reported satisfaction in these men. METHODS: Patients with a history of HIFU requesting consultation for stricture were identified from 2010 to 2020. Demographic and prior treatment data were recorded. Patients who presented for evaluation underwent retrograde cystoscopy, retrograde urethrogram, voiding cystourethrogram, and antegrade cystoscopy through a suprapubic tract. Patients who only had virtual consultation and did not present for in-person evaluation, were followed longitudinally to assess long-term outcomes and quality of life. RESULTS: Over the 10-year study period, 17 patients were identified with a mean age of 65.8 years. Prior to initial consultation, a total of 88% of patients had at least 1 failed surgical intervention at a mean of 45 months post-HIFU. The majority of patients (94%) had strictures that included but were not necessarily limited to the prostatic urethra. Patients underwent various treatments postevaluation, favoring endoscopic therapy (38%), and proximal diversion (20%) at a mean follow-up of 68.2 ± 7.5 months. Only 38% reported satisfaction with urinary symptoms. CONCLUSION: Urethral narrowing post-HIFU appears to overwhelmingly involve the prostatic urethra. Patients usually have a significant treatment burden over a prolonged period and are often managed with repeated endoscopic treatment, extirpative prostatic surgery, or urinary diversion as they have obstruction that is not amendable to urethral reconstruction. Most patients with HIFU strictures experience a diminished QOL due to persistent urinary symptoms.

Long-term outcomes for 2-stage urethroplasty: an analysis of risk factors for urethral stricture recurrence.

PURPOSE: To report long-term results and patient reported outcomes of staged anterior urethroplasties, and isolate risk factors for recurrence. METHODS:  We reviewed urethroplasty database for all patients who underwent staged urethroplasty from 2000 to 2017. Follow-up included a cystoscopy 4 months after their 2nd stage to assess early success, and then annual follow-up thereafter with post-void residual and symptom assessment. Stricture characteristics, etiology and graft type were analyzed with regards to success. RESULTS:  Forty-nine patients were eligible for inclusion. The median stricture length was 7 cm (3-17 cm). The early success rate demonstrated by cystoscopy at 4 months was 100%. Long-term success was 96.4% in buccal graft (BMG) only patients; however, long-term success fell considerably to 53% in patients requiring any use split thickness skin graft (STSG) in the first stage. Median follow up time was 57 months (6-240 months). On analysis, age, increased stricture length and especially the use of STSG all appeared to be associated with late recurrence. The recurrence group had longer stricture length and were more likely to be panurethral. All recurrences occurred after the initial 4-month cystoscopy with a median time to recurrence of 78 months. CONCLUSION: Staged repairs that are amenable to BMG-only repairs have high long-term success rates. Increasing stricture length and the addition of split-thickness skin graft were associated with lower success rate in staged urethral reconstruction. Patients requiring staged repairs often experience recurrence in a very delayed fashion reinforcing the need for close, long-term follow up.

Urethral Stricture Disease: Evaluation of the Male Urethra.

The diagnosis of urethral stricture disease is often made when a man with obstructive voiding symptoms undergoes flexible cystoscopy (urethroscopy). However, a more complete and definitive diagnosis is then achieved when the urethra is subsequently evaluated with a retrograde urethrogram, and in many cases, a voiding cystourethrogram (VCUG). In situations where there is stricture disease involving the meatus or fossa navicularis that prevents the passage of adult flexible cystoscope, other testing appropriate in these cases include distal urethral calibration using bougie-a-boules and possibly the advancement of a pediatric cystoscope. It is only after the exact location and length and severity of the stricture is assessed that patients can be properly advised of all options before decision-making and the implementation of a treatment plan. This section will review the evaluation of the male urethra.

Endoscopic Management of Urethral Stricture Disease and Bladder Neck Contractures.

This section aims to review general principles of endoscopic management of urethral stricture disease and posterior urethral stenosis, with a special focus on the indications for treatment and technical aspects of urethral dilation and internal incision.

Urinary and Sexual Outcomes Following Bulbar Urethroplasty-An Analysis of 2 Common Approaches.

OBJECTIVE: To report success and patient reported urinary and sexual outcomes of patients who underwent anastomotic urethroplasty and dorsal buccal onlay urethroplasty. MATERIALS AND METHODS: Patients who underwent primary transecting anastomotic or dorsal buccal onlay urethroplasty for bulbar strictures at our institution between 1998 and 2015 were analyzed. Patients who had a prior urethroplasty, involvement of a different portion of the urethra, or a diagnosis of lichen sclerosis (LS) or hypospadias were excluded. Outcomes were assessed by cystoscopy at 4 months, validated questionnaires assessing urinary, erectile, and ejaculatory function at the time of their most recent assessment. RESULTS: A total of 40 and 139 patients were included in the dorsal buccal and anastomotic groups, respectively. Wide patency at 4-month cystoscopy was 97.5% and 100% (P= .06) and the long-term success was 95% and 99.3% (P= .06) with a mean follow-up of 51.4 and 63.3 months. Patient reported outcomes were similar with 2 exceptions: postvoid dribbling was reported more often in the onlay group (28.1% vs 8.3%, P< .0001), and tethering with erections in the anastomotic group (23.4% vs 3.1%, P= .008). Ninety-eight percent of patients in the anastomotic group and 91% in the dorsal buccal onlay group would choose their surgery again (P= .07). CONCLUSION: Both anastomotic urethroplasty and dorsal onlay graft are associated with high success with comparable satisfaction. Patient reported outcome measures were similar regardless of approach, despite inherent differences in stricture length. Our data indicates that anastomotic urethroplasty should not be avoided due to concerns of sexual side effects.

Complications of Genital Enlargement Surgery.

INTRODUCTION: The objective of genital enlargement surgery is to increase length and/or girth for cosmetic reasons; however, newer techniques have been recently reported to be associated with only minor complications in a small percentage of patients. AIM: We aim to report the severe complications of penile augmentation surgery seen at a referral center and describe their subsequent management. METHODS: Institutional review board approval was obtained. We reviewed our prospectively collected database for all patients who presented with complications of genital enlargement surgery from 2002-2016. MAIN OUTCOME MEASURE: Interventions following complications of genital enlargement surgery. RESULTS: 11 Patients were identified. Mean age was 47 (21-77) years. Prior procedures included subcutaneous injection of silicone outside a medical setting, girth enhancement procedures involving the subcutaneous placement or injection of substances including fat, other substances, or subcutaneous silicone implants. All patients who underwent subcutaneous penile implant underwent removal prior to presentation. Adverse changes included sexually disabling penile deformity and severe shortening, curvature, edema, subcutaneous masses, infection, non-healing wounds, and sexual dysfunction. 10 patients underwent corrective surgery, with 2 requiring multiple procedures and 3 requiring split-thickness skin grafting. All 10 patients had an improved cosmetic appearance and those who had disabling shortening had significantly improved functional length. CLINICAL IMPLICATIONS: Report of such adverse events should assist in appropriate perioperative counseling prior to genital enhancement surgery. STRENGTH & LIMITATIONS: Few reports of debilitating complications of penile enlargement exist in literature. However, without knowing the overall number of procedures performed, the true complication incidence is not known. CONCLUSION: Penile and scrotal enhancement surgery can be associated with major disabling complications, leading to deformity and functional compromise in men with prior normal anatomy and function. Patients should be aware of these risks. Furr J, Hebert K, Wisenbaugh E, et al. Complications of Genital Enlargement Surgery. J Sex Med 2018;15:1811-1817.

Evaluation and management of adult acquired buried penis.

Adult acquired buried penis represents the clinical manifestation of a wide spectrum of pathology due to a variety of etiologies. It can be related to obesity, a laxity in connective tissue, lichen sclerosis (LS), complications from penile/scrotal enlargement surgery, scrotal lymphedema, or hidradenitis suppurativa (HS). Buried penis can be associated with poor cosmesis and hygiene, voiding dysfunction, and sexual dysfunction. Evaluation and management of buried penis largely depends on etiology and degree of affected tissue. It is an increasingly common problem seen by reconstructive urologists and here we present several frequently seen scenarios of buried penis and management options.

Reconstruction of Massive Localized Lymphedema of the Scrotum: Results, Complications, and Quality of Life Improvements.

OBJECTIVE: To review the surgical technique, outcomes, and complications of surgical excision of massive localized lymphedema (MLL) of the scrotum, and to determine changes in weight and quality of life (QOL) after excision. METHODS: A retrospective review was performed for all patients who have undergone excision of MLL of the scrotum at our institution between 2008 and 2014. Standard baseline characteristics, complications, pre- and postoperative weight, and QOL data were recorded. RESULTS: Eleven patients were included, with a mean follow-up of 26 months after surgery. The mean preoperative body mass index was 60, and the mean weight of resected tissue was 21 kg. No patient required an orchiectomy for completion of the resection. Skin grafting was performed in 1 patient, and the rest were closed primarily. Wound complications were common but generally managed successfully with local wound care. At the time of most recent follow-up, most patients had actually gained weight since surgery (mean weight change of +5.2 kg). However, QOL scores improved across all domains, and overall QOL improved from a mean of 1.3 preoperatively to 7.7 postoperatively (where 1 is poor, and 10 is excellent). CONCLUSION: Surgical treatment of MLL of the scrotum can be performed successfully for masses even up to 61 kg (134 lbs). Short-term wound complications are common, but subjective QOL scores improve dramatically. Despite expectations, most patients gained weight after mass removal, which indicates that they would benefit from a comprehensive weight loss plan that includes, but is not limited to, scrotal surgery.

Men with Anterior Urethral Strictures are Often Treated without Imaging or Discussion of all Treatment Options.

INTRODUCTION: We determined how men presenting to our institution with anterior urethral strictures and recurrent strictures after treatment were evaluated, counseled and treated. METHODS: A prospective study was performed of all patients presenting to our institution with recurrent anterior urethral stricture disease between 2011 and 2014. Outside records were reviewed and all patients were queried to determine if they had any urethral imaging before treatment, what treatment was given and what other options were discussed. Patients were excluded from the study if they had a history of hypospadias, or if they were initially treated more than 10 years ago or treated outside of the United States. RESULTS: A total of 100 men were included in the study, of whom 89 (89%) had prior treatment with urethral dilation or endoscopic incision. Of these patients 81 (91%) were treated without prior urethral imaging. Of the 90 patients who were treated or advised to have treatment with direct visual internal urethrotomy or dilation, 81 (90%) were not offered urethroplasty as an option. There were 66 patients who had multiple such treatments and of this group only 6 (9%) were offered urethroplasty before subsequent treatment. CONCLUSIONS: In this study the majority of men with urethral strictures were treated without urethral imaging. Furthermore, most men were not offered urethroplasty as an option before undergoing 1 or more urethral dilations or internal urethrotomies.

Posterior Urethral Strictures.

Pelvic fracture urethral injuries are typically partial and more often complete disruptions of the most proximal bulbar and distal membranous urethra. Emergency management includes suprapubic tube placement. Subsequent primary realignment to place a urethral catheter remains a controversial topic, but what is not controversial is that when there is the development of a stricture (which is usually obliterative with a distraction defect) after suprapubic tube placement or urethral catheter removal, the standard of care is delayed urethral reconstruction with excision and primary anastomosis. This paper reviews the management of patients who suffer pelvic fracture urethral injuries and the techniques of preoperative urethral imaging and subsequent posterior urethroplasty.

The Use of Flaps and Grafts in the Treatment of Urethral Stricture Disease.

The use of various grafts and flaps plays a critical role in the successful surgical management of urethral stricture disease. A thorough comprehension of relevant anatomy and principles of tissue transfer techniques are essential to understanding the appropriate use of grafts or flaps to optimize outcomes. We briefly review these principles and discuss which technique may be best suited for a given anterior urethral stricture, depending on the location and length of the stricture, the presence or absence of an intact corpus spongiosum, and the availability of adequate and healthy penile skin.

Ventral and dorsal buccal grafting for 1-stage repair of complex anterior urethral strictures.

OBJECTIVE: To describe our 14-year experience with a 1-stage tissue transfer urethroplasty technique. METHODS: Eighteen patients underwent reconstruction with circumferential buccal grafting. All patients had anterior urethral strictures that included segments of total or near-total obliteration not amenable to excisional or augmented anastomotic repair and intact corpus spongiosum that could serve as a graft recipient bed. The mobilized corpus spongiosum was incised dorsally without transection, thereby preserving the continuity of the blood supply within the spongy tissue. Buccal mucosa was quilted to the corporal bodies to reconstruct the dorsal aspect of the urethra. Where there was obliterative or near-obliterative stricture disease, additional buccal mucosa was quilted to the dorsally incised, nontransected corpus spongiosum in continuity with the distally and proximally spatulated urethra. The repair was then completed by approximating dorsal and ventral buccal mucosal graft segments. RESULTS: Follow-up included voiding cystourethrogram at 3 weeks, cystoscopy 4 months after surgery (1 patient refused), and subsequent follow-up. There was 1 early stricture recurrence, which was successfully treated with direct vision internal urethrotomy (success 94%, and 100% after 1 urethrotomy). Every patient was contacted and assessed at the time of manuscript preparation. All patients are currently free of obstructive symptoms attributed to stricture disease with a mean follow-up of 50 months (range, 5-171 months). CONCLUSION: Dorsal and ventral buccal grafting appears to be an excellent option for a 1-stage repair of long obliterative anterior urethral strictures and strictures that include segments of obliterative or near-obliterative disease in selected cases.