Transurethral dorsal buccal graft urethroplasty for proximal female urethral strictures.

INTRODUCTION AND HYPOTHESIS: We present a novel outpatient transurethral dorsal buccal graft urethroplasty for managing proximal female urethral strictures. METHODS: A 69-year-old female presented with a 2.5-year history of slowing urinary stream. After discussing treatment options, she opted for transurethral dorsal buccal graft urethroplasty. The procedure begins with buccal graft harvest, and care is taken to avoid Stetson's duct. A nasal speculum is placed transurethrally, distal to the stricture. The full length of the dorsal urethra is incised superficially. A suture-passing device is used to place three sutures at the bladder neck and then through the buccal graft. The sutures are tied transurethrally using a laparoscopic knot pusher, parachuting the graft into place. The distal aspect of the buccal graft is secured to the urethral meatus with interrupted suture and surgical glue used to secure the midportion of the graft. RESULTS: Following the outpatient procedure, she had an uneventful recovery, including catheter removal at 3 weeks. At 3 months she had significant improvement in her urinary stream and no stress incontinence. CONCLUSIONS: The transurethral approach to dorsal buccal graft urethroplasty is technically feasible and, in the short term, effective. Longer follow-up and larger series are needed to validate this procedure.

Novel Peyronie's algorithm at the time of penile implant.

INTRODUCTION: Peyronie's disease (PD) is a fibrous transformation of the tunica albuginea within the corpora cavernosa causing curvature of the penis while erect. This cannot only be painful but can also cause narrowing, shortening, an hourglass deformity and problems with penetrative intercourse. There are many means of management of Peyronie's disease at the time of penile implant. Modeling is a commonly used approach but leaves the penis without increased length. Multi-incisional techniques enhance length restoration, but risk significant vascular and neurologic compromise. Herein, we present our experience with a novel algorithm to approach Peyronie's disease with an effort to enhance and restore length without elevation of the neurovascular bundle. MATERIALS AND METHODS: A retrospective review was performed of an institutional review board approved database. Patients treated for Peyronie's disease and erectile dysfunction with penile implant from 8/16/18 to 8/20/2020 were evaluated. RESULTS: In our cohort of 33 patients there is an average of 1.9 cm average stretch difference in stretch penile length before and after management. There was a 2.15 cm difference in the cohort subset that utilized the Brock technique. We had no loss of sensation or glans ischemia. There was one patient with autoinflation. All patients had less than 10 degrees of residual curvature. CONCLUSION: With the proposed algorithm, we are able to safely maximize length restoration without elevation of the neurovascular bundle. More patients with longer follow up is needed to ensure the safety and validity of this algorithm.

Virtue male sling outcomes and application to a contemporary nomogram.

INTRODUCTION To report outcomes of our Virtue male sling series and evaluate predictors of surgical success and failure. We also retrofit the Male Stress Incontinence Grading Scale (MSIGS) refined nomogram, including the standing cough test (SCT), to assess its application to our cohort. MATERIALS AND METHODS: A retrospective review was completed at a single institution over a 4 year period of all Virtue male slings implanted for stress urinary incontinence (SUI). Patient demographics including pad usage per day (PPD) and MSIGS were obtained on all patients after their bladders were filled cystoscopically. Failure was defined as > 1 PPD and/or conversion to another anti-incontinence procedure. Incidence, management and outcomes of complications were also evaluated. RESULTS: Forty-six men who underwent Virtue male sling at a median follow up of 15.6 months were analyzed with an objective success rate of 78% and a subjective success rate of 85%. Preoperative predictors of surgical success were ability to stop stream on physical exam, lack of total incontinence and no history of posterior urethral stricture. MSIGS alone was not predictive of sling success or failure. Penile numbness occurred in 11% of patients and reoperation with incision of the sutured together transobturator arms improved sensation in all patients. CONCLUSION: Virtue male sling has high objective and subjective success rates with a manageable side effect profile. Evidence of residual sphincteric function appears to be more predictive of sling success rather than MSIGS.

Continent cutaneous ileocecal cystoplasty in the treatment of refractory bladder neck contracture and urinary incontinence after prostate cancer treatment.

INTRODUCTION: To assess the use, complications, and outcomes of continent cutaneous ileocecal cystoplasty (CCIC) for the management of refractory bladder neck contractures and/or urinary incontinence after prostate cancer therapy. MATERIALS AND METHODS: An institutional review board approved database was reviewed for patients who underwent CCIC from January 1, 2003 to December 31, 2018. Preoperative, perioperative and postoperative factors were assessed, including complications and outcomes. RESULTS: Thirteen patients were identified. Indications for CCIC included refractory bladder neck contracture (n = 3), urinary incontinence (n = 5), or both (n = 5). Median age was 69. Median follow up was 78.1 months. Seventy-seven percent of patients (10/13) had a history of radiation. The median number of procedures between initial prostate treatment and augmentation was 3. Sixty-nine percent (9/13) of patients had a bladder neck closure along with augmentation (5 transabdominal and 4 transperineal). Median operative time was 375 minutes. Median blood loss was 175 mL. The overall complication rate was 69% (9/13), with 38% (5/13) occurring within 30 days. One patient (8%) required stomal revision. Thirty-three percent (3/9) of patients with bladder neck closure required revision due to perineal fistula. All had a history of radiation therapy. At last follow up all patients were satisfied with their urinary control. Eighty-five percent of patients (11/13) were fully continent via both urethra and stoma. One patient had urethral leakage with bladder spasms controlled with medication and one had mild stomal incontinence. CONCLUSIONS: CCIC is an effective means of treating refractory bladder neck contractures and/or urinary incontinence. While morbidity rates are high, subjective patient satisfaction is high.

Ureteroenteric anastomotic revision as initial management of stricture after urinary diversion.

OBJECTIVE: To report our experience with ureteroenteric anastomotic revision as initial treatment of stricture after urinary diversion. METHODS: An institutional review board-approved retrospective study was carried out. A total of 41 patients who underwent primary ureteroenteric anastamotic revision were identified between 2007 and 2015. Data analyzed included patient characteristics, type of diversion, estimated blood loss, operative time, change in renal function, length of stay, postoperative complications and time with nephrostomy/stent. Success of revision was defined as an improvement in hydronephrosis on radiographic imaging and/or reflux during pouchogram. Predictors of length of stay and complications were analyzed using analysis of covariance. RESULTS: A total of 50 renal units were revised with a success rate of 100%. The median length of stay was 6 days (2-16 days). There were a total of 15 complications (one major, 14 minor) in 14 patients (33% 30-day complication rate). The most common were wound infection (n = 4) and arrhythmia (n = 4). Robotic revision (n = 5) had a median length of stay of 3 days (2-4) with no complications. CONCLUSIONS: Primary ureteroenteric anastomotic revisions have an excellent success rate at an experienced center and might obviate the need for multiple interventions. Open revision is associated with mostly minor complications. Robotic revision might reduce the morbidity of open revision in select cases.

Age-stratified outcomes of holmium laser enucleation of the prostate.

OBJECTIVE: To present the first age-stratified assessment of outcomes after holmium laser enucleation of the prostate (HoLEP) for the treatment of lower urinary tract symptoms resulting from prostate enlargement. PATIENTS AND METHODS: We retrospectively analysed and compared the morbidity, and the peri-operative and functional outcomes of patients aged 50-59, 60-69, 70-79 and ≥80 years. Complications at 30 days were stratified using the Clavien system. Functional outcomes were assessed using the International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax ), post-void residual urine volume (PVR) and urinary continence. RESULTS: A total of 311 patients underwent HoLEP for obstructive voiding symptoms from August 2007 to June 2011, of whom 22 patients were aged 50-59 years, 91 were aged 60-69 years, 153 were aged 70-79 years, and 45 were aged ≥80 years. The overall morbidity rates were similar among the age groups (20, 24.4, 21.6 and 22.1% for groups 1, 2, 3 and 4, respectively), as were the incidence of significant complications (Clavien grade ≥ III), change in serum haemoglobin level, and length of hospital stay. Patients ≥80 years did have a longer catheterization time (3.4 days) than patients aged 50-59 years (1.68 days). By 1 year there were no significant differences in urinary continence, IPSS, Qmax , or PVR among the age groups. CONCLUSIONS: Overall morbidity, hospital stay, and 1-year functional outcomes of HoLEP were similar among all age groups. This study shows that HoLEP is a safe and effective treatment for benign prostatic hyperplasia regardless of age.

Endoscopic Urethroplasty Using Buccal Graft for Male Membranous Urethral Stricture.

OBJECTIVE: To demonstrate a new minimally invasive endoscopic approach to urethroplasty. METHODS: The procedure was performed in a male patient with prior history of prostate cancer managed by radiation who subsequently developed an 8 mm flow-limiting membranous urethral stricture. After stricture dilation a 1 cm wide strip of superficial mucosa was resected from the bladder neck past the area of stricture, creating a bed for the graft to lay. Buccal mucosa graft was harvested in standard fashion. With the graft outside the urethra and using the RD 180 endoscopic suturing device, a suture is placed in the proximal end of the graft, then through the bladder neck, and back through the graft. As the suture is pulled, the pulley phenomenon advances the graft into place on the bladder neck. The graft is then anchored to the posterior urethra with secure straps. A catheter is placed to hold the graft flat during the healing process. RESULTS: The procedure lasted 2.5 hours without any complications. Estimated blood loss was 50cc, and the patient was discharged after the procedure. Catheter was removed at 4weeks. Cystoscopy at 10weeks post-op showed good graft viability, with peak flow improving to 20 mL/s compared to 4 mL/s preoperatively. At 6months, he continues to do well without evidence of recurrent urethral stricture. CONCLUSION: Endoscopic urethroplasty using buccal graft appears to offer a safe and effective repair option for management of ureteral strictures.

Bladder capacity on preoperative urodynamics may impact outcomes on transobturator male slings.

AIMS: Stress incontinence is frequently seen after prostate surgery. We sought to evaluate preoperative urodynamic (UDS) parameters on functional outcomes after transobturator male sling placement. METHODS: 49 male patients with stress urinary incontinence (SUI) after radical prostatectomy or transurethral resection of the prostate underwent transobturator sling (TOS) placement from December 2008 through June 2011 (AdVance® and Virtue®). A retrospective review was performed of those patients who underwent preoperative UDS and had a minimum of 6 weeks of follow up. In total 38 patients were identified. There were 28 patients considered a success and 10 patients considered a failure. We then evaluated the preoperative UDS parameters between these two groups to identify potential adverse parameters. RESULTS: Overall success rate was 74% (28/38) with an average follow up of 3 months. Comparing the success and failure groups there was no difference between the pre-operative parameters. On pre-operative UDS, only bladder capacity was found to be significantly lower in those who failed TOS. Univariate comparisons of sling outcomes stratified by bladder capacity tertiles was performed. These values were chosen as they represented the 25th, 50th, and 75th percentiles, respectively. All patients (10/10) with bladder capacities in the top tertile experienced success with the sling, compared to only 62% and 50% of patients in the 50th and 25th tertiles, respectively; these differences were significant (Fisher's exact P-value = 0.044). CONCLUSION: TOS is an effective therapy for men with SUI. Bladder capacity based on pre-operative UDS may impact the success of the procedure.

Complications Based on Prostate Size After Plasmakinetic Enucleation of the Prostate.

Purpose: Lower urinary tract symptoms among adult men can significantly impact quality of life. We evaluated complications based on prostate size following plasmakinetic enucleation of the prostate. Materials and Methods: Patients were grouped into the small prostate group (SPG, <75 g) and large prostate group (LPG, >75 g) based on preoperative imaging. Patient data on demographics, comorbidities, preoperative international prostate symptom score (IPSS), bother index (BI), prostate-specific antigen (PSA) if indicated, postvoid residual volume (PVR), indwelling catheter or self-catheterization status, and any prior surgical intervention were evaluated. Postoperative IPSS, BI, and PVR values were assessed at 6 weeks, 4 months, and yearly. Postoperative urge urinary incontinence (UUI), stress urinary incontinence (SUI), and pad use were assessed. Results: Between September 2015 and December 2020, 296 patients who underwent bipolar enucleation with minimum follow-up of 4 months were evaluated. Postoperative IPSS, BI, PVR, and PSA values at all time points were significantly decreased compared with preoperative values (p < 0.05). There was no significant difference in the complications between groups. Univariable and multivariable analysis found that size <75 g was predictive of stricture formation and bladder neck contracture (BNC). UUI was more common at 6 weeks in the SPG, and SUI was more common at 6 weeks in the LPG, but no difference was noted at the 4-month and 1-year time points. Pad use was equal between the two groups at all time points. Conclusions: Plasmakinetic enucleation of the prostate provides an effective treatment option for prostates of all sizes; however, prostates <75 g have a higher rate of BNC and urethral strictures compared with those >75 g.

Predictors of Storage Symptom Improvement After Plasma Kinetic Enucleation of the Prostate.

OBJECTIVE: To investigate which preoperative findings portend poor improvement in storage symptoms in patients undergoing plasma kinetic enucleation of prostate (PKEP). METHODS: A single surgeon series of patients who had undergone PKEP with minimum 1 year follow up were evaluated. Patients were grouped into those with less than 33% improvement in storage symptoms (LIS) according to the international prostate symptom score (IPSS) and those with greater than 33% improvement in storage symptoms (GIS). Pre and postoperative factors were evaluated, along with IPSS, storage symptoms percentage (the total from frequency, urgency and nocturia divided by the total IPSS), bother index, and post void residual (PVR) at 6 weeks, 4 months, and yearly. RESULTS: Two hundred sixty-eight patients had a minimum 1 year of follow up and had completed the IPSS. IPSS and bother index improved significantly from preoperatively to all time points post operatively in both groups, but the difference was greater in the GIS group. Patients in the GIS group had significantly larger prostates, more prostatic ingrowth, higher preoperative PVR, and a higher overall IPSS compared to the LIS group. Those in the LIS group had a higher incidence of prior prostate surgery, and a higher BMI. However, storage symptom percentages were equal between the GIS and LIS groups at all time points. CONCLUSION: Greater prostatic ingrowth, larger prostate volume, higher preoperative PVR volume, and a higher overall IPSS was associated with greater improvement in storage symptoms. Prior prostate surgery and higher BMI portend less improvement in storage symptoms.

Impact of margin status at 37 months after robot assisted radical prostatectomy.

INTRODUCTION: We evaluate the impact of margin length, location, and pathologic stage on biochemical recurrence (BCR) after robot assisted radical prostatectomy (RARP) at 37 months of follow up. MATERIALS AND METHODS: A total of 1420 patients underwent a robot assisted radical prostatectomy between March 2004 and May 2010. Patients who received adjuvant therapy, those who never achieved an undetectable prostate-specific antigen (PSA), and those who had less than 18 months of follow up were excluded. Patients were then divided and evaluated based on margin status. RESULTS: In total, 419 patients were included in the analysis. Eighty-three had a positive surgical margin (PSM) (19.8%), 336 had a negative surgical margin (NSM) (80.2%). The overall mean follow up was 37 months. On multivariate analysis the Gleason sum and PSM were independent predictors of BCR. Margin length and location had no significant difference on the rate of BCR. Patients with a PSM and pT2 disease had an increased rate of BCR compared to pT2 and NSM. The relative risk of BCR was 2.03 and 3.21 for patients who have a PSM versus a NSM, overall and in those with pT2 disease respectively. No different BCR is seen in pT2 PSM versus ≥ pT3 NSM; or ≥ pT3 PSM versus NSM. CONCLUSION: With 37 months follow up; positive surgical margin and postoperative Gleason sum impact the rate of BCR. Location and length of the PSM do not appear to have an impact on BCR. There was an increased risk of BCR with PSM, especially in pT2 disease.

Simplified posterior urethroplasty utilizing laparoscopic instrumentation.

BACKGROUND: Posterior urethral stricture disease presents challenges for even the most skilled reconstructive urologists. Regardless of the surgical technique used, these are complex operations that occur in hard-to-access locations. We describe the use of a novel combination of laparoscopic instrumentation to simplify posterior urethral reconstruction. METHODS: We retrospectively identified patients undergoing a posterior urethral stricture repair utilizing a combination of the RD-180® suture device and the Securestrap®. These procedures were performed by a single surgeon at our institution. Patients with greater than or equal to 4 months of follow up were included in the analysis. RESULTS: From October 2016 to October 2020, 20 patients underwent posterior urethral stricture repair using these laparoscopic instruments. Median age was 70 years (28-90 years). Median follow up was 12 months (5-50 months). Mean stricture length was 3 cm (1.5-16 cm). Median operative time was 150 minutes (120-180 minutes). No peripheral neuropathies or positional injuries were noted. With failure defined as inability to pass a 16-Fr scope, success rate was 95% (19/20 patients). CONCLUSIONS: The combination of the RD-180® and the Securestrap® has become essential to our posterior urethral stricture repair armamentarium. Further data and longer follow up is needed to confirm these reliable outcomes.

Transurethral Incision with Transverse Mucosal Realignment for the Management of Bladder Neck Contracture and Vesicourethral Anastomotic Stenosis.

OBJECTIVE: To assess efficacy and safety of a novel cystoscopic technique for definitive repair of bladder neck contracture (BNC) and vesicourethral anastomotic stenosis (VUAS). METHODS: A retrospective review of patients who underwent a transurethral incision with transverse mucosal realignment between July 2019 and December 2020 by a single surgeon was completed. This is novel procedure of incising a scar cystoscopically and using a laparoscopic suturing device transurethrally to bring healthy bladder mucosa across the defect, like a YV plasty. Patients were only included if they had ≥4 months follow-up. Surgical success was defined as ability to pass a 17 French flexible cystoscope through the previously stenotic segment at 4 month follow up. RESULTS: Nineteen patients with a median follow-up of 6 months were included in this analysis. Etiology of posterior urethral stenosis was 53% from VUAS and 47% from BNC, with 32% of patients having prior pelvic radiation. Success was achieved in 89% of patients after 1 procedure and 100% of patients achieved success after a second procedure. There was no de novo incontinence or major complications. CONCLUSION: Transurethral incision with transverse mucosal realignment  for VUAS and BNC has a high success rate after only 1 procedure. This is the first reported series of an endoscopic Y-V plasty type repair for BNC and VUAS. Longer term follow up to ensure durability and reporting from other institutions will be needed to establish reproducibility.

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.

Real-time indocyanine green angiography with the SPY fluorescence imaging platform decreases benign ureteroenteric strictures in urinary diversions performed during radical cystectomy.

BACKGROUND: Ischemia is thought to contribute to benign ureteroenteric stricture (UES) after radical cystectomy with urinary diversion (RCUD). Our institution adopted the use of ureteral perfusion assessment during all RCUDs using real-time indocyanine green angiography using the SPY fluorescence imaging platform (Stryker Corp., Kalamazoo, MI, USA). This guides the location of ureteral transection prior to ureteroenteric anastomosis. We sought to compare UES rates before and after adoption of SPY. METHODS: A retrospective chart review was undertaken for the first 47 consecutive cases of RCUD using SPY as well as the previous 47 consecutive cases, which were performed without SPY. Fisher's exact and Wilcoxon rank-sum tests were used to compare benign UES rates and the length of ureter excised during anastomosis. A p < 0.05 indicated statistical significance. RESULTS: Median follow up was 12.0 months for SPY cases and 24.3 months for non-SPY cases. The UES rate for SPY RCUDs was 0% (0/93 ureters) compared with 7.5% (7/93 ureters) for non-SPY RCUDs (p = 0.01). Amongst SPY RCUDs, 86 ureters had no hydronephrosis and 7 had mild hydronephrosis with reflux on loopogram. A total of 34.4% of ureters (32/93) had poor distal perfusion, requiring a more proximal anastomosis. The median length excised for ureters with poor distal perfusion was 3.8 cm, compared with 2.2 cm for ureters with good distal perfusion (p < 0.0001). No complications attributable to the use of SPY were noted. CONCLUSION: Use of SPY to assess ureteral perfusion was associated with a decrease in the UES rate after RCUD. A total of 34.4% of ureters demonstrated poor distal perfusion, requiring a significantly more proximal ureteroenteric anastomosis.