Grafting Area Reduction in Peyronie's Disease Surgery: Comparative Assessment Between Double Y Vs iGrafter APP Using 3D-Printed Penile Models.

BACKGROUND: The use of plaque incision and graft techniques (PIG) for the treatment of severe Peyronie's disease (PD), may lead to erectile dysfunction (ED); graft size is 1 of the contributing factors for post-PIG ED. Recently the iGrafter software APP was introduced using a mathematical algorithm to distribute the incisions along the penile length resulting in a smaller grafting area. AIM: Compare 2 PIG techniques, the Double-Y(DY) and iGrafter, in 3 main aspects: (i) Total grafting area; (ii) The variation in calculating the grafting to be used; (iii) time to perform the PIG. METHODS: Six urologists with expertise in sexual medicine performed both techniques twice using four 3-D validated training models for PD with a standard 60° uniplanar dorsal curvature. OUTCOMES: The graft areas and operative partial and total time for each step of the operation were recorded for each procedure. Unpaired t-test and the coefficient of variation for graft area across surgeons was calculated comparing both techniques. RESULTS: For all surgeons, the use of iGrafter resulted in 2 grafts, for the DY technique in 1 graft. Overall, TT for the iGrafter was significantly longer than for DY technique (49.4 ± 11 vs 40.7 ± 5.7 minute; P = .02), The iGrafter grafting area was significantly smaller (11.6 ± 1.2 vs 23.3 ± 5.4 cm2; P: .01), representing a 50.2% area reduction when compared to the DY. The variation of graft area, using the iGrafter also yielded a more consistent graft across all surgeons (CV = 10.56% vs 23.28%). CLINICAL SIGNIFICANCE: The iGrafter, when compared to DY technique, reduced the graft area by 50%, which potentially means less erectile dysfunction. STRENGTHS AND LIMITATIONS: Our study eliminates anatomical variations found in a real clinical case making it possible to compare surgical techniques with the same penile anatomy. However, the 3D-printed model cannot replicate the living human tissue property preventing a simulation close to actual surgery. CONCLUSION: The use of the iGrafter software for PIG surgery has shown to be a promising technique for severe PD management resulting in smaller graft size (about 50% smaller when compared to the DY), although it might be more time-consuming. Tourchi A, Nascimento B, de Freita Miranda A, et al. Grafting Area Reduction in Peyronie's Disease Surgery: Comparative Assessment Between Double Y Vs iGrafter APP Using 3D-Printed Penile Models. J Sex Med 2022;19:669-675.

Rural versus urban compliance in the management of cryptorchidism: is there a difference?

The authors compared the age and referral patterns of pediatric patients undergoing surgical intervention for cryptorchidism at a rural, West Virginia University, versus urban, Johns Hopkins University, tertiary center. A retrospective review of patients undergoing surgical evaluation for cryptorchidism was performed. Patients treated for reasons unrelated to cryptorchidism or referred for multiple urologic diagnoses were excluded. The patients at each institution were then divided into four groups based on their corrected gestational age at time of surgery. Referral times and provider specialties were also obtained. A total of 131 cases at the urban center and 100 cases at the rural center were identified. At the rural center, the average age of referral and surgery were 48.3 and 53.8 months, respectively, compared to 59.6 and 65.2 months at the urban center. Only 40% of patients at the rural site and 29% at the urban institution underwent intervention at less than 18 months of age. There was no significant difference in time of referral to surgery between the institutions. The majority of referrals were made by private practice pediatricians. CONCLUSION: In this study, a pattern of delayed referral and intervention was observed at both institutions despite differing geographic regions and heterogeneous patient populations. It is important that referring providers realize that scrotal U/S does not change management of UDT and should not delay prompt referral. What is known: • Significant referral delay is a challenging issue in the management of cryptorchidism. • Ultrasound is not a valid method for the detection of cryptorchidism. What is new: • The rural and urban management of cryptorchidism is not that different. • More emphasis should be put on the detection management of cryptorchidism.

Bladder reconstruction using scaffold-less autologous smooth muscle cell sheet engineering: early histological outcomes for autoaugmentation cystoplasty.

OBJECTIVE: To investigate the feasibility of a new approach for cystoplasty using autologous smooth muscle cell (SMC) sheet and scaffold-less bladder tissue engineering with the main focus on histological outcomes in a rabbit model. MATERIALS AND METHODS: In all, 24 rabbits were randomly divided into two groups. In the experimental group, SMCs were obtained from the bladder muscular layer, labelled with PKH-26, and seeded on temperature-responsive culture dishes. Contiguous cell sheets were noninvasively harvested by reducing the temperature and triple-layer cell-dense tissues were constructed. After partial detrusorectomy, the engineered tissue was transplanted onto the urothelial diverticulum. The control group underwent partial detrusorectomy followed by peritoneal fat coverage. At 2, 4, and 12 weeks the rabbits were humanely killed and haematoxylin and eosin, Masson's trichrome, cluster of differentiation 34 (CD34), CD31, CD3, CD68, α-smooth muscle actin (α-SMA), picrosirius red, and pentachrome staining were used to evaluate bladder reconstruction. RESULTS: At 2 weeks after SMC-sheet grafting, PKH-26 labelled SMCs were evident in the muscular layer. At 4 weeks, 79.1% of the cells in the muscular layer were PKH-positive cells. The portion of the muscular layer increased in the experimental group during the follow-up and was similar to normal bladder tissue after 12 weeks. α-SMA staining showed well organised muscle at 4 and 12 weeks. CD34+ endothelial progenitor cells and CD31+ microvessels increased continuously and peaked 4 and 12 weeks after grafting, respectively. CONCLUSION: In the present study, we show that autologous SMC-sheet grafting has the potential for reliable bladder reconstruction and is technically feasible with a favourable evolution over the 12 weeks following implantation. Our findings could pave the way toward future bladder tissue engineering using the SMC-sheet technique.

Anal sphincter repair with muscle progenitor cell transplantation: serial assessment with iron oxide-enhanced MRI.

OBJECTIVE: The purpose of this study was to assess homing of ultrasmall superparamagnetic iron oxide (USPIO)-labeled muscle progenitor cells in an experimental rabbit model of anal sphincter repair using MRI. MATERIALS AND METHODS: Twelve rabbits underwent external anal sphincterotomy and randomly received injection of either autologous muscle progenitor cells labeled with USPIO at a concentration of 4 mg/10(6) cells (experimental group) or saline (control group) at the site of sphincter damage. In vivo MRI, electromyography, and manometry were performed before, 1 hour after, and 1, 2, and 4 weeks after the injection. At the end time point, anal sphincter sections were obtained for histologic analysis. Semiquantitative analysis of fibrosis, desmin, iron, CD3, and CD68 was performed using two microscopic fields in two distinct regions of the sphincter according to either presence (zone I) or absence (zone II) of signal loss on the corresponding MR images. RESULTS: Labeling efficiency was 88.67% and did not influence cell viability. On follow-up images of the cell-transplanted rabbits, significant influence was reported at 1 hour, 1 and 2 weeks after transplantation. The maximum signal loss was detected at 1 hour (75.7%). Regenerating myofibers stained positively for desmin and mainly correlated to zone I on MR images. Clusters of iron-positive particles were detectable in the myofibers located mainly at the site of injection, which correlated well to zone I. Significant signal loss and Perls Prussian blue-positive area were not detected in the control group. Functional studies showed significant improvement in sphincter pressure and electrical activity in the experimental group after 4 weeks (p<0.001). CONCLUSION: Our results support the potential of iron oxide-enhanced MRI for serial monitoring of transplanted cells in an animal model of anal sphincter repair.

Sub-urothelial polyp enucleation resection and urothelial auto-augmentation cystoplasty: a simple method for bladder exstrophy-epispadias complex reconstruction in bladder plate polyposis.

OBJECTIVES: To report the results of a novel technique of sub-urothelial polyp enucleation resection (SUPER) and urothelial auto-augmentation cystoplasty (UAAC) in patients with bladder exstrophy and polyposis plate. METHODS: Twenty-eight patients with bladder exstrophy covered by plate polyposis were referred for further management. From these, 12 patients had undergone SUPER, UAAC technique, and subsequent bladder closure. In this technique, the urothelium covering the polyps was utilized as tissue for auto-augmentation cystoplasty. Sixteen patients had been operated by simple polyps' excision and bladder closure. Biopsies of polyps were obtained in both groups at the time of closure for pathological evaluations. The bladder plate was measured pre-and post-bladder plate augmentation. The patients were evaluated every 3 months for 1 year and biannually thereafter for urinary continence and social dryness. Dry period of >3 h during the day with or without nocturnal incontinence was defined as social dryness. RESULTS: All patients experienced an uneventful postoperative period. No sign of metaplasia or dysplasia was observed in the histological and cystoscopy evaluations. These findings suggest that neither polyp recurrence nor bladder tumor development has occurred in any of the groups. The urinary continence improved significantly in the polyp's urothelial coverage augmentation cystoplasty technique (66.7%), while 31.3% of patients in simple closure technique achieved continence. Significantly higher mean bladder capacity was obtained in the augmentation group (190 ± 38 ml) and (119 ± 21 ml), respectively. Postoperative mild hydronephrosis and vesicoureteral reflux were significantly lower in auto-augmentation technique. CONCLUSION: The final clinical outcome of children with bladder exstrophy polyposis is promising. The combined SUPER and UAAC technique is feasible, safe and reproducible option for bladder exstrophy-epispadias complex (BEEC) patients with bladder plate polyposis. However, it will add one supplementary operation to the single or staged bladder reconstruction. These patients may warrant further surveillance with histopathological evaluations during the adult life.

Superselective α-adrenergic blockers versus transurethral resection of the prostate: a prospective comparison of health-related quality of life outcome after treating patients with benign prostatic hyperplasia.

PURPOSE: We prospectively evaluated the impact of transurethral resection of the prostate (TURP) versus superselective α-adrenergic blocker treatment on health-related quality of life (HRQOL) in men with clinically diagnosed benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: A total of 219 patients with lower urinary tract symptoms (LUTS) caused by BPH were recruited in this study. Treatment modalities consisted of standard TURP (n = 104) and tamsulosin medical treatment (n = 115). HRQOL was assessed by SF-36-Item Health Survey 1.0. LUTS were estimated by The International Prostate Symptom Score. Patients' outcome 4 weeks after treatment was compared to pre-treatment status and to that of the other group. Statistically significant changes in each HRQOL scale from baseline to follow-up period were investigated. RESULTS: Baseline characteristics were similar in both groups except for the duration of disease before treatment that was longer in TURP group. Both treatments resulted in statistically significant improvements from pre-treatment in all scales of QOL after 4 weeks, with no significant differences observed between the two groups. In medical treatment group, there was a significant association between higher educational level and better QOL in all 8 scales. Our outcomes revealed a significant decrease in the IPSS in both groups but this improvement was more evident in TURP group. CONCLUSION: All scales concerning HRQOL were favorably improved 4 weeks after both surgical and medical treatment, and no significant differences were observed between these two treatment modalities for patients with symptomatic BPH. This information may aid patients when deciding which treatment option to take.

No-touch intermittent catheterization: caregiver point of view on sterility errors, duration, comfort and costs.

AIMS: To determine which method of intermittent urinary catheterization, sterile with a catheterization-set or the no-touch method, offers the most advantages for caregivers in a hospital setting BACKGROUND: The no-touch catheter is assumed to decrease the risk for infection and increase the comfort for caregivers due to its construction, however, evidence is lacking DESIGN: A cross-over experimental study was carried out from October until December 2009, 100 nurses and 71 nursing students participated. METHOD: Every participant had to catheterize as well according to the no-touch method as to the standard intermittent catheterization method. A randomization programme determined whether the subjects had to catheterize a male or female simulation model. FINDINGS: Multiple regression analysis shows that nurses and nursing students appear to make on average two more errors with the sterile intermittent catheterization method with set than with the no-touch method. The duration of the no-touch method is 92 seconds less than the classical catheterization method. On a scale with 10 points for comfort, the classical sterile method with set scored on average two points lower than the no-touch method, as well for the nurses as for the students. CONCLUSIONS: Compared with the classical method, both students and nurses spend less time on performing the no-touch method, less sterility errors are made and a higher score is assigned to the no-touch method. Also classical catheterization of men implies higher costs compared with the no-touch method. No-touch intermittent catheterization is thus expected to be preferred above the gold standard catheterization method.

Usefulness of concomitant autologous blood and dextranomer/hyaluronic acid copolymer injection to correct vesicoureteral reflux.

PURPOSE: We present the long-term results of a new modification of endoscopic treatment of vesicoureteral reflux involving concomitant injection of autologous blood following the standard hydrodistention injection technique to prevent bulking agent leakage immediately after the procedure. MATERIALS AND METHODS: A total of 341 children underwent endoscopic implantation of dextranomer/hyaluronic acid for vesicoureteral reflux. A subset of 171 patients underwent hydrodistention autologous blood injection, while 170 underwent classic hydrodistention injection. Frequency of symptomatic urinary tract infection after endoscopic treatment was recorded. Success was defined as absence of vesicoureteral reflux on postoperative voiding cystourethrography. RESULTS: A total of 523 ureters in 214 girls and 127 boys were treated. In patients undergoing hydrodistention autologous blood injection mean age was 39.48 months, mean maximal reflux grade was 3.02 and success rate was 93.6% after the first injection (98.0% in patients with grade II, 92.1% with grade III, 93.3% with grade IV and 85.7% with grade V reflux). In patients who underwent classic hydrodistention injection mean age was 36.12 months, mean maximal reflux grade 3.05 and success rate was 81.8% after the first injection (91.5% in patients with grade II, 89.4% with grade III, 74.4% with grade IV and 44.4% with grade V reflux). The success rate was significantly higher (p = 0.001) in patients undergoing hydrodistention autologous blood injection vs classic hydrodistention injection. Of the patients 1.7% in the hydrodistention autologous blood injection group and 2.9% in the classic hydrodistention injection group reported symptomatic urinary tract infection during followup. CONCLUSIONS: Immediate injection of autologous blood following dextranomer/hyaluronic acid injection to create a blood clot and barricade against bulking agent leakage is more effective than pure dextranomer/hyaluronic acid implantation. This novel modification stabilizes the subureteral implant mount and may affect the antireflux outcome.

Safety, efficacy and health related quality of life of autologous myoblast transplantation for treatment of urinary incontinence in children with bladder exstrophy-epispadias complex.

PURPOSE: Children with bladder exstrophy-epispadias complex undergoing endourethral autologous myoblast transplantation to treat urinary incontinence were evaluated at 4 years of followup regarding the safety, efficacy and durability of the procedure, and health related quality of life. MATERIALS AND METHODS: Seven boys underwent autologous myoblast transplantation between May and December 2006. All patients had persistent urinary incontinence after bladder neck reconstruction and bulking agent injection. Patients were followed for 4 years after autologous myoblast transplantation regarding clinical outcomes and cystometric, urodynamic, uroflowmetric and urethrocystoscopic evaluations. Health related quality of life was also measured before treatment and at final followup. RESULTS: No evidence of urinary obstruction was observed. Five children (71%) were completely continent and 2 (29%) were socially dry with complete daytime dryness at final followup. Health related quality of life was improved significantly. Urodynamic studies revealed a progressive increase in bladder capacity (p <0.001). Mean detrusor leak point pressure showed a 27 cm H(2)O (158%) increase during 4-year followup. Uroflowmetry parameters of voided volume and average maximum flow rate were improved significantly (p <0.001). CONCLUSIONS: The 4-year outcomes demonstrate that autologous myoblast transplantation for urinary incontinence in children with bladder exstrophy-epispadias complex is relatively reliable, reproducible, safe and effective with minimal morbidity. This novel treatment represents a promising therapeutic approach in patients with urinary incontinence. Further randomized trials with larger numbers of patients and longer followup are needed.

Single-stage subsymphyseal cystoscopic-guided bladder neck plication and urethrogenitoplasty in female epispadias: presentation of long-term follow-up.

OBJECTIVE: • To investigate the feasibility of an endoscopic technique as a guide to evaluate bladder outlet resistance during bladder neck plication (BNP) for treatment of female epispadias. PATIENTS AND METHODS: • The postoperative outcomes with long-term follow-up of 10 girls with epispadias were reviewed (four had a previous history of bulking agent injection into the BN). • After taking a skin flap from the area between the crura of the bifid clitoris, subsymphyseal dissection was continued to the BN. • Under cystoscopic guidance, BNP was performed using absorbable sutures (two cases) or non-absorbable sutures (eight) aiming to attain a smooth closure of the BN during gradual withdrawal of the cystoscope. • Finally, urethrogenitoplasty was accomplished by urethral reconstruction with tubularization of the inter-clitorial flap followed by monsplasty and approximation of the two hemi-clitorises. RESULTS: • The mean (range) follow-up was 9.1 (5-15) years. • After primary surgery seven of the 10 girls were continent and all could void normally. • Of the three failed cases (including two that underwent BNP using absorbable suture), two became dry after injection of bulking agent into the BN and the remaining girl underwent BN reconstruction; she was socially continent at the final follow-up. • Ultimately, all 10 girls were socially continent, including six who were completely dry. • Urodynamic studies showed an increase in mean bladder capacity (P < 0.001) and a significant time-dependent improvement of the leak-point pressure and maximum urinary flow rate. CONCLUSIONS: • The present series suggests that single-stage subsymphyseal urethrogenitoplasty together with cystoscopic-guided BNP for management of female epispadias is reliable and effective with definite advantages. • The high success rate and safety of the procedure are important factors for the introduction of this method as a valid option for treatment of this rare congenital anomaly.

Single incision miniature pyeloplasty and ipsilateral inguinal herniorrhaphy in infants.

PURPOSE: We describe a single incision miniature open pyeloplasty and retroperitoneal herniorrhaphy technique in infants. MATERIALS AND METHODS: A total of 22 patients with ureteropelvic junction obstruction and concomitant inguinal hernia were referred to our center between November 2003 and November 2008. A total of 13 patients (mean age 5 months) with extensively dilated pelves (extending down to pelvic cavity) and ipsilateral inguinal hernia underwent single incision miniature open pyeloplasty and retroperitoneal herniorrhaphy. All patients had decreased differential renal function (less than 40%), urinary tract infection, palpable kidney and obstructive pattern on renal diethylenetriamine pentaacetic acid scan. The incision was made along the most dependent part of the lower quadrant. After dissection of the ureteropelvic junction component, we pulled out the affected section and performed classic dismembered pyeloplasty without renal pelvis reduction. Next, we performed retroperitoneal herniorrhaphy from the same incision. Surgical incision size, operative time, hospital stay, postoperative analgesic use and complication rate were recorded for further evaluation. RESULTS: The operation was uneventful in all patients. Mean operative time was 64 minutes (range 47 to 93) and patients were discharged home after a mean +/- SD of 19 +/- 3 hours (15 to 24). Incision size was 12 to 18 mm and the incision was closed by inserting a mini Hemovac closed drain. No narcotic supplementation was required postoperatively and there were no complications during followup. CONCLUSIONS: Single incision miniature pyeloplasty with ipsilateral inguinal herniorrhaphy in an extensively dilated pelvis and ipsilateral inguinal hernia is technically feasible and safe in selected cases. The exact incision site must be reconfirmed intraoperatively by physical examination or renal ultrasound. The technique adds the advantages of minimally invasive procedures (small incision, negligible postoperative pain) to the short operative time and high success rate of the open approach.

Vesicoureteral reflux and primary bladder neck dysfunction in children: urodynamic evaluation and randomized, double-blind, clinical trial on effect of α-blocker therapy.

PURPOSE: Primary bladder neck dysfunction has been under diagnosed as a treatable cause of vesicoureteral reflux. We evaluated the effect of prazosin administration on vesicoureteral reflux resolution and urodynamic parameters in children with idiopathic primary reflux and primary bladder neck dysfunction. MATERIALS AND METHODS: A total of 62 children (mean ± SD age 7.9 ± 2.4 years) with documented vesicoureteral reflux and urodynamics proved primary bladder neck dysfunction were randomized to receive either 0.025 mg/kg α-blocker (prazosin, 40 patients) or placebo (22) nightly for 1 week with a subsequent increase to 2 divided doses. Patients were followed for 12 months with clinical evaluation and uroflowmetry performed every 2 months, and each patient underwent complete urodynamic study at 6-month intervals. RESULTS: In the placebo group no uroflowmetry or urodynamic parameter changed significantly at 1-year followup. A 60% decrease in reflux grade was observed in the treatment group compared to 17% in the placebo group. Mean maximal detrusor pressure, post-void residual and opening time were significantly decreased in both followup sessions in the prazosin group (p <0.05). Average flow rate improved from 4.30 to 12.80 ml per second at 6 months and to 13.10 ml per second at 12 months (both p <0.05). CONCLUSIONS: Special attention should be given to secondary causes of vesicoureteral reflux (such as primary bladder neck dysfunction, an underdiagnosed entity in children), since conventional treatment will most likely fail if these conditions are not addressed promptly. In this study prazosin was effective therapy for children with vesicoureteral reflux and primary bladder neck dysfunction.

Functional external anal sphincter reconstruction for treatment of anal incontinence using muscle progenitor cell auto grafting.

PURPOSE: This study aimed to investigate the feasibility of autologous muscle progenitor cell transplantation for anal sphincter regeneration in a rabbit model of anal incontinence. We examined the serial changes in structure, with particular emphasis on histology and functional properties of the anal sphincter. METHODS: External anal sphincterotomy was performed in 21 rabbits; these rabbits were randomly assigned to 2 groups. In group I (n = 9), autologous muscle progenitor cells were isolated from quadriceps myofiber explants, labeled with PKH-26, and injected into sphincter 3 weeks after sphincterotomy. In group II (n = 12), saline buffer was injected at the site of damage. Sphincter electromyography and manometry were performed immediately before sphincterotomy and 14, 28, and 60 days after injection in 3 animals in each group at every interval and the findings were correlated with histomorphological studies. In addition, electromyography and manometry were performed in the remaining 3 rabbits in group II after 6 months. RESULTS: In group II, a flaccid sphincter persisted during the 6 months of follow-up. In group I, muscle progenitor autografting accelerated sphincter myofiber repair and improvement in functional capacity of the damaged sphincter. Fluorescently labeled cells were detected in all of the grafted sphincters; regenerated myotubes were detectable at the injection site as evidenced by the presence of desmin. We also observed a significant decrease in interstitial fibrosis in the 4th week and strikingly higher amounts of Ki-67-positive cells in group I. Manometry and electromyography showed a significant improvement in the mean resting anal canal pressure and sphincteric electrical activity 4 weeks after cell injection, respectively. CONCLUSION: Transplanting muscle progenitor cells showed the potential for recapitulation of a myogenic program when injected into deficient rabbit anal sphincter. Objective anal measures of resting and stimulated pressures and electromyographic profile improved. Stem cell-mediated anal myoplasty warrants additional investigation as a new method to treat anal incontinence before attempting this modality in the clinical setting.

Hypospadias repair and glans augmentation using a modified Mathieu technique.

PURPOSE: To describe a modification in Mathieu (perimeatal-based flap urethroplasty) technique that incorporates glans augmentation into the procedure and is applicable for hypospadias patients with small glans and shallow urethral grooves. PATIENTS AND METHODS: Fifty-four children with primary hypospadias and small glans underwent either the new double-faced Mathieu (DF-Mathieu) technique (33 patients) or tubularized incised plate (TIP) procedure (21 patients). DF-Mathieu perimeatal-based skin flap was meant to cover the distance from urethral orifice to the tip of the glans and flip back to fill the gap between glans wings. Patients were followed up for 20 months (12-30). TIP group underwent the conventional procedure. RESULTS: The mean age in DF-Mathieu and TIP group was 43.1 and 39.8 months, respectively. Post-operative results in DF-Mathieu group revealed one urethral fistula and no urethral break down or necrosis. In TIP group, there were one glans fistula (4.7%) and one meatal stenosis (4.7%). Overall success rate was 97% in DF-Mathieu and 90.5% in TIP operation. After 6 months, all DF-Mathieu patients had slit-like meatus and their cosmetic results were satisfactory. CONCLUSION: Double-faced Mathieu technique seems applicable in patients with shallow urethral grooves when TIP procedure may increase the risk of complications. Unlike its predecessor, this technique eliminates the tension on glans wing sutures and the risk of subsequent neo-urethral break down.

Vessel and Muscle Sparing Techniques in Bulbous Urethroplasty: A Review.

INTRODUCTION: Excision and primary anastomosis has emerged as a standard of care for urethral strictures in men with satisfactory results for urethral patency. Several improvements, particularly in repair of proximal bulbous strictures, aim to preserve the vascular pedicle and avoid violating the bulbospongiosus muscle and its innervation during perineal access to the urethra. For patients with anterior urethral strictures these techniques may offer benefits such as decreased sexual dysfunction, post-void dribbling and ejaculatory changes. We describe techniques for and potential functional effects of bulbar artery sparing and bulbospongiosus muscle sparing excision and primary anastomosis, as well as pertinent anatomical principles. METHODS: We searched PubMed® and Web of Science™ for relevant articles using the keywords "urethroplasty," "urethral reconstruction," "anterior," "bulbous," "vessel sparing," "muscle sparing," "non-transecting," "bulbar artery" and "bulbospongiosus." Two authors independently screened results, and articles not relevant or not written in English were excluded. RESULTS: Preservation of proximal urethral blood supply is imperative, particularly for patients with multiple prior urethral reconstructions, hypospadias or potential need for artificial sphincter for incontinence (eg after prostatectomy). Since vessel sparing excision and primary anastomosis was first described, there have been several modifications with promising outcomes. In the same context bulbospongiosus muscle sparing urethroplasty has been described and is associated with favorable outcomes for post-void dribbling and ejaculatory dysfunction. CONCLUSIONS: Preservation of vessels, nerves and muscles around the urethra is associated with favorable functional outcomes. Short-term results are reassuring, although longer followup and more uniform criteria for measuring patient reported outcomes are needed.

Early Postoperative Morbidity of Robotic Versus Open Radical Cystectomy in Obese Patients.

Aims: To compare the 30-day postoperative complications of robotic radical cystectomy (RRC) vs open radical cystectomy (ORC) in obese patients (body mass index ≥30) with bladder cancer (BC). Methods: The National Surgical Quality Improvement Program database was queried to identify obese BC patients who underwent RRC or ORC between 2005 and 2016. Patient demographics, postoperative mortality rate, morbidity, operating time (OPTIME), length of stay (LOS), readmission, and reoperation rates were recorded and compared between the two groups. Each RRC patient was matched with three ORC patients using a propensity score approach. Results: Four hundred forty-two RRC patients were matched with 1326 ORC patients. No difference in early postoperative mortality rate between RRC and ORC (0.7% vs 1.3%, relative risk, RR [95% confidence interval CI]: 0.27 [0.07-1.02]). Compared with ORC, the RRC group showed shorter mean OPTIME (364.7 [standard deviation, SD = 133.4] vs 387.8 [SD = 129.7] minutes, p = 0.001) and mean LOS (7.1 [SD = 5.6] vs 10.6 [SD = 6.6] days, p < 0.001). Compared with ORC, the RR of developing the following events in RRC group was lower: 30-day postoperative any complication (45%), any wound occurrence (64%), blood transfusion (70%), superficial surgical-site infection (78%), and wound disruption (77%). There was no difference in the RR of any-cause readmission (RR [95% CI]: 0.77 [0.57-1.05]) and reoperation (RR [95% CI]: 0.48 [0.22-1.04]) between the two groups. Conclusions: The study revealed that RRC for obese BC patients is associated with shorter OPTIME, shorter LOS, and lower risk of early postoperative complications when compared with a matched group of patients who received ORC. In addition, no difference in early postoperative mortality rate between RRC and ORC was observed.

Predictors of a successful primary bladder closure in cloacal exstrophy: A multivariable analysis.

PURPOSE: To investigate the factors affecting primary bladder closure in cloacal exstrophy (CE). A successful primary closure is important for optimizing reconstructive outcomes, and it is a critical first-step in the reconstruction of CE. The authors' hypothesize that a smaller diastasis and use of an osteotomy are independent predictors of a successful closure. METHODS: A prospectively maintained database of 1332 exstrophy-epispadias complex (EEC) patients was reviewed for CE patients closed between 1975 and 2015. Univariate and multivariable analyses were performed to identify significant factors associated with CE primary bladder closure. RESULTS: Of 143 CE patients identified, 99 patients met inclusion criteria. Median follow-up time was 8.82 [IQR 5.43-14.26] years. In the multivariable model, the odds of having a successful closure are about 4 times greater for the staged cloacal approach compared to the 1-stage approach (OR, 3.7; 95% CI 1.2-11.5; p-value = 0.023). Also, having an osteotomy increases the chance of a successful closure by almost six-fold (OR, 5.8; 95% CI 1.7-19.6; p-value = 0.004). CONCLUSIONS: Using the staged approach with a pelvic osteotomy is paramount to a successful primary closure in CE. The authors strongly recommend using the staged approach and osteotomy as these factors independently increase the chance for a successful primary bladder closure. STUDY TYPE: Therapeutic study. LEVEL OF EVIDENCE: Level III, Retrospective comparative study.

Autophagy, Apoptosis, and Cell Proliferation in Exstrophy-Epispadias Complex.

OBJECTIVE: To investigate the state of autophagy and its interactions with apoptosis and cell proliferation in patients who underwent successful early closure or delayed closure of exstrophy. They compared those outcomes with cell culture samples from patients with vesicoureteral reflux as control. PATIENTS AND METHODS: Primary cultures of bladder smooth muscle cells (SMCs) were established from patients with successful neonatal bladder closure (group 1, N = 5), delayed closure because of small bladder template (group 2, N = 5), and vesicoureteral reflux as control (group 3, N = 5). The myogenicity of the cultures was determined using anti-Desmin antibody. Immunostainings for LC3 to assess autophagy and Ki67 to assess cell proliferation were applied. Apoptosis was assessed by the terminal deoxynucleotidyl transferase-mediated dUTP digoxigenin nick-end labeling assay. RESULTS: Autophagy marker (LC3) expression was significantly higher in the delayed closure group than in the other groups, whereas no significant difference was noted between the neonatal closure and the control groups. Apoptotic indices of the SMCs were remarkably higher in SMC cultures from the delayed closures than in the neonatal closure and the control groups. A significantly lower expression of proliferation marker (Ki67) in the delayed closure group compared with the control and the neonatal closure group was also of note. CONCLUSION: Patients with small bladder template and delayed closure showed upregulated autophagic process and increased apoptotic indices while experiencing a dramatic decrease in the proliferation of their bladder SMCs. Finally, the concept of manipulating autophagy may lead to promising outcomes for patients with bladder exstrophy in the future.

Complete Penile Disassembly for Repair of Epispadias Causes Erectile Tissue Alteration Through Transforming Growth Factor Beta 1 Overexpression in a Rabbit Model.

OBJECTIVE: To investigate corporal tissue viability and changes in endothelial content following current techniques used for epispadias repair in an animal model. MATERIALS AND METHODS: Sixty rabbits were allocated into 3 groups: sham operation (penile degloving), complete disassembly model, and Cantwell-Ransley model. On weeks 2, 4, 12, and 24 postoperation, the penile tissue was harvested and processed for (1) Masson's trichrome staining for smooth muscle cell (SMC)-to-collagen ratios, (2) immunohistochemical staining for endothelial factor (CD31), and transforming growth factor beta 1 (TGF-ß1) (3) terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate biotin nick-end labeling (TUNEL) assay to detect apoptosis. RESULTS: Masson trichrome staining of corporal tissue showed significant decrease in SMC-to-collagen ratio in complete disassembly group compared with sham operation group. The expression of CD31 was significantly lower (P <.05) in complete disassembly group compared with the other groups at all time points, whereas no significant difference was observed between the Cantwell-Ransley group and the sham operation group. Moreover, apoptotic index was markedly higher in the complete disassembly group compared with the 2 other operation groups (P <.05). Immunohistochemistry also showed a significantly higher expression of TGF-ß1 in the penile tissue after complete disassembly than Cantwell-Ransley or sham operation. CONCLUSION: Complete detachment of the urethra from the corpus cavernosa may result in endothelial dysfunction, alteration of SMC content of erectile tissue, and replacement of the native cavernosal tissue with fibrotic tissue. An increased expression of TGF-ß1, following the complete disassembly technique, might be one of the important factors causing the abovementioned alterations.

The Surgical Management of Bladder Polyps in the Setting of Exstrophy Epispadias Complex.

OBJECTIVE: To investigate the surgical course for treating bladder polyps in patients with exstrophy epispadias complex (EEC). EEC bladder polyps are unique pathologic entities, with a distinct difference between polyps discovered at birth and polyps developed after failed exstrophy closure. METHODS: A prospectively maintained database of 1300 patients with EEC was reviewed for bladder exstrophy patients with bladder polyps. The following data were obtained: patient demographics, polyp type, past medical and surgical history, and continence outcomes. Polyps were categorized as (1) primary, bladder polyps at birth or during neonatal period; and (2) secondary, bladder polyps following a failed exstrophy closure. RESULTS: Of 1300 EEC patients, 43 patients with polyps met the inclusion criteria. All closures for primary polyp patients were successful, and continence outcomes remained similar in early and delayed closures (P = .689). Secondary polyp patients were more likely to require augmentation to increase bladder capacity (P = .033). Bladder neck reconstruction (n = 8) was successful in 83.0% of patients with primary polyps, and none were successful for those with secondary polyps (P = .035). CONCLUSION: Delaying primary bladder closure for patients with small polypoid bladder templates did not affect closure or continence outcomes. However, primary and secondary polyps may require different surgical interventions. Bladder neck reconstruction was markedly less successful in secondary polyp patients, and secondary polyp patients were more likely to need augmentation to increase bladder capacity. This study emphasizes the importance of a successful primary closure and suggests that secondary polyps are an indicator of decreasing potential for bladder growth.