Transurethral reconstruction of fossa navicularis strictures with dorsal inlay buccal mucosa graft urethroplasty.

PURPOSE: To describe a single stage, glans-sparing urethroplasty technique for fossa navicularis strictures using a transurethral dorsal inlay buccal mucosa graft. METHODS: We conducted a retrospective review of a prospectively maintained urethral stricture database to identify all fossa navicularis strictures reconstructed with a single stage, transurethral dorsal inlay buccal mucosa graft urethroplasty (5/2015-6/2020). Primary outcomes were anatomic success, defined as the ability to pass a 17 Fr flexible cystoscope, and functional success, defined as the lack of obstructive voiding symptoms and no need for further procedures. Secondary outcomes were postoperative complications and patient satisfaction. RESULTS: Sixteen patients were included. Mean age was 63.1 years (43.9-75.6) and mean stricture length was 1.7 cm (1.4-2.0). Stricture etiology included internal trauma (62.5%), idiopathic (25.0%), and lichen sclerosus (12.5%). Prior endoscopic procedures were done in 75% of patients. Over a median follow-up of 28.8 months (IQR 17.6-38.0), anatomic success was 15/16 (93.8%) and functional success was 16/16 (100%). The single anatomic recurrence was at 4.2 months postoperatively. No additional procedures were required. Urinary tract infection occurred in 25% (4/16). There were no instances of de novo erectile dysfunction, chordee, or wound infection. All patients would recommend urethroplasty to others and all patients were either very satisfied (83.3%) or satisfied (16.7%) with the procedure. Penile sensitivity was unchanged in 83.3%, increased in 8.3% and decreased in 8.3%. CONCLUSION: Transurethral dorsal inlay buccal mucosa graft urethroplasty is a viable option for reconstruction of fossa navicularis strictures that avoids splitting the glans and results in excellent cosmesis.

Hypoalbuminemia Is Associated with Increased 30-Day Complications following Rectourethral Fistula Repair: A National Surgical Quality Improvement Program Study.

INTRODUCTION: We sought to assess patient risk factors for 30-day postoperative complications among men undergoing surgical management of rectourethral fistula (RUF). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all male patients who underwent RUF repair (2006-2018). Hypoalbuminemia was defined as preoperative serum albumin <3.5 gm/dL. Postoperative 30-day complications included wound infection, organ space surgical site infection, urinary tract infection, sepsis, venous thromboembolism, pneumonia, cerebrovascular accident, myocardial infarction, return to operating room and mortality. The association between pre-selected patient covariates and postoperative complications was investigated using logistic regression analysis. RESULTS: A total of 250 patients were identified. Concurrent procedures during RUF repair were bowel diversion in 43/250 patients (17.2%), bowel resection (34/250, 13.6%), cystectomy (20/250, 8.0%) and urethroplasty (37/250, 14.8%). Overall, median age was 66.0 years (IQR 59.0-72.0), body mass index 26.6 kg/m2 (IQR 23.7-29.5) and 247/250 patients (98.8%) were functionally independent. Comorbidities included hypertension (140/250, 56.0%), smoking (55/250, 22.0%), diabetes (17/250, 6.8%), chronic obstructive pulmonary disease (11/250, 4.4%) and congestive heart failure (1/250, 0.4%). Hypoalbuminemia (<3.5 gm/dL) was present in 25/126 patients (19.8%). Overall, 51/250 patients (20.4%) experienced a complication within 30 days of surgery including wound infection (14/250, 5.6%), sepsis (13/250, 5.2%), organ space infection (11/250, 4.4%), urinary tract infection (8/250, 3.2%), venous thromboembolism (8/250, 3.2%) and mortality (5/250, 2.0%). After adjusting for covariates, hypoalbuminemia was associated with increased odds of a 30-day complication (OR 2.49, 95% CI 1.06-5.86, p=0.036). CONCLUSIONS: Hypoalbuminemia was associated with increased odds of short-term complications after surgical management of RUF.

Current Perspectives on the Diagnosis and Management of Primary Urethral Cancer: A Systematic Review.

Primary urethral cancer (PUC) is a rare but highly aggressive malignancy that causes malignant urethral obstruction. We conducted a literature review using PubMed to identify original research studies that assessed the diagnosis and management of primary urethral cancer. PUC affects men more than women, is more common in African Americans than Caucasians, and is associated with history of chronic inflammation and irritation of the urinary tract. Patients suspected of PUC should undergo a complete work-up including cystoscopy, magnetic resonance imaging, and biopsy. In men and women, surgical monotherapy ranging from organ-sparing to more radical reconstructive procedures has adequate survival rates for early stage PUC and has been shown to be similarly as effective as radiation monotherapy, while multimodal therapy has become the standard of treatment for advanced stage PUC. Salvage surgery or radiation therapy has been linked with increased survival rates. Nodal involvement at the time of diagnosis is a negative prognosticator and should be treated with multimodal therapy. Further prospective studies with greater sample sizes and standardized clinical trials would allow for greater consistency in evaluating the different treatment modalities for PUC.

Peyronie's Disease and the Female Sexual Partner: A Comparison of the Male and Female Experience.

BACKGROUND: Peyronie's disease (PD) is characterized by penile pain, deformity, and sexual dysfunction, often resulting in an impaired sexual experience and significant psychological bother for the patient. However, there are limited data on the impact of PD on female sexual partners (FSPs). AIM: To compare the psychosexual experience of men with PD and their FSPs. METHODS: We retrospectively reviewed all prospectively enrolled men and their FSPs who presented for initial PD evaluation to our sexual health clinic from July 2018 to February 2020. All men completed a PD-specific survey and the PD questionnaire (PDQ). If the patient was accompanied by an FSP during initial evaluation, she completed the PDQ for Female Sexual Partners and Female Sexual Function Index. We further queried our database that included information on patient demographics and clinical characteristics. OUTCOMES: The main outcome of this study is retrospective comparison of responses with the PDQ and PDQ for Female Sexual Partners. RESULTS: Data were available for 44 men with PD (median age, 56 years; interquartile range, 49-63) and their FSPs (median age, 54 years; interquartile range, 50-61). The majority of men presented in the chronic phase (35 of 44, 79.5%), and median objective composite curvature was 75° (interquartile range, 50-90°). Owing to PD, female and male partners reported similar difficulty with vaginal intercourse (VI) (74.3% vs 81.5%, P = .555), decreased frequency of VI (70.6% vs 85.2%, P = .228), and at least moderate discomfort/pain with VI (48.6% vs 33.3%, P = .232). FSPs were "very" or "extremely" bothered by the appearance of their partner's erect penis less often than male partners (20.0% vs 59.3%, P < .001). FSPs were "very" or "extremely" bothered by their partner's PD during VI less often than men with PD (32.3% vs 65.2%, P = .017). Few FSPs (22.9%) had "severe" or "very severe" concern with damaging their partner's penis during VI. CLINICAL IMPLICATIONS: The sexual experience for men with PD and their FSPs differs, thus emphasizing the importance of active engagement of both men with PD and FSP during initial PD evaluation. STRENGTHS AND LIMITATIONS: This initial study draws data from a single, high-volume men's health clinic with a limited sample size. Survey responses may have been shared by patients with PD and their FSPs. CONCLUSION: PD impacts the sexual experience for both men and FSPs. A similarly large proportion of men with PD and FSP noted decreased frequency of and difficulty with vaginal intercourse. Yet, FSPs were less bothered by the appearance of the erect penis and the deformity during VI compared with men. Farrell MR, Ziegelmann MJ, Bajic P, et al. Peyronie's Disease and the Female Sexual Partner: A Comparison of the Male and Female Experience. J Sex Med 2020;17:2456-2461.

Minimally invasive therapies for Peyronie's disease: the current state of the art.

Peyronie's disease (PD) is a relatively common condition that can result in significant penile deformity, sexual dysfunction, and psychological bother. Surgical straightening offers the highest probability of success during the stable phase of the disease. However, for men in the acute phase of PD or for those with less severe deformity who elect to avoid surgery, a variety of non-surgical treatment options are available. Oral therapies, including L-citrulline and pentoxifylline, are most useful as part of a combination regimen rather than as monotherapy. Intralesional therapy with IFN-α2b, verapamil, and collagenase clostridium histolyticum (CCH) can cause significant reduction in penile curvature, yet these results may not be clinically significant for men with more severe curvature. Further investigation into the timing of administration and optimal patient characteristics is required. Penile traction therapy offers a clinically significant improvement in penile length and curvature. However, this has traditionally required hours of daily therapy. Overall, a combination of oral, topical, injection and traction therapies may provide the most significant benefit among the non-surgical modalities for PD.

Modern treatment strategies for penile prosthetics in Peyronie's disease: a contemporary clinical review.

Peyronie's disease is a common condition resulting in penile deformity, psychological bother, and sexual dysfunction. Erectile dysfunction is one common comorbid condition seen in men with Peyronie's disease, and its presence significantly impacts treatment considerations. In a man with Peyronie's disease and significant erectile dysfunction who desires the most reliable treatment, penile prosthesis placement should be strongly considered. In some instances, such as those patients with relatively mild curvature, prosthesis placement alone may result in adequate straightening. However, many patients will require additional straightening maneuvers such as manual modeling, penile plication, and tunica albuginea incision with or without grafting. For patients with severe penile shortening, penile length restoration techniques may also be considered. Herein, we provide a comprehensive clinical review of penile prosthesis placement in men with Peyronie's disease. Specifically, we discuss preoperative indications, intraoperative considerations, adjunctive straightening maneuvers, and postoperative outcomes.

Evaluation and Management of Chronic Scrotal Content Pain-A Common Yet Poorly Understood Condition.

Chronic scrotal content pain (CSCP) refers to bothersome pain localized to structures within the scrotum that has been present for ≥ 3 months. Etiologies include infection, trauma, and referred pain from the spine, abdomen, and retroperitoneum. However, in many patients there is no obvious identifiable cause. The initial evaluation should include a thorough history and physical examination with adjunctive imaging and laboratory tests as indicated. Treatments vary based on the underlying etiology and include both nonsurgical and surgical options with high levels of success when selectively utilized. The spermatic cord block with local anesthetic is an important tool that helps identify those patients who may benefit from surgery such as microscopic denervation of the spermatic cord. Other treatments including pelvic floor physical therapy may also be indicated in specific circumstances. Using a thoughtful and thorough approach to evaluation and treatment of CSCP, urologists can work with patients to achieve significant improvements in quality of life.

Follicular cystitis in urine cytology: A clinical and cytopathologic study.

Despite being an important differential diagnosis of bladder tumor on cystoscopy, follicular cystitis (FC) is rarely diagnosed on cytologic material. We performed a retrospective study on cases of FC diagnosed on bladder biopsy and/or urine cytology in our institution. A total of 35 cases of FC were identified with a female predominance (F:M = 2:1). Hematuria was the most common clinical presentation. Cystoscopic findings included mass lesions, yellow plaques, and surface erythema. History of urinary tract infection was reported in 48% of the patients, and majority of those patients had positive concurrent urine culture, most commonly with beta-hemolytic streptococcus, Group B. A total of 17 out of 35 patients had urine cytology specimens. When the presence of follicular dendritic cells in clusters of variously sized lymphocytes is used as the cytological diagnostic criterion, 6 out of 17 cases were diagnosed as FC and 5 out of 6 were confirmed by concurrent biopsy. This retrospective study not only analyzed the clinical characteristics of FC but also elucidated the cytological diagnostic criteria of FC and confirmed its specificity.

Preliminary Outcomes of the Male Urethral "Mini-Sling": A Modified Approach to the Andrianne Mini-Jupette Procedure With Penile Prosthesis Placement for Climacturia and Mild Stress Urinary Incontinence.

INTRODUCTION: Previous worked showed that the Andrianne Mini-Jupette (AMJ) procedure with inflatable penile prosthesis (IPP) significantly improves climacturia or stress urinary incontinence (SUI) that may accompany erectile dysfunction (ED) after radical prostatectomy. However, with the AMJ procedure, the graft is incorporated into the medial aspect of the corporotomy, thereby requiring a more complex closure. Moreover, in the original report, multiple graft materials were used. AIM: To describe our technique for "male urethral mini-sling" (MUMS) with a Virtue sling mesh, which is a modified approach to the AMJ, and to assess early postoperative outcomes. METHODS: A retrospective chart review was performed for men who underwent IPP and MUMS placement with a modified Virtue mesh by 2 high-volume prosthetic urologic surgeons using the same technique. After proximal urethral exposure, the MUMS is sutured to the latera corpora over the bulbar urethra, proximal to and separate from the planned corporotomy, with care taken to avoid excessive urethral tension. The IPP is then placed in standard fashion. Changes in patient-reported climacturia and pads per day for SUI were assessed before and after surgery. RESULTS: 36 men underwent both IPP and MUMS placement between January 2016-October 2018. Mean patient age was 68 years. Etiology for ED and urinary symptoms was prostatectomy alone in 30 of 36 (83%) and prostatectomy plus radiation in 6 of 36 (17%). Preoperative urinary symptoms included climacturia in 30 of 36 (83%) and SUI in 27 of 36 (75%). Mean (SD) follow-up was 5.9 (3.7) months. Climacturia resolved in 28 of 30 (93%), and SUI improved in 23 of 27 (85%). The mean (SD) number of pads per day for those patients with SUI decreased significantly from 1.4 (1.1) before surgery to 0.4 (0.6) after surgery (P = .02). 1 patient required MUMS explantation for urethral erosion after prolonged postoperative catheterization. CLINICAL IMPLICATIONS: The MUMS with modified Virtue mesh at the time of IPP placement can be used to treat ED with climacturia or mild SUI after radical prostatectomy. STRENGTHS & LIMITATIONS: Strengths include the use of a consistent operative technique with a single graft material by 2 experienced prosthetic urologic surgeons. Limitations include the retrospective study design, use of subjective postoperative outcomes, lack of comparison group, and relatively moderate follow-up duration. CONCLUSIONS: Our early results suggest that the MUMS significantly improves bothersome climacturia and mild SUI in addition to treating ED, with little added morbidity. Although further study, including longer-term follow-up, is needed, this approach may be considered in the appropriately counseled patient. Valenzuela RJ, Ziegelmann MJ, Hillelsohn JH, et al. Preliminary Outcomes of the Male Urethral "Mini-Sling": A Modified Approach to the Andrianne Mini-Jupette Procedure With Penile Prosthesis Placement for Climacturia and Mild Stress Urinary Incontinence. J Sex Med 2019;16:1310-1317.

A Comparison of Hemostatic Patches Versus Pericardium Allograft for the Treatment of Complex Peyronie's Disease With Penile Prosthesis and Plaque Incision.

OBJECTIVE: To compare outcomes between hemostatic patches (HP) versus pericardium allografts (PA) for complex Peyronie's disease with erectile dysfunction managed with inflatable penile prosthesis (IPP) and plaque incision and grafting (PIG). METHODS: We reviewed all men who underwent IPP with PIG for PD at our institution (4/2010-9/2018). PIG was performed via relaxing tunical incisions during IPP implantation following manual modeling if there was persistent curve >30° and/or significant narrowing. Tunical defects >2 cm were grafted. PA (Coloplast, Minneapolis, MN) or HP consisting of either Evarrest, Nu-Knit (Ethicon Inc., Somerville, NJ), or TachoSil (Baxter Int., Deerfield, IL) were used. RESULTS: HP was placed in 18 men (n = 10 Evarrest, n = 6 Nu-Knit, and n = 2 TachoSil), 15 had PA. There was no difference in mean age, preoperative curvature (HP:75° vs PA:78°), or grafted area (HP:11.9 cm2 vs PA:10.9 cm2) between HP and PA cohorts. Mean operative time was shorter for HP (122 vs 166 minutes, P = .01). Median follow-up: 6.6 months (range: 2-27 months) for HP and 34.6 months (range: 13-103 months) for PA. Residual curvature >20° was present following HP in 16.7% (n = 3) and PA in 13.3% (n = 2; P = 1.0). There were no complications attributable to HP/PA material and no IPP herniation through the tunical defect. Postoperatively, 94.4% (n = 17) of HP and 93.3% (n = 14) of PA patients were engaged in penetrative intercourse (P = 1.0). CONCLUSION: HP are effective materials to cover the tunical defect over an IPP following plaque incision for PD. HP outcomes are similar to PA, while operative time is shorter for HP.

The Penile Sensitivity Ratio: A Novel Application of Biothesiometry to Assess Changes in Penile Sensitivity.

INTRODUCTION: Biothesiometry allows for evaluation of penile vibratory sensitivity and can be used as a non-invasive and rapid surrogate test of penile sexual sensitivity. However, no standardized measurement methodology currently exists. AIM: To describe and optimize a novel, standardized biothesiometry parameter-the penile sensitivity ratio (PSR). METHODS: We reviewed all biothesiometry data from men presenting to our institution from July 2013-May 2017. 3 iterations of the PSR were evaluated using the threshold for vibratory detection from a combination of different input variables including the penile glans, penile shaft, index finger, and thigh. Numerator values for the PSR included the penile glans and penile shaft, whereas denominator inputs included the index finger and thigh. PSR is inversely correlated with penile sensitivity. MAIN OUTCOME MEASURE: The primary outcome measure was the association between reported diminished penile sensitivity and PSR value. Secondary outcome measures were the association between PSR and age, diabetes, ejaculatory dysfunction, and Peyronie's disease (PD). RESULTS: Biothesiometry data were evaluated from 1,239 men. Mean age was 53.2 years (SD 14.0 years). Diabetes was present in 7.4% (n = 92); 52.0% (n = 644) had PD. Ejaculatory dysfunction was identified in 15.8% (n = 196), with 12.2% (n = 151) having premature ejaculation and 3.6% (n = 45) reporting delayed ejaculation. Decreased penile sensitivity was reported in 20.3% (n = 252). 3 PSR iterations were analyzed to identify associations with decreased penile sensation. On univariate and multivariate analysis controlling for age, diabetes, ejaculatory dysfunction, and PD, only the PSR iteration, which included data from the penile glans and finger (PSRG/F), was significantly different between patients reporting diminished penile sensitivity and those without reported diminished sensitivity (univariate P < .01, multivariate P = .03). On univariate analysis, a higher PSRG/F was associated with older age (P < .01) and diabetes (P < .01), whereas men with PD had a lower PSRG/F (P < .01). On multivariate analysis, PSRG/F remained increased for age (P < .01) and decreased for PD (P = .01); however, there was no association with diabetes (P = .12). No association existed between ejaculatory function and PSRG/F on univariate (P = .25) or multivariate analysis (P = .35). CLINICAL IMPLICATIONS: The PSR may be used as a standardized biothesiometry parameter to evaluate penile sensitivity. STRENGTH & LIMITATIONS: This study included a large cohort of men undergoing biothesiometry (n = 1,239); however, it is limited by the multifactorial nature of perceived diminished penile sensitivity. CONCLUSION: The PSR using penile glans and index finger input variables is a non-invasive, painless, office-based, standardized biothesiometry parameter that is a clinically useful tool for measuring penile sexual sensitivity. Wiggins A, Farrell MR, Tsambarlis P, et al. The Penile Sensitivity Ratio: A Novel Application of Biothesiometry to Assess Changes in Penile Sensitivity. J Sex Med 2019;16:447-451.

Internal Urethrotomy With Intralesional Mitomycin C: An Effective Option for Endoscopic Management of Recurrent Bulbar and Bulbomembranous Urethral Strictures.

OBJECTIVE: To describe our experience with direct visual internal urethrotomy (DVIU) and mitomycin C (MMC) for recurrent bulbar and bulbomembranous urethral strictures of radiation and non-radiation-induced etiologies. METHODS: We reviewed our database of consecutive patients presenting to our tertiary care institution with recurrent bulbar and bulbomembranous urethral strictures who underwent DVIU with MMC from 2011 to 2016. Patients were stratified by radiation-induced strictures (RIS) vs non-RIS. Cold-knife incisions were made at 12-, 3-, and 9-o'clock positions followed by intralesional injection of 10 mL MMC (0.4 mg/mL) in 0.2-0.4 mL aliquots and 1 month of postoperative daily clean intermittent catheterization (CIC). RESULTS: All 44 patients (RIS n = 18, non-RIS n = 26) failed prior endoscopic management or urethroplasty. Median stricture length was 2.0 cm (interquartile range [IQR] 1.0-2.5). Over a median follow-up of 25.8 months (IQR 12.9-47.2), 75.0% of patients (33/44) required no additional surgical intervention (RIS 12/18, 66.7%; non-RIS 21/26, 80.8%). Median time to stricture recurrence among those who recurred was 10.7 months (IQR 3.9-17.6; RIS 9.4 months, IQR 3.5-17.6; non-RIS 11.2 months, IQR 8.0-25.6). Four patients (RIS n = 2, non-RIS n = 2) elected to undergo urethroplasty for recurrence. A second DVIU with MMC was performed in the remaining recurrences (n = 7) with no further surgical intervention required in 37 of 40 of patients (92.5%) overall (RIS 14/16, 87.5%; non-RIS 23/24, 95.8%). No long-term complications were attributable to MMC. CONCLUSION: DVIU with MMC and short-term CIC for recurrent, short, bulbar and bulbomembranous urethral strictures is a safe endoscopic modality with promising early results. This approach may be useful for patients who are suboptimal candidates for open reconstruction.

Short- and long-term morbidity and outcomes after robotic surgery for comprehensive endometrial cancer staging.

OBJECTIVE: Although intra-operative and immediate postoperative complications of robotic surgery are relatively low, little is known about long-term morbidity. We set out to assess both short- and long-term morbidities after robotic surgery for endometrial cancer staging. METHODS: All patients who underwent robotic staging for EMCA between 2006 and 2009 from two institutions were identified. Patient charts were retrospectively reviewed for surgical complications and postoperative morbidities. RESULTS: Five hundred three patients were identified. No differences in complication rates were found between 2006-2007 and 2008-2009, even though the median BMI increased from 29.9 (range 19-52) to 32 (range 17-70) (p=0.03). 6.4% of cases were converted to laparotomy. Median length of stay was one day (range 1-46). No cystotomies, two enterotomies, one ureteric injury, and five vessel injuries occurred (1.6% intra-operative complications). Thirty-eight (7.6%) patients developed major postoperative complications, 11 (2.2%) had wound infections, and 15 (3%) required a transfusion in the 30-day peri-operative period. The total venous thromboembolism (VTE) rate for robotic cases was 1.7%. Partial cuff dehiscence managed conservatively occurred in 5 (1%) and complete dehiscence requiring closure in 7 (1.4%) patients; Sixty-three (13.4%) patients who had robotic staging developed lymphedema, with 40 (8%) requiring physical therapy. CONCLUSIONS: This study provides one of the largest cohorts of patients with robotic-assisted hysterectomy and lymphadenectomy (in 92.6%) with an assessment of morbidity. Our data demonstrates that robotic surgical staging can be safely performed with a low risk of short-term complications and lymphedema is the most frequent long-term morbidity.