Patient Interaction With the Health Care System Following a Nonopioid Discharge Strategy for Anterior Urethroplasty.

INTRODUCTION: Continued efforts have been made to minimize postoperative opioids following urologic interventions. Studies show that patient-reported pain outcomes are similar between those patients discharged with and without opioids following anterior urethroplasty, but we do not know what impact this has on health care utilization. We aim to show that a nonopioid discharge following anterior urethroplasty does not increase postoperative health care utilization. METHODS: Five hundred patients who underwent anterior urethroplasty from January 2016 to October 2022 were identified from retrospective chart review. Patient demographic information, surgical characteristics, and postoperative interactions with the health care system were extracted from the electronic medical record. We then compared these outcomes by discharge opioid prescription status. RESULTS: A total of 253 patients were discharged without an opioid prescription. Patients who received an opioid were more likely to have had a perineal incision (73% vs 64%, P = .02), more likely to have had an overnight hospital stay (30% vs 14%, P < .01), and were more likely to have been prescribed an opioid preoperatively (13% vs 7%, P = .03). There were overall low rates of interaction with the health system in both groups with no significant difference in 30-day unplanned office visits, emergency department visits, or office phone calls. Overall, by the end of our study period 97% were discharged without an opioid and 94% of patients were discharged the same day. CONCLUSIONS: Patients undergoing anterior urethroplasty can safely be discharged home without opioids following surgery without undue postoperative burden on the health care system.

Buried Penis Reconstruction in the Management of Localized Penile Cancer.

INTRODUCTION: The objective of this article is to describe surgical techniques for the management of localized penile cancer concurrent with adult acquired buried penis. Penile cancer, while rare, invariably impacts quality of life as the primary surgical management ranges from local excision to total penectomy. Penile cancer has recently been linked to adult acquired buried penis (AABP) with the hypothesis that chronic inflammation of the penis contributes to risk of penile malignancy. Buried penis reconstruction is now a well-described procedure involving escutcheonectomy and split thickness skin grafting which has been shown to improve quality of life in individuals with adult acquired buried penis. TECHNICAL CONSIDERATIONS: This report describes a patient with AABP requiring partial penectomy and inguinal node dissection who also underwent adult acquired buried penis repair during his procedure. A review of cases of buried penis cases was carried out and four other cases of penile cancer were identified who were managed with penile preserving procedures. CONCLUSIONS: This combination of surgical techniques strives to improve quality of life and facilitate cancer surveillance without compromising oncologic outcomes.

Outcomes of Vesicourethral Anastomotic Stenosis and Bladder Neck Contracture With Direct Visual Internal Urethrotomy With Mitomycin-C After Prostate Cancer Treatment.

OBJECTIVE: To examine the use of Direct Visual Internal Urethrotomy with Mitomycin-C (DVIU-MMC) for bladder neck contracture and vesicourethral anastomotic stenosis in men who have undergone treatment for prostate cancer with radical prostatectomy and/or radiation therapy. METHODS: Retrospective chart review of patients at a tertiary care center who underwent DVIU-MMC for recurrent bladder neck contracture/vesicourethral anastomotic stenosis between 2012 and 2020. Patients with complete urethral obliteration, prior bladder neck reconstruction, or less than 3 months of follow-up were excluded. Patients were sorted into three groups based on prostate cancer treatment history: radical prostatectomy (RP), RP with subsequent external beam radiation therapy (RP-EBRT), and radiation therapy (RT). RESULTS: Fifty-one patients with a median follow up of 32 months were included. Twenty-nine percent had pre-operative suprapubic tube (SPT), Foley, or required clean intermittent catheterization. Overall success after initial DVIU-MMC was 45%. In all patients with up to four procedures, cumulative overall success was 84%. There was no significant difference in relative success rates between groups. However, the interval to recurrence after initial DVIU-MMC was shortest for RP-EBRT group (P = .018). Three patients required SPT, all were in the RP-EBRT group. There was no statistical difference in recurrence after any number of procedures between patients in radiation (RP-EBRT and RT) and non-radiation (RP) groups. CONCLUSION: There was no significant difference in success rates between patients who had undergone RP-EBRT, RT, or RP. However, our data suggests that RP-EBRT patients experience poorer outcomes given that their interval to recurrence was more rapid and all patients requiring SPT placement were in this group.

The concealed morbidity of buried penis: a narrative review of our progress in understanding adult-acquired buried penis as a surgical condition.

Adult acquired buried penis (AABP) is a condition of entrapment of the phallus resulting most commonly from morbid obesity and formation of cicatrix with other etiologies including genital lymphedema, hidradenitis and trauma. The incidence of this syndrome is invariably connected to the increasing prevalence of obesity. The purpose of this review is to examine the current literature in AABP with a focus on the morbidity of AABP and perioperative management. The discussion and literature surrounding buried penis reconstruction started with the goal of correcting a cosmetic problem and has recently become fairly successful in this aim with an over 85% rate of successful reconstruction in many series with a more uniform surgical approach. The most recent trends have examined the significant burden of morbidity and even mortality that AABP can place on patients as it contributes to risk of penile cancer, urethral strictures and mood disorders. Studies in this space have shown that surgical repair can be successful in improving quality of life for patients with AABP and the removal of the offending pathophysiology suggests its success in correcting the physical morbidities. New directions for research and management of this condition should include a focus on educating providers and patients to make reconstruction more accessible to patients in need as AABP continues to journey toward mainstream acceptance as a surgical condition.

The Use of a Hartmann's Pouch for Bowel Vaginoplasty: A Case Report.

Bowel vaginoplasty is a well-described procedure utilizing a pedicled segment of large or small bowel. It has most commonly been used for vaginal agenesis, male-to-female gender affirmation surgery when the phallus skin is not sufficient, or a revision after failure of the primary reconstruction. Our case report describes the usage of a pedicled segment of large bowel to reconstruct the vagina after severe stricture of the original reconstruction. We were able to provide relief of the symptomatic Hartmann's pouch mucocele, urethral stricture, and provide a functional introitus and vaginal canal. This technique can provide a framework that can be used as a salvage plan in patients with previously irritated and inhospitable defects.

The Prevalence of Penile Cancer in Patients With Adult Acquired Buried Penis.

OBJECTIVE: To determine the prevalence of penile cancer in patients with adult acquired buried penis (AABP). Penile cancer is a rare but aggressive cancer. Several case reports have recently been published that indicate that AABP may increase the risk of penile cancer. MATERIALS AND METHODS: A retrospective review was conducted of adults diagnosed with AABP and penile cancer between January, 2008 and December, 2018 seen at a tertiary referral center. Demographics including age, BMI, comorbidities, etiology of AABP, smoking history, circumcision status, and premalignant lesions (condyloma, lichen sclerosus [LS] carcinoma in situ [CIS]) were recorded. For patients with penile cancer, AJCC staging, grade, TNM staging and treatments were recorded. Basic descriptive statistics were performed for the overall cohort. We used Chi-square tests and Fisher exact tests to compare differences between patients with benign pathology and patients with malignant or pre-malignant pathology. RESULTS: We identified 150 patients with the diagnosis of AABP. The prevalence of penile squamous cell carcinoma was 7%. There was a 35% rate of premalignant lesions. This study is limited by its retrospective and single-institution nature. CONCLUSION: AABP is a condition that incorporates multiple risk factors for penile cancer. The prevalence of penile cancer appears to be higher in patients with AABP; however, more data are needed to confirm these initial findings. Patients with AABP should be counseled on these risks and should be considered for buried penis repair if a physical examination cannot be performed.

Prevalence and surgical management of concurrent adult acquired buried penis and urethral stricture disease.

PURPOSE: To describe the prevalence and surgical management of coexistent adult acquired buried penis (AABP) and urethral stricture disease. AABP patients often have urinary dribbling with resultant chronic local moisture, infection, and inflammation that combine to cause urethral stricture disease. To date, no screening or surgical management algorithms have been described. METHODS: A multi-institutional retrospective study was conducted of the surgical management strategies for patients with concurrent AABP and urethral stricture disease from 2010 to 2017. AABP patient demographics, physical exam findings, and comorbidities were compared between those with and without stricture disease to suggest those that would selectively benefit from screening for stricture disease. RESULTS: Of the 42 patients surgically managed for AABP, 13 had urethral stricture disease (31.0%). Stricture location was universal in the anterior urethra. Sixty-one percent (n = 8) of strictures were 6 cm or longer and managed prior to AABP repair with Kulkarni urethroplasty. Patients with urethral stricture disease were significantly more likely to have clinically diagnosed lichen sclerosus (p = 0.00019). There was no significant difference in BMI, age, or comorbidities between patients with and without urethral stricture disease. CONCLUSIONS: Extensive anterior urethral stricture is common in patients with AABP. Clinical characteristics cannot predict stricture presence except possibly the presence of lichen sclerosus. Definitive stricture surgical options include extensive Johanson Urethroplasty or Kulkarni Urethroplasty. Kulkarni Urethroplasty prior to AABP repair has the benefits of a single-stage repair, good cosmetic outcome with meatal voiding, and dorsal graft placement to allow safe degloving of the penis in the subsequent AABP repair.

Cowper's Gland Syringocele.

Cowper's gland syringoceles are rare cystic dilations of the Cowper's gland duct. They are typically diagnosed in childhood but occasionally occur in adults. We report the case of a 28-year-old man who presented with a painful perineal and inferior scrotal mass and was found to have a large Cowper's gland syringocele extending into the scrotum associated with a scrotal abscess. Treatment consisted of surgical excision. The magnetic resonance imaging findings of this case are described.

Surgical Management of Adult Acquired Buried Penis.

PURPOSE OF REVIEW: Adult acquired buried penis is a morbid condition characterized by complete entrapment of the phallus as a result of morbid obesity, post-surgical cicatrix formation, or primary genital lymphedema. Hygienic voiding is not possible and urinary dribbling is frequent with accompanying inflammation, skin breakdown, and infection from the chronic moisture. The end result is penile skin fibrosis resulting in permanent functional loss. Herein, we describe the etiology of adult acquired buried penis, advances in its surgical management, and quality of life outcomes with treatment. RECENT FINDINGS: Adult acquired buried penis is increasing in incidence as morbid obesity becomes more prevalent. Frequently comorbid conditions affect treatment including those affecting wound healing such a diabetes mellitus. Functional and cosmetic surgical outcomes are being published in greater volume in recent years leading to more refined treatment algorithms. Patient quality of life is greatly improved by definitive surgical management. Adult acquired buried penis is a morbid condition that is increasing in incidence as obesity becomes more commonplace. Surgical management often necessitates surgical lipectomy of the suprapubic fat pad, scrotoplasty, and penile split thickness skin graft. Substantial quality of life improvements have been consistently reported after surgical treatment.

Three-Dimensional Imaging of Urethral Stricture Disease and Urethral Pathology for Operative Planning.

Diagnosing urethral pathology can prove difficult, as clinically, the presentation is often nonspecific and may be suggestive of multiple etiologies. Therefore, detailed and accurate urethral imaging in both males and females is critical. Since the early 1900s, conventional imaging studies including RUG and VCUG, with adjunct cystourethroscopy, have remained the gold standard diagnostic techniques to evaluate urethral pathology. However, limitations of conventional imaging have generated interest in finding alternative imaging modalities with comparable, if not superior, diagnostic accuracy, the goal being a more complete assessment of urethral pathology and anatomy that would allow for appropriate surgical planning. Imaging modalities with three-dimensional (3D) capabilities may provide more comprehensive information regarding urethral diseases through a more detailed illustration of periurethral soft tissue structures. Whether or not these imaging modalities will replace conventional studies is unclear, though there is an increasing body of literature that support their use.