Experiences and Outcomes of the Society of Genitourinary Reconstructive Surgeons Fellowship Training: Growth in Fellowships Mirrors the Evolution of the Discipline.

OBJECTIVE: To describe experiences and outcomes of the Society of Genitourinary Reconstructive Surgeons (GURS) fellowship match. In 2012, GURS developed a centralized fellowship match which has grown from 13 to 30 programs. METHODS: GURS match statistics and case logs were reviewed from 2013-2024. Additionally, a 37-question survey evaluating satisfaction, procedural competency, fellowship experience, and employment opportunities were sent to graduates. Linear regression was performed to examine trends over time. RESULTS: Over the study period, program match success remained stable (94.7%; P = .50) while applicant success (63.3%) increased over time (P = .04). North American and female applicants experienced higher match success (72.8% and 73.6%) compared to their international (35.5%; P <.0001) and male counterparts (60.0%; P = .02). On case log analysis, mean surgical volumes per year increased in urethral reconstruction (mean=88.1; P = .02), male sexual health (n = 32.7; P = .03), genital reconstruction (mean=16.4; P <.01) and abdominal reconstruction (mean=24.5; P = .03). Male incontinence surgeries remained stable (mean=30.5; P = .21) while female reconstruction declined (mean=23.2; P = .01). With a survey response rate of 54.5% (97/178), training satisfaction was 95.9% which did not differ by gender (P = .54) or year of training (P = .22). Around 97.9% felt competent to enter unsupervised reconstructive practice, 94.8% reported an understanding of the relevant literature and 96.9% were satisfied with their job as a reconstructive urologist. Around 49.5% identified a different case mix in practice compared to fellowship, most commonly related to abdominal (44.9%) or genital reconstruction (16.3%). CONCLUSION: GURS fellowships have grown organically over the last decade and mirror the growth and evolution of the discipline with sustained high levels of graduate satisfaction, surgical experience, competence, scholarly inquiry and employment.

The Impact of Social Deprivation on Anterior Urethral Stricture Recurrence After Urethroplasty - A Trauma and Urologic Reconstructive Network of Surgeons (TURNS) Analysis.

INTRODUCTION AND OBJECTIVES: Several factors influence recurrence after urethral stricture repair. The impact of socioeconomic factors on stricture recurrence after urethroplasty is poorly understood. This study aims to assess the impact that social deprivation, an area-level measure of disadvantage, has on urethral stricture recurrence after urethroplasty. METHODS: We performed a retrospective review of patients undergoing urethral reconstruction by surgeons participating in a collaborative research group. Home zip code was used to calculate Social Deprivation Indices (SDI; 0-100), which quantifies the level of disadvantage across several sociodemographic domains collected in the American Community Survey. Patients without zip code data were excluded from the analysis. The Cox Proportional Hazards model was used to study the association between SDI and the hazard of functional recurrence, adjusting for stricture characteristics as well as age and body mass index. RESULTS: Median age was 46.0 years with a median follow up of 367 days for the 1452 men included in the study. Patients in the fourth SDI quartile (worst social deprivation) were more likely to be active smokers with traumatic and infectious strictures compared to the first SDI quartile. Patients in the fourth SDI quartile had 1.64 times the unadjusted hazard of functional stricture recurrence vs patients in the first SDI quartile (95% CI 1.04-2.59). Compared to anastomotic ± excision, substitution only repair had 1.90 times the unadjusted hazard of recurrence. The adjusted hazard of recurrence was 1.08 per 10-point increase in SDI (95% CI 1.01-1.15, P = .027). CONCLUSIONS: Patient social deprivation identifies those at higher risk for functional recurrence after anterior urethral stricture repair, offering an opportunity for preoperative counseling and postoperative surveillance. Addressing these social determinants of health can potentially improve outcomes in reconstructive surgery.

Outcomes of Robot-assisted Appendiceal Ureteroplasty From a Multi-institutional Experience.

OBJECTIVE: To evaluate the viability of robot-assisted appendiceal ureteroplasty as an innovative surgical approach for the reconstruction of ureteral strictures in cases where traditional methods are unsuitable. METHODS: We conducted a retrospective review of 14 patients who underwent robot-assisted appendiceal ureteroplasty for right-sided ureteral stricture disease at three academic centers between March 2018 and November 2022. Patients were selected based on stricture characteristics, tissue quality, and the need for tissue transfer techniques. Surgical outcomes, including stricture-free rates, renal function, and complication rates, were analyzed. RESULTS: The median patient age was 63years, with a balanced gender distribution. The median stricture length was 4.75 cm. The majority of strictures were located in the proximal ureter (50%). Surgical approaches included appendiceal onlay flaps (71.4%) and interposition flaps (28.6%). The median operative time was 268 minutes, with an average estimated blood loss of 75 mL. Postoperatively, ureteral patency was achieved in 92.9% of patients. Two patients (14.3%) experienced urinary tract infections requiring readmission. There was no significant change in serum creatinine levels postoperatively. Hydronephrosis grade significantly improved following surgery (P = .025). CONCLUSION: Robot-assisted appendiceal ureteroplasty is a safe and effective technique for managing ureteral strictures. It offers a high success rate with minimal complications, making it a valuable addition to the urologic surgeon's armamentarium for complex ureteral reconstructions.

Delayed gangrenous penile necrosis following prolonged utilization of penile constriction ring.

Penile strangulation secondary to utilization of a constrictive ring is a rare urologic emergency that requires urgent decompression to prevent prolonged vascular obstruction resulting in necrosis and gangrene. Current literature is mainly comprised of case presentations that focus on management in the acute setting via removal of the ring. Herein, we describe surgical management of a patient who presents in delayed fashion after self-removal of the constrictive ring. We discuss our penectomy-sparing technique of debridement and split thickness skin graft.

Outcomes of Urethroplasty for Synchronous Anterior Urethral Stricture Utilizing the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System.

OBJECTIVE: To describe the characteristics, management, and functional outcomes of patients with synchronous urethral stricture disease (SUSD) utilizing a multi-institutional cohort. METHODS: Data were collected and assessed from a prospectively maintained, multi-institutional database. Patients who underwent anterior urethroplasty for urethral stricture disease (USD) were included and stratified by the presence or absence of SUSD. USD location and etiology were classified according to the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System. Anterior urethroplasty techniques were recorded for both strictures. Functional failure was compared between groups. RESULTS: One thousand nine hundred eighty-three patients were identified, of whom, 137/1983 (6.9%) had SUSD. The mean primary stricture length for patients with SUSD was 3.5 and 2.6 cm for the secondary stricture. Twelve anterior urethroplasty technique combinations were utilized in treating the 27 different combinations of SUSD. Functional failure was noted in 18/137 (13.1%) patients with SUSD vs 192/1846 (10.4%) patients with solitary USD, P = .3. SUSD was not associated with increased odds of functional failure. S classifications: S1b, P = .003, S2a, P = .001, S2b, P = .01 and S2c, P = .02 and E classifications: E3a, P = .004 and E6, P = .03, were associated with increased odds of functional failure. CONCLUSION: Repair of SUSD in a single setting does not increase the risk of functional failure compared to patients with solitary USD. Increasing S classification, S1b through S2c and E classifications E3a and E6 were associated with increased functional failure. This reinforces the importance of the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System as a necessary tool in large-scale multi-institutional analysis when assessing highly heterogenous patient populations.

The Role of Alumni Networks and Career Advising in Early Career Stability of Urologists: Results of a Multi-institutional Study.

OBJECTIVE: To characterize training program and early career factors that impact decision-making and job retention following graduation in a diverse population of urologists. MATERIALS AND METHODS: We performed a computer-based survey distributed to residency graduates from 25 urology training programs. Five focus institutions were identified with a goal >30% response rate. The survey included questions about training program specifics and post-training employment characteristics. RESULTS: We obtained 180 responses from urology residency graduates of 25 programs. Overall, 72% (N = 129) remain in their initial post-training position at a median of 6years postgraduation (Interquartile Range (IQR) 3-10). On Cox-regression analysis stronger trainee-rated formal career advising was associated with lower risk of changing jobs (HR 0.77, 0.60-0.99, P = .048). Location/proximity to family was the most consistently cited as the top reason for selecting a job (41%). Sixty-three respondents (35%) joined practices employing graduates of the same residency program. Cox regression analysis showed that joining a practice with alumni of the same program was associated with lower risk of changing jobs from one's initial post-training position (HR 0.39, 95% CI 0.17-0.91, P = .03). CONCLUSION: In this multi-institutional study of urologists, we observed a high rate of job retention out to a median of 6years following completion of training, with formal career advising and joining alumni in practice being associated with job retention. Collectively, our data highlights that training programs should emphasize advising programs and alumni networking in guiding their graduates in the job search process.

Clinical Validation of an Adult-acquired Buried Penis Classification System Based on Standardized Evaluation of the Penis, Abdomen, and Scrotum.

OBJECTIVE: To clinically validate a previously developed adult-acquired buried penis (AABP) classification system that is based on a standardized preoperative physical examination that subtypes patients by their penile skin/escutcheon complex (P), abdominal pannus (A), and scrotal skin (S). METHODS: The Trauma and Urologic Reconstruction Network of Surgeons (TURNS) database was used to create an AABP cohort. Patients were retrospectively classified using the previously described PAS classification system. The frequency of subtypes, surgical methods utilized for AABP repair, and correlations between PAS classification and surgery subtypes were analyzed. RESULTS: The final cohort consisted of 101 patients from 10 institutions. Interrater reliability between two reviewers was excellent (κ = 0.95). The most common subtypes were P2c (contributory escutcheon+insufficient penile skin; 27%) and P2a (contributory escutcheon+sufficient penile skin; 21%) for penile subtypes, A0 (no pannus; 41%) and A1 (noncontributory pannus; 39%) for abdominal subtypes, and S0 (normal scrotal skin with preserved scrotal sulcus; 71%) for scrotal subtypes. AABP repair procedures included escutcheonectomy (n = 59, 55%), scrotoplasty (n = 51, 48%), split-thickness skin grafting (n = 50, 47%), penile skin excision (n = 47, 44%) and panniculectomy (n = 7, 7%). P, A, and S subtypes were strongly associated with specific AABP surgical techniques. CONCLUSION: The PAS classification schema adequately describes AABP heterogeneity, is reproducible among observers, and correlates well with AABP surgery types. Future work will focus on how PAS subtypes affect both surgical and patient-centered outcomes.

Functional outcomes after prostate cancer treatment: A comparison between single and multiple modalities.

Prostate cancer is a widely common and treatable disease, and functional outcomes can greatly affect survivor quality of life. A retrospective review of the SEER-Medicare database was performed to identify patients who underwent prostate cancer treatment between January 1, 2004 and December 31, 2013 and review the rates of diagnosis and treatment of common functional side effects of surgery, radiation, or a combination of the 2 and perform a comparison of the outcomes. A total of 67,527 patients were included in the analysis. Radiation therapy (RT)-only compared to radical prostatectomy (RP)-only had lower rates of diagnosis of erectile dysfunction (30.4%, 95% CI 29.9%-30.9% vs. 56.1%, 95% CI 55.1%-57.04%, P < 0.0001), UI (29.7%, 95% CI 29.0%-30.3% vs. 44.5%, 95% CI 43.3%-45.6%, P < 0.0001), but higher rates of urethral stricture disease (8.44%, 95% CI 8.1%-8.8% vs. 5.35%, 95% CI 4.9%-5.9%, P < 0.0001), cystitis (33.1% 95% CI 32.4%-33.7% vs. 20.3%, 95% CI 19.2%-21.4%, P < 0.0001), and proctitis (14.7%, 95% CI 14.3%-15.1& vs. 2.75%, 95% CI 2.3%-3.3%, P < 0.0001). Compared to either single modality, the RP-then-RT group had higher incontinence medication use (12.0% 95% CI 10.8%-13.2% vs. 9.8%, 95% CI 9.5%-10.1% for RT-only and 8.3%, 95% CI 7.8%-8.8% for RP-only, P < 0.0001), overall incontinence therapy (18.5%, 95%CI 17.1%-20.0% vs. 10.2%, 95%CI 9.9%-10.5% for RT-only and 14.9%, 95% CI 14.3%-15.5% for RP-only, P < 0.0001), and stricture therapy (12.7%, 95% CI 11.5%-13.9% vs. 8.2%, 95% CI 8.0%-8.5% for RT-only and 9.1% 95% CI 8.6%-9.6% for RP-only, P < 0.0001). The RT-then-RP group had higher rates of stricture (25.4% compared to 8.2% for RT-only, 9.1% for RP-only, and 12.7% for RP-then-RT) and fistula (1.0% compared to 0.07% for RT-only, 0.18% for RP-only, and 0.092% for RP-then-RT) treatment than all the other groups. Multimodality therapy is generally associated with higher treatments rates for conditions such as erectile dysfunction , incontinence, urethral stricture disease , irritative cystitis and proctitis in patients older than 65. Radiation therapy followed by prostatectomy is associated with significantly worse functional outcomes. Patients undergoing or anticipating undergoing multimodality therapy for prostate cancer should be counseled regarding the possibility of increased risk of declining functional outcomes.

Robotic Ureteral Reconstruction.

It is generally accepted that robotic ureteral reconstruction provides equivalent results to open and laparoscopic approaches while decreasing pain and length of stay. There is a rapid expansion of robotic ureteral reconstructive techniques, platforms, and adjunctive technologies, enabling more efficient, safer, and novel surgical approaches that could not be done in the past. For instance, indocyanine green use allows rapid, precise location of ureteral stenosis and determination of tissue perfusion. Multi-image display allows the surgeon to integrate the robotic field and ureteroscopic images. Novel robotic surgical techniques, such as buccal mucosa ureteroplasty, are changing the treatment algorithm for ureteral strictures.

Patient Risk Factors Associated with Reported Urinary Quality of Life Following Artificial Urinary Sphincter Placement: A Paired Pre and Postoperative Analysis.

OBJECTIVE: To evaluate potential associations between patient risk factors and incontinence related patient-reported outcome measures (PROMs) preandpost artificial urinary sphincter (AUS) implantation. We hypothesize patient risk factors, including prior radiation and diabetes will have a negative association with post AUS PROMs. METHODS: A review of prospectively collected preandpostoperative Incontinence Symptom Index [ISI] and Incontinence Impact Questionnaire-7 (IIQ-7)s from multiple institutions in the Trauma and Urologic Reconstruction Network of Surgeons was performed. Changes in preandpost AUS ISI and IIQ-7 scores were compared for the entire cohort then stratified by patients with prior AUS, obesity, diabetes, prior radiation, and mixed urinary incontinence. RESULTS: A total of 145 patients, 67.2 (SD 10.9) years had complete preandpost AUS questionnaires (median follow up 186 days, IQR 136-362). Post AUS ISI and IIQ-7 scores improved significantly for the group at large. Prior radiation was associated with less improvement in total IIQ-7 scores, -25.5 (31.9) vs -39 (33.0), P = .03. Obesity was associated with a greater reduction in incontinence severity -13.6 (SD 9.1) vs -9.2 (SD 8.9), P<0.01, urge -5.2(SD 4.2) vs -2.5(SD 4.5), P <.01, and total ISI score -29.7(SD19.7) vs -21.2 (SD 19.9), P = .02. Prior AUS, diabetes, and mixed incontinence were not associated with post AUS PROMs outcome. CONCLUSION: Overall, patients reported a significant reduction in incontinence severity, bother, impact, and distress following AUS placement. Prior radiation was associated with less improvement in total IIQ-7 scores. In contrast, obesity demonstrated a greater reduction in ISI severity and urge scores compared to non-obese patients.

The "Fragile" Urethra as a Predictor of Early Artificial Urinary Sphincter Erosion.

OBJECTIVES: To identify predictors of early artificial sphincter (AUS) erosion among a cohort of men with erosion, who underwent AUS placement by either university or community-based surgeons. METHODS: The records of all patients with AUS erosions, including men who underwent AUS placement at outside facilities, were retrospectively reviewed. A Cox proportional-hazards model for time to erosion was performed with the predictors being the components of a fragile urethra (history of radiation, prior AUS, prior urethroplasty), androgen deprivation therapy (ADT), trans-corporal (TC), and 3.5 cm cuff, controlling for other risk factors. Kaplan-Meier survival curves and log-rank test compared "fragile" urethras with "not fragile" urethras. All statistical analysis was done using R version 3.5.2. RESULTS: Of the 156 men included, 36% had undergone AUS placement in the community. Median time to erosion was 16.0 months (1.0-240.0 months), and 122 (78%) met at least one fragility criteria. Radiation (HR 2.36, 95% CI 1.52-3.64) and prior urethroplasty (HR 2.12, 95% CI 1.18-3.80) were independently associated with earlier time to erosion. The Kaplan-Meier estimates demonstrate 1- and 5-year survival rates of 76.5% and 50.0%, respectively, for "non-fragile" and 44.1% and 14.8% for "fragile" urethras (P < .0001). CONCLUSION: In a diverse cohort of men with AUS erosion, men with "fragile" urethras eroded sooner. Radiation and prior urethroplasty were independent risk factors for earlier time to erosion, but prior AUS, ADT, TC and 3.5 cm cuff were not.

The Lived Experience of Patients with Adult Acquired Buried Penis.

PURPOSE: We describe the lived experience of adults with acquired buried penis (AABP) through thematic analysis of patient interviews. We examine the challenges that patients face and the impacts of surgery. MATERIALS AND METHODS: This mixed-methods study utilized validated instruments and semi-structured interviews to capture pre- and postsurgical outcomes. Semi-structured interviews were conducted with open-ended questions to elicit the impact of AABP on a patient's quality of life in several domains including urinary function, sexual function, interpersonal relationships and mental health. Recruitment was completed once we achieved thematic saturation. RESULTS: Twenty patients participated in the study; 11 underwent surgical treatment for AABP. Semi-structured interviewee responses were coded into 12 different themes and 39 subthemes. The most common themes were problems with urinary (19/20, 95%) and sexual function (19/20, 95%). Most participants (16/20, 80%) reported negative impacts of AABP on social life. Interviewees struggled with relationships (8/20, 40%) and mental health (11/20, 55%), often avoiding romantic relationships and reporting fear of rejection with concomitant depression and/or anxiety. The majority (70%, 14/20) experienced difficulties accessing care. Among patients who underwent surgery, the majority discussed improvement in urinary and sexual function (82% [9/11] and 73% [8/11], respectively). Though weight gain was a precipitating factor, weight loss did not result in symptom improvement. Rather, in 4/20 (20%), weight loss made their condition worse. CONCLUSIONS: Patients living with AABP experience profound negative impacts on quality of life including their urinary and sexual function, social life and mental health. Many patients face issues with access to care.

Defining Success after Anterior Urethroplasty: An Argument for a Universal Definition and Surveillance Protocol.

PURPOSE: A successful urethroplasty has been defined in different ways across studies. This variety in the literature makes it difficult to compare success rates and techniques across studies. We aim to evaluate the success of anterior urethroplasty based on different definitions of success in a single cohort. MATERIALS AND METHODS: Data were collected from a multi-institutional, prospectively maintained database. We included men undergoing first-time, single-stage, anterior urethroplasty between 2006 and 2020. Exclusion criteria included lack of followup, hypospadias, extended meatotomy, perineal urethrostomy, posterior urethroplasty and staged repairs. We compared 5 different ways to define a "failed" urethroplasty: 1) stricture retreatment, 2) anatomical recurrence on cystoscopy, 3) peak flow rate <15 ml/second, 4) weak stream on questionnaire and 5) failure by any of these measures. Kaplan-Meier survival curves were generated for each of the definitions. We also compared outcomes by stricture length, location and etiology. RESULTS: A total of 712 men met inclusion criteria, including completion of all types of followup. The 1- and 5-year estimated probabilities of success were "retreatment," 94% and 75%; "cystoscopy," 88% and 71%; "uroflow," 84% and 58%; "questionnaire," 67% and 37%; and "any failure," 57% and 23%. This pattern was inconsistent across stricture length, location and etiology. CONCLUSIONS: The estimated probability of success after first-time, anterior urethroplasty is highly dependent on the way success is defined. The variability in definitions in the literature has limited our ability to compare urethroplasty outcomes across studies.

Minimizing Antibiotic Use in Urethral Reconstruction.

PURPOSE: There are no established guidelines regarding management of antibiotics for patients specifically undergoing urethral reconstruction. Our aim was to minimize antibiotic use by following a standardized protocol in the pre-, peri- and postoperative setting, and adhere to American Urological Association antibiotic guidelines. We hypothesized that prolonged suppressive antibiotics post-urethroplasty does not prevent urinary tract infection and/or wound infection rates. MATERIALS AND METHODS: We prospectively treated 900 patients undergoing urethroplasty or perineal urethrostomy at 11 centers over 2 years. The first-year cohort A received prolonged postoperative antibiotics. Year 2, cohort B, did not receive prolonged antibiotics. A standardized protocol following the American Urological Association guidelines for perioperative antibiotics was used. The 30-day postoperative infectious complications were determined. We used chi-square analysis to compare the cohorts, and multivariate logistic regression to identify risk factors. RESULTS: The mean age of participants in both cohorts was 49.7 years old and the average stricture length was 4.09 cm. Overall, the rate of postoperative urinary tract infection and wound infection within 30 days was 5.1% (6.7% in phase 1 vs 3.9% in phase 2, p=0.064) and 3.9% (4.1% in phase 1 vs 3.7% in phase 2, p=0.772), respectively. Multivariate logistic regression analysis of patient characteristics and operative factors did not reveal any factors predictive of postoperative infections. CONCLUSIONS: The use of a standardized protocol minimized antibiotic use and demonstrated no benefit to prolonged antibiotic use. There were no identifiable risk factors when considering surgical characteristics. Given the concern of antibiotic over-prescription, we do not recommend prolonged antibiotic use after urethral reconstruction.

Durable Treatment of Refractory Vesicourethral Anastomotic Stenosis via Robotic-assisted Reconstruction: A Trauma and Urologic Reconstructive Network of Surgeons Study.

BACKGROUND: Refractory vesicourethral anastomotic stenosis (VUAS) after radical prostatectomy poses challenges distinct from bladder neck contracture, due to close proximity to the sphincter mechanism. Open reconstruction is technically demanding, risking de novo stress urinary incontinence (SUI) or recurrence. OBJECTIVE: To demonstrate patency and continence outcomes of robotic-assisted VUAS repair. DESIGN, SETTING AND PARTICIPANTS: Patients with VUAS underwent robotic-assisted reconstruction from 2015 to 2020 in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) consortium of institutions. The minimum postoperative follow-up was 3 mo. SURGICAL PROCEDURE: The space of Retzius is dissected and fibrotic tissue at the vesicourethral anastomosis is excised. Reconstruction is performed with either a primary anastomotic or an anterior bladder flap-based technique. MEASUREMENTS: Patency was defined as either the passage of a 17 French flexible cystoscope or a peak flow on uroflowmetry of >15 ml/s. De novo SUI was defined as either more than one pad per day or need for operative intervention. RESULTS AND LIMITATIONS: A total of 32 patients met the criteria, of whom 16 (50%) had a history of pelvic radiation. Intraoperatively, 15 (47%) patients had obliterative VUAS. The median length of hospital stay was 1 d. At a median follow-up of 12 mo, 24 (75%) patients had patent repairs and 26 (81%) were voiding per urethra. Of five men with 30-d complications, four were resolved conservatively (catheter obstruction and ileus). In eight patients, recurrent stenoses were managed with redo robotic reconstruction (in two), endoscopically (in four), or catheterization (in two). Of 13 patients without preexisting SUI, 11 (85%) remained continent at last follow-up. No patients underwent urinary diversion. CONCLUSIONS: Robotic-assisted VUAS reconstruction is a viable and successful management option for refractory anastomotic stenosis following radical prostatectomy. The robotic transabdominal approach demonstrates high patency and continence rates. PATIENT SUMMARY: We studied the outcomes of robotic-assisted repair for vesicourethral anastomotic stenosis. Most patients, after the procedure, were able to void per urethra and preserve existing continence.