Secondary phallic prosthesis placement in transgender patients postmetoidioplasty: a case report on technique and outcome.

Introduction: Gender affirming surgery is common among transgender and gender-nonconforming individuals. Genital gender-affirming surgery is a form of surgery that involves transformation and reconstruction of the genitalia while maintaining urologic and sexual function. Masculinizing genital gender-affirming surgery can involve the removal of the female genital and reproductive organs and the creation of a more masculine appearance by using phalloplasty or metoidioplasty techniques. While metoidioplasty has advantages such as limited scarring and preserved genital sensation and clitoral erection, it may not always guarantee the ability to void while standing or even penetrate a sexual partner. Aim: To describe our method of secondary phallic enhancement after metoidioplasty with a phallic prosthesis. Methods: Our case is based on a 39-year-old transgender male who underwent metoidioplasty with vaginectomy, scrotoplasty, and urethral lengthening. However, the original surgery was complicated by extensive hematoma formation in the suprapubic area and neoscrotum, leading to a buried position of the neophallus. Subsequent surgery was performed to reduce the prepubic fat pad and penoscrotal interposition, but it too was complicated by hematoma formation and wound dehiscence. To maximize phallic elongation, the tethering urethra was removed, and perineal urethrostomy was performed but could not sufficiently alleviate the buried phallus. As a further step to improve the outcome, we proposed the implantation of a specific phallic prosthesis designed for metoidioplasty with testicular prosthesis placement. Surgery was performed as a single procedure through a penoscrotal incision and greatly enhanced genital appearance. Results: Three months after surgery, the patient had good sensation of the phallus and was able to have satisfactory sexual activity with his partner. However, he remained dissatisfied with the amount of prepubic tissue and opted to undergo further liposuction. Conclusion: Phallic prosthesis implantation can be a procedure to improve the condition of multioperated cases of metoidioplasty with resistant phallic burying. Reconstruction with a phallic prosthesis was performed successfully in this case. However, long-term complications and functional outcomes, such as the ability to void while standing or penetrate a sexual partner, remain uncertain. Further experience is needed to determine the efficacy and safety of using a phallic prosthesis as a secondary procedure in patients undergoing metoidioplasty.

Robot-assisted radical nephrectomy for Wilms' tumor in children.

INTRODUCTION: Surgical removal of the tumor is a key step in the management of nephroblastoma. Less invasive surgical approaches such as robot-assisted radical nephrectomy (RARN) has gained momentum over the past few years. This video presents a comprehensive step-by-step video for two cases: one uncomplicated left RARN and one more challenging right RARN. MATERIALS & METHODS: Following the UMBRELLA/SIOP protocol, both patients received neoadjuvant chemotherapy. Under general anesthesia, in a lateral decubitus position, four robotic and one assistant port are placed. After mobilization of the colon, the ureter and gonadal vessels are subsequently identified. The renal hilum is dissected, and the renal artery and vein are divided. The kidney is dissected with sparing of the adrenal gland. The ureter and gonadal vessels are divided, and the specimen is removed through a Pfannenstiel incision. Lymph node sampling is performed. RESULTS: Patients were 4 and 5 years old. The total surgical time was 95 and 200 min, with an estimated blood loss of 5 and 10 cc. The hospital stay was limited to 3 and 4 days. Both pathological reports confirmed the diagnosis of nephroblastoma, with tumour-free resection margins. No complications were observed 2 months postoperatively. CONCLUSION: RARN is feasible in children.

Exstrophic bladder duplication in the sagittal plane: Surgical management of a rare case.

INTRODUCTION: The bladder-Exstrophy-Epispadias complex (BEEC) contains a wide spectrum of congenital malformations. A treatment naïve refugee was referred to our center with what was identified as BEEC. MATERIALS AND METHODS: A 27-year-old female patient was referred for total incontinence since birth by the general practitioner from the refugee center. An exstrophic bladder with blind ending ureteral orifices and a second non-exstrophic bladder with two orthotopic ureters was identified, demonstrating the bladder duplication in the sagittal plane. Laparotomy was performed, dissecting the exstrophic bladder plate caudally and using it as a ventral onlay to augment the non-exstrophic bladder. A Mitchell-type bladder neck reconstruction was performed with an autologous fascia sling around the bladder neck to obtain continence. As the patient had never voluntarily voided, chances of spontaneous voiding after surgery were low. Therefore creation of a continent Mitrofanoff-type vesicostomy was additionally realized and genital reconstruction was achieved. RESULTS: 12 months post operatively, the patient was completely continent, had a bladder capacity of 250 ml, and performed self-catheterization 5 times a day. No post-operative complications were observed. CONCLUSION: Admission of political refugees can implicate challenging surgeries for congenital malformations in adults, such as BEEC. This demonstrates the importance of multidisciplinary transitional care.

Robot-assisted pyeloplasty: How to deal with anatomic variants? A step-by-step video presentation.

INTRODUCTION: Pyeloplasty (open or Robot-assisted) is the gold standard of a symptomatic UPJ stenosis. Sometimes anatomic variants make the procedure challenging. This video describes a step-by-step approach in three settings: a crossing blood vessel and two different presentations of incomplete duplicated system. MATERIALS AND METHODS: Under general anesthesia, patient positioned in lateral decubitus, three trocars are placed. After mobilization of the colon, the Gerota's fascia is opened, and the renal pelvis is dissected off the surrounding structures. Ureter and obstructed pyelum were subsequently identified, mobilized, and hinged on a traction stitch. The pyelum and ureter are divided and spatulated according to the Anderson-Hynes technique; anastomosis is achieved. In variants, the drainage is one of the challenging steps, needing custom-made drainage of both moieties. Correct positioning of the drainage is confirmed with reflux of methylene blue from the bladder. RESULTS: JJ stent was removed 6 weeks postoperatively in surgical day-clinic, additional drainage was removed 1 week after surgery in the outpatient clinic. All three children remain asymptomatic with over a year of follow-up. CONCLUSION: A step-by-step plan for pyeloplasty in case of anatomic variants is presented with a video demonstrating a robot-assisted approach in duplicated systems. Moiety drainage can be challenging.

Penoscrotal Incision for the Primary Implantation of an Artificial Urinary Sphincter.

BACKGROUND: The artificial urinary sphincter (AUS) has become the gold standard to treat severe stress urinary incontinence in men. The traditional placement of an AUS requires 2 incisions. The cuff is placed through a perineal incision and the reservoir and pump are placed via an inguinal incision. The implantation of an AUS is also possible via a single penoscrotal approach. OBJECTIVES: The objective is to demonstrate that the penoscrotal approach is not inferior to the perineal approach. METHODS: Retrospective review of a single surgeon database from 2014 to 2019 was performed. A total of 40 patients have undergone implantation of an AUS via a penoscrotal incision. The outcome of patients was followed for an average of 31.3 months for adverse outcomes. RESULTS: A primary American Medical Systems 800 sphincter was placed in 40 patients via a penoscrotal incision. The average age was 72 years. The average operating time was 35 minutes. The average cuff size was 4 cm. There were no infections of the prothesis so far. Three patients required a revision, 2 other patients needed an explant of the AUS, 1 patient underwent a cystectomy because of persistent radiocystitis. After activation of the sphincter, 33 patients (82.5%) were completely dry or using 1 pad per day for accidents. The remainder were all improved. CONCLUSIONS: AUS implantation via a single penoscrotal approach is not inferior to the perineal approach and has several advantages. The operating time is shorter and the procedure requires only 1 incision which both reduce the risk of infections, while the continence results are similar for both approaches.

Idiopathic Partial Thrombosis (IPT) of the Corpus Cavernosum: A Hypothesis-Generating Case Series and Review of the Literature.

INTRODUCTION: Idiopathic partial thrombosis (IPT) of the corpus cavernosum is a rare condition. The etiology is not fully understood; however, the presence of an either or not congenital web in these patients may contribute to the development of IPT. AIM: The aim of this study was to describe 18 new IPT cases and compare these with 38 cases found in the literature. METHODS: A multicenter retrospective analysis was performed. Descriptive statistics are given. MAIN OUTCOME MEASURES: The main outcome measures used were clinical presentation, clinical and radiographical diagnostics, treatment and resolution of symptoms. RESULTS: Patients most frequently presented with perineal swelling (10/18; 56%) and pain (13/18; 72%), unilateral (12/18; 67%) or bilateral (4/18; 22%), and pain during erection (10/18; 72%). Penile curvature, dysuria or fever (each 1/18; 6%) were uncommon presenting symptoms. In our series, magnetic resonance imaging demonstrated a fibrous web in the corpus cavernosum in 100% of cases and was more bilaterally (11/18; 61%) than unilaterally (7/18; 39%) diagnosed. Cycling was found to be a provocative factor for IPT occurrence in patients at risk as 61% (11/18) of patients reported being a frequent cyclist with the episode of IPT occurring immediately after or during cycling activity in 8 out of 18 patients (8/18; 44%). In five centers, 15 patients were treated conservatively, the majority being treated with therapeutic doses of low molecular weight heparin and simultaneous anti-aggregant therapy. In one center, all three patients were treated with a surgical approach. Complete resolution of symptoms was noted in only 50% of cases. CONCLUSION: IPT is a condition that presents typically with perineal pain and swelling. Cycling is often seen as a provocative factor, while the presence of a fibrous web at the level of the crurocavernosal junction is the underlying disorder allowing for entrapment of blood in the crura. Conservative treatment provides a reasonably good outcome in most cases. For therapy resistant cases, surgery can be considered.