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.

Holmium Laser Enucleation of the Prostate vs Robot-Assisted Simple Prostatectomy for Lower Urinary Tract Symptoms in Patients with Extremely Large Prostates ≥200 cc: A Comparative Analysis.

Introduction and Objectives: Robot-assisted simple prostatectomy (RASP) and holmium laser enucleation of the prostate (HoLEP) are both well-established, minimally invasive surgical treatment options for lower urinary tract symptoms caused by benign prostatic enlargement. We have reported the first comparative analysis of both techniques in patients with prostates of ≥200 cc. Materials and Methods: Between 2009 and 2020 a total of 53 patients with a prostate volume of ≥200 cc were surgically treated at OLV Hospital Aalst (Belgium): 31 underwent RASP and 22 underwent HoLEP. Preoperative and postoperative assessments included uroflowmetry with maximum urinary flow rate (Qmax) and postvoid residual volume (PVR), as well as the International Prostate Symptom Score (IPSS) and quality of life (IPSS-QoL). The complication rates were evaluated according to the Clavien-Dindo Classification. Results: Patients treated with RASP had significantly larger prostate volumes compared with HoLEP (median 226 cc vs 204.5 cc, p = 0.004). After a median follow-up of 14 months, both groups showed a significant improvement in the maximum flow rate (+10.60 mL/s vs +10.70 mL/s, p = 0.724) and a reduction of the IPSS score (-12.50 vs -9, p = 0.246) as well as improvement of the QoL (-3 vs -3, p = 0.880). Median operative time was similar in both groups (150 minutes vs 132.5 minutes, p = 0.665). The amount of resected tissue was lower in the RASP group (134.5 g vs 180 g, p = 0.029) and there was no significant difference in postoperative prostate-specific antigen (1.2 ng/mL vs 0.8 ng/mL, p = 0.112). Despite a similar median catheterization time (3 days vs 2 days, p = 0.748), the median hospitalization time was shorter in the HoLEP group (4 days vs 3 days, p = 0.052). Complication rates were similar in both groups (32% vs 36%, p = 0.987). Conclusion: Our results suggest similar outcomes for RASP and HoLEP in patients with very large prostates ≥200 cc. These findings will require external validation at other high-volume centers.

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.

Time to Move On: The Impending Need for a New Disease-specific Comorbidity Index for Bladder Cancer Patients Undergoing Robot-assisted Radical Cystectomy.

The Charlson comorbidity index is an outdated comorbidity assessment tool which is not disease specific and is not applicable to contemporary BCa patients.

The Effect of Surgical Experience on Perioperative and Oncological Outcomes After Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Evidence from a Referral Centre with Extensive Experience in Robotic Surgery.

BACKGROUND: Evidence on the learning curve for robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is limited. OBJECTIVE: To assess the effect of surgical experience (SE) on perioperative and intermediate-term oncological outcomes in a large contemporary cohort of RARC patients after accounting for the impact of intersurgeon variability. DESIGN, SETTING, AND PARTICIPANTS: The study cohort included 164 patients treated with RARC and ICUD by two surgeons between 2004 and 2017 at a single European referral centre. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: For each patient, SE was defined as the total number of RARCs performed by each surgeon before the patient's operation. The relationship between SE and operative time (OT), lymph node yield (LNY), positive surgical margins (PSMs), Clavien-Dindo grade ≥2 30-d postoperative complication (CD≥2), and oncological outcomes (18-mo recurrence rate) was evaluated in multivariable linear and logistic regression models, clustering at a single-surgeon level. RESULTS AND LIMITATIONS: After adjusting for case mix, SE was associated with shorter OT (p= 0.003), lower probability of postoperative CD≥2 rates (p= 0.01), and lower 18-mo recurrence rates (p= 0.002). Conversely, SE did not predict lower PSM rates (p= 0.3) and higher LNY (p= 0.4). The relationship between SE and OT was nonlinear, with a plateau observed after 50 cases. Conversely, the relationship between SE and CD≥2 and 18-mo recurrence was linear without reaching a plateau after 88 procedures. CONCLUSIONS: SE affects perioperative and oncological outcomes after RARC with ICUD in a linear fashion, and its beneficial effect does not reach a plateau. Conversely, after 50 cases, no further improvement was observed for OT. PATIENT SUMMARY: Robot-assisted radical cystectomy with intracorporeal urinary diversion is a complex surgical procedure with a relatively long learning curve.

The effect of a multidisciplinary weight loss program on renal circadian rhythm in obese adolescents.

Adolescent obesity is a serious health problem associated with many comorbidities. Obesity-related alterations in circadian rhythm have been described for nocturnal blood pressure and for metabolic functions. We believe renal circadian rhythm is also disrupted in obesity, though this has not yet been investigated. This study aimed to examine renal circadian rhythm in obese adolescents before and after weight loss.In 34 obese adolescents (median age 15.7 years) participating in a residential weight loss program, renal function profiles and blood samples were collected at baseline, after 7 months, and again after 12 months of therapy. The program consisted of dietary restriction, increased physical activity, and psychological support. The program led to a median weight loss of 24 kg and a reduction in blood pressure. Initially, lower diurnal free water clearance (- 1.08 (- 1.40-- 0.79) mL/min) was noticed compared with nocturnal values (0.75 (- 0.89-- 0.64) mL/min). After weight loss, normalization of this inverse rhythm was observed (day - 1.24 (- 1.44-1.05) mL/min and night - 0.98 (- 1.09-- 0.83) mL/min). A clear circadian rhythm in diuresis rate and in renal clearance of creatinine, solutes, sodium, and potassium was seen at all time points. Furthermore, we observed a significant increase in sodium clearance. Before weight loss, daytime sodium clearance was 0.72 mL/min (0.59-0.77) and nighttime clearance was 0.46 mL/min (0.41-0.51). After weight loss, daytime clearance increased to 0.99 mL/min (0.85-1.17) and nighttime clearance increased to 0.78 mL/min (0.64-0.93).Conclusion: In obese adolescents, lower diurnal free water clearance was observed compared with nocturnal values. Weight loss led to a normalization of this inverse rhythm, suggesting a recovery of the anti-diuretic hormone activity. Both before and after weight loss, clear circadian rhythm of diuresis rate and renal clearance of creatinine, solutes, sodium, and potassium was observed.What is Known:• Obesity-related alterations in circadian rhythm have been described for nocturnal blood pressure and for metabolic functions. We believe renal circadian rhythm is disrupted in obesity, though this has not been investigated yet.What is New:• In obese adolescents, an inverse circadian rhythm of free water clearance was observed, with higher nighttime free water clearance compared with daytime values. Weight loss led to a normalization of this inverse rhythm, suggesting a recovery of the anti-diuretic hormone activity.• Circadian rhythm in diuresis rate and in the renal clearance of creatinine, solutes, sodium, and potassium was preserved in obese adolescents and did not change after weight loss.