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Gender-affirming surgery is classically done using the penile inversion vaginoplasty technique, however in some patients it may not promote adequate depth. In patients whose vaginal conduits became short or stenotic, we propose to perform a secondary vaginoplasty using an abdominal free skin mesh graft. In this study, we present ours results of a series of cases using this technique.A retrospective review of patients undergoing secondary vaginoplasty with free skin mesh graft from 2000 to 2017 at our hospital was performed. Demographic data, surgical characteristics, complications, personal satisfaction and neovagina functionality (defined as the ability to have satisfactory sexual intercourse) were evaluated.Of 186 patients who were submitted to primary vaginoplasty, 36 patients (19.3%) were then submitted to secondary vaginoplasty. This study sample included 35 patients. The average age of patients was 41.0 years (37.0 to 50.5) and the average time between gender affirmation surgery and secondary vaginoplasty was 6 months (4-24). Ten patients (28.6%) developed postoperative complication, the most frequent being: neovagina introitus stenosis (22.9%), rectal fistula (8.6%), tissue dehiscence (2.9%), and urethral fistula (2.9%). Subjective personal satisfaction and neovagina functionality of patients was reported by 77.1% of the sample.Our study demonstrates that secondary vaginoplasty surgery using a free skin mesh graft has good results and is a functional option with low complexity and low rate of serious complications.

Pelvic malignancies, including prostate, rectal, and bladder cancers, are among the most frequent malignancies found in the male population. These issues are most effectively and commonly treated with radiotherapy and/or surgery. However, these treatments can cause collateral damage, resulting in significant impacts on quality of life, with erectile dysfunction being one of the most frequent postoperative complications. Currently, there are several treatment options for erectile dysfunction, including oral phosphodiesterase type 5 inhibitors, vacuum erection devices, intracorporeal injections, and penile prosthesis. The latter has shown to be an effective and safe technique, with results comparable to those obtained by patients without pelvic surgery or radiotherapy. The results of early penile rehabilitation programs are promising and they have been incorporated into a greater proportion of treatment plans more recently, with varying degrees of success. In this narrative review, we summarize the literature on erectile dysfunction after pelvic cancer treatments and its management.

Webster described a step-based perineal approach for repairing the posterior urethra in patients with pelvic fracture urethral injury (PFUI). The higher the complexity of the step, the higher the morbidity for the patient and the lower the surgical outcomes. We evaluated the outcomes of anastomotic urethroplasty (especially Step 4 or higher) or substitution urethroplasty in patients with PFUI at our center. Between 2013 to 2021, we retrospectively collected data on patients with PFUI. Surgical procedures were categorized according to the Webster classification and rates of each step were reported. The success rate was defined as Qmax above 10 mL/s and no need for further treatment. In this period, 737 male patients with PFUI were surgically treated. Notably, 18.8%, 17.6%, 46%, 1.8%, and 5.6% of included patients received steps 1, 2, 3, and 4 and the abdominoperineal approach, respectively. In 68 (9.2%) patients, the substitution of urethroplasty with a pedicled preputial tube (PPT) was needed. The success rate was 69.2% in Step 4, 74.4% in the abdominoperineal approach, and 86.4% in PPT; however, recurrence-free survival was not significantly different between groups (p = 0.22). Step 4 perineal anastomotic urethroplasty represents a surgical option in the armamentarium of PFUI treatment. Indications should be carefully reviewed to improve patient selection and avoid surgical failure, stopping at the step which first gives a tension-free anastomosis.

(1) Background: This study examined outcomes of second-line ATOMS implantation after failure of the fixed male sling (FMS) AdVance/AdVance XP. (2) Methods: A retrospective multicenter cohort analysis was carried out in men implanted with an ATOMS between 2011 and 2020 after failure of an AdVance/AdVance XP. Success was assessed on the basis of objective (dryness, 0–1 pad/24 h or >20 g/24 h pad test) and subjective results (PGI-I). We performed the Wilcoxon rank sum test, Fisher’s exact test, logistic regression, and multivariate analysis. (3) Results: The study included 88 patients from 9 centers with a mean age of 71.3 years. No Clavien–Dindo > II complications occurred within the first 3 months after ATOMS implantation. A total of 10 cases (9%) required revision in the ensuing clinical course. After a mean follow-up of 42.5 months, 76.1% achieved social continence, and 56.8% used no pads at all. Mean urine leakage/24 h dropped from 422 g (3.9 pads) to 38 g (0.69 pads) and the mean ICIQ-SF decreased from 16.25 to 5.3 (p < 0.0001). PROMs (patient-reported outcome measures) showed improvement in 98.9% of cases, and 63.6% gave a “very much better” PGI-I rating. Multivariate analysis identified a lower probability of achieving maximum satisfaction for the following factors: the AdVance XP as first-line therapy (OR 0.35), a lower ICIQ-SF question 1 (OR 0.26), status post-irradiation (OR 0.14), and more severe pain prior to ATOMS implantation (OR 0.51). (4) Conclusions: Implantation of an ATOMS is an effective and safe second-line treatment option for recurrent urinary incontinence after implantation of an AdVance/AdVance XP sling. High patient satisfaction was demonstrated in a long-term follow-up.

Introduction: The objective of this study was to compare a double-layer running suture re-anastomosis urethral stricture repair with early catheter removal to the conventional interrupted suture re-anastomosis after excision of a bulbar urethral stricture. Methods: A consecutive series of patients with bulbar urethral stricture were enrolled in the study. The patients were randomized into two groups according to an odd/even serial number distribution. Patients’ medical records were analyzed for demographics, stricture characteristics, and lower urinary tract obstructive symptoms. The outcomes were based on the presence/absence of obstructive voiding symptoms, and retrograde urethrography (RGU) performed on the first post-operative day in Group 1 and in both groups (Groups 1 and 2) at six weeks after surgery. Flexible urethroscopy was only performed on specific cases where RGU was unclear both pre- and post-operatively or when clinical recurrence was suspected. The minimum follow-up (FU) was 18 months. Success was defined as no need for subsequent dilatation, direct vision internal urethrotomy (DVIU), or urethroplasty. Results: A total of thirty-six patients with a mean age of 45 years (range 20 to 69 years) with bulbar urethral stricture were included in this study. Group 1 and Group 2 included 19 and 17 patients, respectively. Two patients were lost during randomization and subsequently to FU. The average stricture lengths were comparable between the two groups according to the retrograde urethrogram: 1.20 cm (range 0.6 to 2) in Group 1 and 1.27 cm (range 0.5 to 2.4) in Group 2, respectively (p = 0.631). The success rate for Group 1 was 90% after a mean follow-up of thirty-six months (range 20 to 40), which was clinically significant compared to the 71% in Group 2 after a mean FU of thirty-three months (range 19 to 40; p = 0.0218; 95% CI: 0.462–41.5766). Conclusions: Anastomotic urethroplasty (AR) performed with a double layer re-anastomosis had a cure rate comparable to the conventional anastomosis with interrupted sutures after a follow-up of eighteen months and longer. The urethral catheter can be safely removed within twenty-four hours after the excision of stricture and double-layer re-anastomosis.

Female urethral stricture is an underdiagnosed condition and a diagnostic challenge. Traditionally treatment has been urethral dilatation. Recent studies have shown promising outcomes after female urethroplasty (FU). We report our two-institutional experience with dorsal onlay substitution FU using buccal mucosal graft (BMG) and vaginal wall graft (VWG).In this retrospective study, 32 women who underwent dorsal onlay urethroplasty at two institutions in India and Portugal were included for comparison of outcomes between BMG and VWG. The need for re-intervention was defined as failure. Their assessment included American Urological Association (AUA) symptom score, peak flow rate (Qmax), urethral calibration, postvoid residual urine (PVR), voiding cystourethrogram, and cystoscopy. Other parameters such as age, need for suprapubic cystostomy, prior interventions, location, length, etiology, operating time, postoperative catheter time, complications, and follow-up were evaluated. Statistical analysis was done with two-sample21 patients underwent BMG and 11 underwent VWG, respectively. The overall mean age was 49 years (range: 25-75) and follow-up was 26 months (range: 13-62). The overall change in AUA symptom score was from 22 to 6, Qmax from 4ml/s to 26mL/s, and PVR from 185ml to 17 ml with no statistical difference between the two groups. Other parameters showed no difference except operating time. The overall urethral patency rate was 94% with no statistical difference in these groups (Dorsal onlay substitution FU is easy to perform with low complication rate. We found no difference in outcome of FU in these groups. Early FU should be encouraged to avoid the adversities of repeated dilatations.

Although urethral strictures have been known since antiquity, the surgical management of urethral strictures has undergone a great (re)evolution over the last six decades, both in the perception of the disease and in the surgical repair techniques, always presenting itself as a challenge for the surgeon and patient. Reconstruction of urethral stricture disease involving a combination of grafts and flaps consists of a group of complex procedures with specific clinical indications. The knowledge of these procedures by reconstructive urologists is both necessary and relevant. A thorough understanding of the anatomy, including blood supply, is a crucial proviso for the correct evaluation and successful management of urethral stricture disease. We discuss the main techniques and indications in combined graft and flap urethroplasties.

Background: Reconstructive approaches for distal urethral strictures range from simple meatotomy to utilizing grafts or flaps depending on the etiology, length and location. We describe a contemporary cohort of distal urethral strictures and report a surgical technique termed distal one-stage urethroplasty developed to address the majority of distal urethral strictures encountered. Methods: Thirty-four patients were included. The mean age was 56.7 years (range 15.7–84.9 years), the mean stricture length was 1.1 cm (0.5–1.5) and the mean follow-up was 42.5 months (28–61.3). Results: The vast majority of distal strictures (27/34 (79.4%)) were treated with our hybrid one-stage approach combining a distal urethral reconstruction with excision of the scar tissue without the need to use grafts or flaps. The average stricture length was 0.68 cm and average operative time was 24.43 min. Post-operative spraying was reported in a minority of patients (4/27 (14.8%)). The length of stricture and surgery were significantly longer in those 7/34 (20.6%) patients in whom grafts or flaps were used (2.88 cm and 154.8 min, respectively, p < 0.001 for both when compared to the hybrid one-stage approach). We noted 6/34 (17.6%) recurrences of distal urethral strictures, all of which were treated successfully with graft and flap repairs. Conclusions: The vast majority of distal urethral strictures are amenable to a distal one-stage urethroplasty, avoiding the use of grafts and/or flaps while achieving reasonable outcomes. This limited approach, at least initially, is associated with shorter operative time and time of catheter placement and avoids morbidity associated with graft or flap harvesting. Spraying of urine is seldomly encountered and comparable to other approaches addressing distal urethral strictures.

Background: Recurrent stress urinary incontinence (SUI) following male sling can be managed surgically with artificial urinary sphincter (AUS) insertion. Prior small, single-center retrospective studies have not demonstrated an association between having failed a sling procedure and worse AUS outcomes. The aim of this study was to compare outcomes of primary AUS placement in men who had or had not undergone a previous sling procedure. Methods: A retrospective review of all AUS devices implanted at a single academic center during 2000–2018 was performed. After excluding secondary AUS placements, revision and explant procedures, 135 patients were included in this study, of which 19 (14.1%) patients had undergone prior sling procedures. Results: There was no significant difference in demographic characteristics between patients undergoing AUS placement with or without a prior sling procedure. Average follow up time was 28.0 months. Prior sling was associated with shorter overall device survival, with an increased likelihood of requiring revision or replacement of the device (OR 4.2 (1.3–13.2), p = 0.015) as well as reoperation for any reason (OR 3.5 (1.2–9.9), p = 0.019). While not statistically significant, patients with a prior sling were more likely to note persistent incontinence at most recent follow up (68.8% vs. 42.7%, p = 0.10). Conclusions: Having undergone a prior sling procedure is associated with shorter device survival and need for revision or replacement surgery. When considering patients for sling procedures, patients should be counseled regarding the potential for worse AUS outcomes should they require additional anti-incontinence procedures following a failed sling.