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To analyze current standards in urethroplasty by urologists employing buccal mucosal grafts (BMG) for treating urethral stricture disease (USD). An IRB-approved online survey was distributed to members of the Society of Genitourinary Reconstructive Surgeons (GURS) between July and October 2022 to assess BMG utilization in urethroplasty. Questions covered surgeon experience, graft harvest site, graft length, surgical technique, and perceived success rates. Of 350 invited GURS members, 134 responded (38%). Sixty-nine percentage were GURS fellowship-trained, performing 10-30 urethroplasties annually. Ninety-five percentage harvested their own grafts, with 99% preferring buccal mucosa as the primary site. Buccal mucosa was favored over fasciocutaneous flap for penile urethroplasty, regardless of circumcision status (95% with, 84% without). For bulbar urethroplasty with BMG, dorsal graft placement was favored (66%) over ventral (34%). Most surgeons (90%) preferred multiple BMGs over combined graft/flap for panurethral strictures. When harvesting long grafts, 56% preferred using both cheeks. Anastomotic urethroplasty was preferred over buccal graft urethroplasty for short bulbomembranous stenosis post-radiotherapy (63% vs 37%). Surgeons reported a success rate of 80%-90% (53%). The expanded scope of reconstructive urology has led to increased use of BMG in diverse urethral reconstructions. Buccal grafts are now preferred for penile, bulbar, and panurethral strictures, demonstrating high perceived success rates in the reconstructive community. [ABSTRACT FROM AUTHOR]

To assess changes in the urinary microbiota after buccal urethroplasty. At the University of California San Francisco, we enrolled 9 adult males with urethral strictures undergoing buccal urethroplasty where we collected urine and oral swabs intraoperatively and 3 months postoperatively. 16S rRNA sequencing was used to profile the microbiota. At baseline, the mouth contains twice the number of unique bacteria (alpha diversity) and the microbial community is significantly distinct compared to the urinary tract. Despite having a buccal mucosa in the urinary tract after urethroplasty, the number of unique bacteria in the urine remained stable. However, the bacterial community composition and structure significantly changed in the urinary tract with the enrichment of Corynebacterium genus at 3 months post-urethroplasty procedure. In this pilot study, we showed that the alpha diversity in the urinary microbiota did not significantly change despite having a buccal tissue with the capacity to support high bacterial diversity in the urinary tract. To our surprise, the post-urethroplasty urinary microbiota was not a hybrid of baseline oral and urine microbiotas; the changes detected, such as an enrichment of the Corynebacterium genus, were more nuanced yet could profoundly impact surgical outcomes like graft changes and stricture recurrence. Our study not only established the feasibility but also outlined a blueprint for conducting a large-scale study to assess alterations in the urinary microbiome in relation to surgical outcomes. [ABSTRACT FROM AUTHOR]

To compare outcomes among patients undergoing first-time urethroplasty with buccal mucosa graft (BMG) who receive postoperative antibiotics vs those who do not. A retrospective cohort study was conducted using the TriNetX claims database between 2008-2022. Using CPT, ICD10, and LOINC codes, patients >18 years old undergoing primary urethroplasty with BMG who received an outpatient prescription for antibiotics between postoperative day 0-30 or did not were queried. Patients with positive preoperative urine culture or urinary tract infection (UTI) within 30 days preoperatively were excluded. Surgical outcomes included 5-year revision rates and revision-free survival. Safety outcomes included new UTI within 30 days, surgical site infection within 90 days, or Clostridium difficile infection within 30 days of urethroplasty. We identified 884 patients (81% antibiotic cohort, 19% nonantibiotic cohort) that met inclusion criteria. Age at time of urethroplasty, suprapubic tube presence, and pre-existing medical comorbidities were comparable between cohorts (Table 1A). There was no difference in 5-year rates and revision-free survival for endoscopic revision (11.5% vs 9.5%, relative risk (RR) 1.2, 95% CI [0.7, 2.0], recurrence-free survival (RFS) log-rank P =.6), re-do urethroplasty (12.9% vs 13.7%, RR 0.9, 95% CI [0.6, 1.5], RFS log-rank P =.7), or all-cause revision (19.8% vs 17.7%, RR 1.1, 95% CI [0.8, 1.6], P =.5) between groups. Postoperative rates of UTI, surgical site infection, and C difficile infection were similar between groups. In this large retrospective cohort study of patients undergoing urethroplasty with BMG, we observed no significant benefit from use of postoperative antibiotics on long-term revision rates or perioperative infectious complications. [ABSTRACT FROM AUTHOR]

The most prevalent complication in hypospadias repair is fistula formation. Adhering to the principle of providing urethroplasty coverage to mitigate fistula occurrence, we implemented a modification by integrating a spongiosum layer between the urethroplasty and the dartos flap. Our hypothesis posited that this approach would result in a reduced fistula formation rate. This study is a comparative analysis involving patients under 18 years of age who underwent primary hypospadias repair. The cases were allocated into two groups. In the study group, in addition to performing tubularized incised plate (TIP) repair, a spongiosum layer harvested from both sides of the urethra was used to cover the urethroplasty (modification of the Y-to-I urethroplasty). The control group underwent a standard TIP repair. The primary outcome was to assess urethrocutaneous fistula formation. Secondary outcomes included evaluating the development of meatal stenosis and glans dehiscence, along with assessing cosmetic results by the Hypospadias Objective Penile Evaluation (HOPE) score. Overall, 154 hypospadias cases were included in the study. Eighty-seven patients (56%) were allocated to the study group, and 67 (44%) were allocated to the control group. Urethrocutaneous fistula developed in 3 (3.4%) and 11 (16.4%) patients in the study and control group, respectively (p = 0.006). Glans dehiscence occurred in 2 (2.3%) patients in the study group and 4 (6%) patients in the control group (p = 0.198). Meatal stenosis was observed in 4 (4.6%) patients in the study group and 5 (7.5%) patients in the control (p = 0.452). The mean HOPE score was 59 in both groups (p = 0.36). This study details our encounters with the novel modification and compares the results with standard TIP. Our data suggest that adding a layer of spongiosum tissue over the urethroplasty reduces the complication of urethrocutaneous fistula without increasing the occurrence of dehiscence, significant meatal stenosis, or compromising cosmetic outcomes. We advocate for implementing the described surgical modification as a viable option for hypospadias repair. Summary table Complications observed among patients who underwent hypospadias repair. Summary table Complication Control: Standard TIP n = 67 Study: Additional layer n = 87 p -value Fistula 11 (16.4%) 3 (3.4%) 0.006 Meatal Stenosis 5 (7.5%) 4 (4.6%) 0.452 Dehiscence 4 (6%) 2 (2.3%) 0.198 [ABSTRACT FROM AUTHOR]

Over the years, Dorsal Inlay Graft (DIG) urethroplasty has gained worldwide acceptance for primary hypospadias repair. However, its safety and effectiveness for revision surgery are yet to be proven. The aim of the study is to assess and compare complication rates and functional outcomes of DIG surgery in revision versus primary hypospadias repair. We carried out a retrospective analysis of data collected from 53 consecutive DIG urethroplasties performed by a single surgeon at our institution. Patients were stratified in two groups – primary repair and redo-urethroplasty. For each group, we recorded standard pre-operative characteristics, surgical technicalities, complication rates and uroflowmetry parameters. Out of 53 DIG urethroplasties, 21 (39.6 %) where primary and 32 (60.4 %) were re-do. As expected, the two groups differed for median age at surgery: 20 months for primary and 68.5 months for revision surgery (p < 0.001). Additionally, all 21 (100 %) primary interventions were performed with a preputial graft, whereas among revision DIG urethroplasties only 2 (6.3 %) where preputial and 30 (93.8 %) were buccal (p < 0.001). Catheterization time (7 vs 8 days, p = 0.155) and postoperative complication rates (14.3 % vs 9.4 %, p = 0.581) were comparable between the primary and revision surgery group, respectively (all p >.05). Forty-two of the 53 patients underwent uroflowmetry during follow-up. Of these, 19 (63 %) patients presented with abnormal uroflowmetry and 11 (37 %) had equivocal parameters with no difference between the two groups. Dorsal Inlay Graft urethroplasty has long been known to be safe and effective for primary hypospadias repair. On the other hand, data on dorsal inlay graft urethroplasty as a salvage surgery after primary hypospadias repair failure is scarce. Surprisingly, according to our findings, surgical outcomes and complication rates are comparable between primary and revision hypospadias cases. Additionally, our results in the redo group are absolutely encouraging if compared to those reported in the literature for the same subset of patients. According to our findings, DIG urethroplasty is a safe and effective option to treat revision hypospadias repair. [ABSTRACT FROM AUTHOR]

To determine urethral outcomes of single-stage metoidioplasty and radial forearm free flap (RFFF) phalloplasty using the labia minora ring flap for urethral lengthening (UL). A retrospective review was performed of patients undergoing single-stage metoidioplasty and RFFF phalloplasty utilizing the labia minora ring flap technique. The ring flap consists of endodermal labia minora tissue ventral to the clitoris and surrounding the vaginal introitus. During metoidioplasty, the ring flap accounts for the entirety of UL. During RFFF phalloplasty, the ring flap becomes the pars fixa (PF) urethra. The primary outcomes measured were rates of fistula, stricture, and surgical revision. Between November 2017 and August 2023, 311 patients underwent metoidioplasty or RFFF phalloplasty (mean follow-up 37 months). Of the 69 metoidioplasties, urethrocutaneous fistulas developed in 11 patients (16%); strictures occurred in 4 (6%). Of the 242 phalloplasty patients, there were 71 fistulas (29%), 56 of which resolved spontaneously. Strictures developed in 44 patients (18%). Twenty-five patients (10%) developed both a stricture and fistula. Surgical repair was required in 8/69 (12%) metoidioplasty patients and in 46/242 (19%) RFFF phalloplasty patients for an overall revision rate of 17%. UL during metoidioplasty or RFFF phalloplasty can be accomplished in a single stage using the labia minora ring flap with comparable surgical revision rates to previously described techniques. This approach can also be applied to other phalloplasty techniques. Many fistulas of the PF urethra resolve spontaneously. Higher urethral revision rates were seen in phalloplasty compared to metoidioplasty. [ABSTRACT FROM AUTHOR]

To assess whether omitting routine post-operative imaging adversely impacts clinical outcomes after bulbar urethroplasty. Contrast imaging is commonly performed prior to catheter removal after urethroplasty but the clinical need for this is unclear. This was a matched, case-control analysis comparing patients undergoing routine voiding cystourethrogram (VCUG) prior to catheter removal after bulbar urethroplasty to patients without imaging. Patients were matched with respect to age, stricture etiology, length, and urethroplasty technique. Follow-up consisted of clinical assessment 3 weeks post-operatively for VCUG/catheter removal, cystoscopy at 3-4 months with clinical assessment annually. Outcome measures were 90-day complications (Clavien ≥2) and stricture recurrence (failure to pass a 16-Fr flexible cystoscope on follow-up). Chi-square and Kaplan-Meier analysis were conducted where appropriate. Hundred patients undergoing bulbar urethroplasty with VCUG prior to catheter removal were compared to 100 matched case controls without imaging. Groups did not differ with respect to failed endoscopic treatment (P =.82), prior urethroplasty (P =.09), comorbidities (P =.54), smoking (P =.42), or pre-operative bacteriuria (P = 1.00). The incidence of extravasation in the VCUG group was 2%. Overall 90-day complications were 9.5% and 15 patients developed recurrence with a median follow-up of 174 months. On chi-square analysis, 90-day complications did not differ between patients undergoing VCUG and those without (12% vs 7.0%; P =.34). On log-rank analysis, stricture recurrence did not differ between groups (P =.44). Routine imaging with VCUG after bulbar urethroplasty does not influence the risk of post-operative complications or stricture recurrence. Surgeons should consider avoiding this potentially unnecessary examination in routine clinical practice. [ABSTRACT FROM AUTHOR]

To implement a simplified, opioid-minimized, multimodal pain management (MPM) protocol and assess its effectiveness of reducing opioid dispersion while maintaining low postoperative complications, patient-reported pain, and patient-reported interference with quality of life (QOL) for men undergoing urethroplasty. Ninety-five men at a single academic center from October 2020 to October 2023 received a urethroplasty. We retrospectively reviewed the prior standard pain management (SPM) cohort before August 2021, then prospectively studied the MPM cohort after August 2021. For the SPM cohort, we collected postoperative day (POD) 1 pain scores from our Electronic Medical Record (EMR). For the MPM cohort, we obtained a validated pain and QOL assessment in the early postoperative period. The SPM cohort's POD 1 pain scores were compared with the MPM cohort's POD 2 pain scores. Opioid dispensation records were queried from the Prescription Monitoring Program. Seventy-five morphine milligram equivalent fewer opioids in the MPM cohort were prescribed than the SPM cohort (0 (interquartile range [IQR]: 0-0) vs 75 (IQR:0-150), P <.001, respectively). Patients with opioid discharge prescriptions fell from 50% in the SPM cohort to 11% in the MPM cohort (P <.001). Early postoperative pain scores remained low and showed no significant difference between the cohorts. Pain's interference with QOL measures remained low. Complications were rare across both cohorts. This simplified, multimodal analgesia protocol effectively decreases postoperative pain and opioid dispersion without affecting QOL outcomes after urethroplasty. This pain regimen can be easily adopted to decrease the use of postoperative opioids in men undergoing urethroplasty. [ABSTRACT FROM AUTHOR]

To evaluate the outcomes of ventral onlay buccal mucosal graft urethroplasty (VOBMGU) in bulbomembranous urethral strictures after transurethral resection of the prostate. After approval of the institutional ethical committee, we retrospectively examined the database of patients diagnosed with post-TURP urethral stricture (PTS) and treated by VOBMGU from January 2020 to January 2022. The patients were evaluated by retrograde urethrogram and voiding cystourethrogram. Follow-up evaluation included assessment of lower urinary tract symptoms, physical examination, uroflowmetry (Q-max and International Prostate Symptom Score) 3, 6, and 12 months of follow-up. A total of 30 patients underwent VOBMGU for bulbomembranous PTS were included. The median age of the patients was 63.5 (11.25). The median stricture length was 3.5 (1.5) cm. During follow-up, the mean Q-max significantly increased to 21.1 ± 5.5 mL/s (P <.0001), 20.1 ± 5.4 mL/s (P <.001), and 19.1 ± 5.3 mL/s (P <.003) at 3, 6, and 12 months, respectively. IPSS significantly decreased to 8.93 ± 6.37 at the 12-month follow-up mark (P <.0001). Three patients developed stricture recurrence and two patients developed postoperative urinary incontinence. VOBMGU in cases of bulbomembranous urethral PTS offered excellent functional outcomes with low stricture recurrence and minimal risk of incontinence. Further prospective studies are warranted to confirm the results. [ABSTRACT FROM AUTHOR]

To determine which bacteria are associated with an increased risk of 90-day complications after urethroplasty. Preoperative bacteriuria is associated with an increased risk of complications after urethroplasty. However, it remains unclear which specific micro-organisms are the primary drivers of this morbidity. A single-institution, 2-surgeon retrospective review was performed on patients undergoing urethroplasty from 08/2003 to 06/2021. Preoperative bacteriuria was considered significant when the patient had a mixed culture with ≥108 CFU/L or an identifiable micro-organism with ≥106 CFU/L. Descriptive statistics were used to summarize the results and chi-square was used to determine the association between 90-day complications (Clavien ≥2) and clinical characteristics/bacteria. Out of 1611 patients, 23.2% (373) had significant preoperative bacteriuria. The most common pathogens included coagulase-negative staphylococcus 18.5% (69), mixed growth 15.8% (59), Escherichia coli 10.7% (40), and Enterococcus 14.2% (53). 7.9% (128/1611) experienced a significant 90-day complication (Clavien-Dindo ≥2). Gram-negative bacilli including E coli, Pseudomonas sp, Klebsiella sp, Serratia sp, Citrobacter sp, Achromobacter sp, Stenotrophomonas sp, and Morganella sp were associated with higher rates of postoperative complications (14.2%; P =.01) as well as Enterococcus sp (15.1%; P =.03). However, gram-positive cocci (7.9%; P =.97), gram-positive bacilli (11.8%; P =.47), mixed growth (5.1%; P =.54) and Candida (16.7%; P =.27) were not. Neither escalating concentrations of bacteria (P =.44) or number of strains (P =.08) were associated with increased risk of complications. The main driver of bacteriuria-related complications after urethroplasty are gram-negative bacilli and Enterococcus sp. Patients with bacteriuria related to other micro-organisms can likely proceed with urethroplasty without increased risk of postoperative complications. [ABSTRACT FROM AUTHOR]

Mid-shaft/proximal (msp) and penoscrotal/scrotal/perineal (pssp) hypospadias treated by urethroplasty (UP) terminating at the corona (UPC) or UP terminating at the tip of the glans (UPG) were compared. UP performed at a single institute (n = 234) between 2003 and 2020 were grouped as: msp-UPC (n = 23), msp-UPG (n = 75), pssp-UPC (n = 81), and pssp-UPG (n = 55) to compare data obtained from medical records for post-UP complications (PUC; urethral stenosis, urethrocutaneous fistula, diverticulum formation, and bleeding; n = 234), post-UP uroflowmetry (PUF; average flow rate (Qave), maximum flow rate (Qmax), voiding time (VT), voided volume (VV) and urine flow curves) in 57 UP patients [msp-UPC (n = 5), msp-UPG (n = 12), pssp-UPC (n = 32), pssp-UPG (n = 8)] and 9 controls, and post-UPC esthetics (EST; n = 104). P < 0.05 was considered significant. Mean ages at UP (years) were: msp-UPC (3.1 ± 3.0), msp-UPG (3.3 ± 1.4), pssp-UPC (4.6 ± 2.4), and pssp-UPG (3.4 ± 1.4); p < 0.0001 by ANOVA test. Overall, there were significantly more PUC in pssp-UPG compared with pssp-UPC except for bleeding. Ages at PUF assessment were similar. Mean Qave (mL/s) for pssp-UPG (4.0 ± 1.0) was significantly less than pssp-UPC (5.9 ± 2.5; p < 0.05) and both were significantly less than controls (6.9 ± 1.8; p < 0.05, p < 0.01, respectively). Mean Qmax (mL/s) for pssp-UPC (11.4 ± 4.8) was significantly better than pssp-UPG (7.8 ± 2.3; p < 0.05) and for controls (14.9 ± 4.4) was significantly better than pssp-UPG (7.8 ± 2.3; p < 0.01). All VT (seconds) were similar to controls; all urine flow curves were normal. For EST in UPC (n = 104), 3 cases requested meatal advancement. UPC may be a valid option for treating pssp hypospadias because of significant differences in PUC/PUF and minimal EST issues compared with UPG. Prognosis Study Level-Ⅱ [ABSTRACT FROM AUTHOR]

To compare surgical outcomes among a cohort of eugonadal and hypogonadal patients undergoing primary urethroplasty (UP). A retrospective cohort study was conducted using TriNetX between 2008-2023. Patients who were eugonadal and hypogonadal (symptoms plus testosterone <300 ng/dL) prior to UP were compared. A subgroup analysis of hypogonadal patients was performed to compare those with testosterone replacement therapy (TRT) vs TRT-naïve prior to UP. Propensity-score matching was used to adjust for differences in comorbidities. Outcomes were 5-year revision rates and revision-free survival for endoscopic revision and redo UP following primary UP. We identified 12,556 eugonadal and 488 hypogonadal patients (153 TRT+, 335 TRT−) undergoing UP. Median age at UP and follow-up was 55 years and 5 years, respectively. After propensity-score matching, we compared 477 eugonadal and 477 hypogonadal patients. Hypogonadal patients had a statistically significantly higher 5-year redo UP rate (11% vs 6%, relative risk [RR] 1.5 [95%CI, 1.2-2.2]; P =.01) when compared to eugonadal patients however there was no difference in 5-year rates of endoscopic revision (11% vs 11%, RR 1.0 [95%CI, 0.7-1.5]; P = 1.0). We observed no difference in 5-year revision-free survival time for endoscopic revision or redo UP between groups. Hypogonadal patients treated with TRT had a significantly higher 5-year redo UP rate (15% vs 7%, RR 1.8 [95%CI, 1.1-3.3]; P =.02) compared to hypogonadal patients that were TRT-naïve prior to UP. There was no difference in rates of endoscopic revision (14% vs 10%, RR 1.3 [95%CI, 0.7-2.4]; P =.2) between subgroups. Pre-existing hypogonadism may modestly adversely affect surgical outcomes following primary UP based on data from a large, retrospective cohort study. [ABSTRACT FROM AUTHOR]

To present a unique series of children with previously repaired anorectal malformations (ARM) with subsequent urethral pathology repaired via a posterior sagittal exposure and highlight the associated technical advantages. Using a retrospective review of all procedures performed in our pediatric colorectal and pelvic reconstruction program from January 2020 through December 2022, we compiled a case series of patients with a history of ARM and prior posterior sagittal anorectoplasty (PSARP) who had urethral pathology and concurrent indication for redo-PSARP. Clinical features, operative details, and postoperative outcomes were collected. Six male patients presented at a median age of 4.3 years, all born with an ARM of recto-urinary fistula type, of which 3 were recto-prostatic, 1 recto-bladder-neck, and 2 unknown type. In addition to redo-PSARP, 2 underwent remnant of the original fistula excision and 4 had urethral stricture repair. One required post-operative Heineke-Mikulicz anoplasty. Patients underwent cystoscopy 4-6 weeks post-reconstruction, and none showed urethral stricture requiring treatment. Post-procedurally, 5 patients were able to void urethrally and 1 required additional bladder augmentation/Mitrofanoff. Redo-PSARP completely mobilizes the rectum, thereby providing excellent exposure to the posterior urethra for repair. This approach also allows the option of a rectal flap for augmented urethroplasty as well as harvest of an ischiorectal fat pad for interposition. [ABSTRACT FROM AUTHOR]

To evaluate outcomes of three urethroplasty techniques for pars fixa (PF) urethral strictures and provide a treatment algorithm based on stricture characteristics. The PF is an essential anatomic region of the neourethra created in gender-affirming phalloplasty and metoidioplasty. Urethral strictures in this region present a reparative challenge given its unique anatomy and vascularization. A total of 41 urethroplasties performed on 41 patients between March 2018 and June 2021 were reviewed at two surgical centers. A Heineke-Mikulicz (HM) repair was done for strictures under 20 mm when the proximal and distal urethral segments were mobile and supported a tension-free closure. Substitution urethroplasty with ventral onlay buccal mucosal graft was utilized for strictures under 40 mm not suitable for HM repair. Complex or long (≥40 mm) strictures were treated by two-stage Johansen urethroplasty. Success of each surgical approach was defined by a minimum of 12-month follow-up without the need for a repeat intervention. Mean follow-up was 30.2 months (range: 12.4-52.0 months). Mean stricture length was 16.9 mm (range: 2-55 mm). Most strictures (46%) were located at the distal PF. HM urethroplasty had a success rate of 44% (n = 16). Substitution urethroplasty had a success rate of 92% (n = 13). Two-stage Johansen urethroplasty had a success rate of 75% (n = 12). The success rates of PF urethral stricture repair ranged from 44% to 92% depending on the surgical approach, and the best reparative procedure depends on stricture length, severity, and local tissue mobility. [ABSTRACT FROM AUTHOR]

Current assessment of critical tissue in genitourinary reconstruction, including graft beds and tissue flaps, primarily relies upon qualitative visual and tactile assessment by experienced surgeons. Here we explore the feasibility of using intravenous indocyanine green (ICG) for semiquantitative assessment of perfusion in complex open urethral reconstruction. A standardized protocol for intravenous use of ICG and near-infrared fluorescence was established. Black and white mode was used for qualitative assessment of perfusion based on signal brightness. Quantitative perfusion mode was used to assess relative perfusion to tissue of interest compared to a control area with similar tissue type outside of the studied area. Real-time perfusion was visualized as percentage of perfusion relative to control. In case 1, the graft bed was assessed during dorsal onlay graft substitution urethroplasty. Perfusion to graft bed was compared to that of erectile bodies proximally. A proposed perfusion cutoff of 60% was noted to correlate with clinical judgment of graft bed quality. In case 2, tissue perfusion of Blandy flap in perineal urethrostomy was assessed before and after mobilization. A cutoff of 40% was proposed based on existing flap-based reconstruction literature with the goal to tailor flap and ultimately avoid tissue ischemia and necrosis. In case 3, in a complex staged substitution urethroplasty after hypospadias repair, the use of ICG facilitated a limited excision and shorter graft inlay in this staged reconstruction. The application of near-infrared fluorescence tools in open genitourinary reconstruction has the potential to advance quantitative assessment of graft, flaps, and other critical tissue planes, and help establish meaningful perfusion threshold and correlate with clinical outcomes. [ABSTRACT FROM AUTHOR]

To describe the characteristics, management, and functional outcomes of patients with synchronous urethral stricture disease (SUSD) utilizing a multi-institutional cohort. 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. 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. 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. [ABSTRACT FROM AUTHOR]

To determine surgical outcomes in a large of cohort men undergoing robotic-assisted posterior urethroplasty (RPU), which has been described in small series as a viable option. We performed a retrospective review of all 105 men who underwent RPU from October 2014 to August 2022 at a single institution. We evaluated postoperative outcomes, including complications; surgical success defined as no need for reintervention; and incontinence requiring artificial urinary sphincter placement. We performed descriptive statistics and chi-square testing to determine if outcomes were associated with certain posterior urethral disease etiologies. Mean follow-up time was 18.7 months. Over half of patients (57.1%) received prior pelvic radiation. The most common reconstructive techniques were excision and primary anastomosis (n = 45, 30.0%), resitting of the bladder neck (n = 26, 24.8%), Y-V plasty (n = 21, 20.0%), and buccal mucosal graft urethroplasty (n = 14, 13.3%). Forty-one patients (39.0%) required a combined abdominoperineal approach. Seven patients (6.7%) had ≥CD grade 3 complications within 30 days. Thirty patients (28.6%) developed incontinence with subsequent artificial urinary sphincter placement. One-quarter (24.8%) of patients required at least one subsequent surgical reintervention. In the largest RPU cohort to date, surgical success rates were similar and continence rates were improved compared to open surgery and align with existing robotic series, adding to the growing body of evidence demonstrating advantages of RPU. [ABSTRACT FROM AUTHOR]

To demonstrate a new minimally invasive endoscopic approach to urethroplasty. The procedure was performed in a male patient with prior history of prostate cancer managed by radiation who subsequently developed an 8 mm flow-limiting membranous urethral stricture. After stricture dilation a 1 cm wide strip of superficial mucosa was resected from the bladder neck past the area of stricture, creating a bed for the graft to lay. Buccal mucosa graft was harvested in standard fashion. With the graft outside the urethra and using the RD 180 endoscopic suturing device, a suture is placed in the proximal end of the graft, then through the bladder neck, and back through the graft. As the suture is pulled, the pulley phenomenon advances the graft into place on the bladder neck. The graft is then anchored to the posterior urethra with secure straps. A catheter is placed to hold the graft flat during the healing process. The procedure lasted 2.5 hours without any complications. Estimated blood loss was 50cc, and the patient was discharged after the procedure. Catheter was removed at 4 weeks. Cystoscopy at 10 weeks post-op showed good graft viability, with peak flow improving to 20 mL/s compared to 4 mL/s preoperatively. At 6 months, he continues to do well without evidence of recurrent urethral stricture. Endoscopic urethroplasty using buccal graft appears to offer a safe and effective repair option for management of ureteral strictures. [ABSTRACT FROM AUTHOR]

To compare outcomes of monopolar incision and Allium Round Posterior Stent (RPS) insertion for the treatment of recurrent vesicourethral anastomosis stricture. Having a suprapubic catheter and an obstructed pattern with a peak flow rate (PFR) ≤12 mL/s on uroflowmetry were the indications for the surgery. Once the fibrotic vesicourethral anastomosis was incised, RPS was inserted at the level of vesicourethral anastomosis under fluoroscopic guidance. All the stents were removed at postoperative first year. Patients were evaluated 3 months after stent removal. Objective cure was defined as no need to further treatments and PFR ≥12 mL/s while subjective cure was defined as having points <4 on Patient Global Impression of Improvements scale. Of the 30 patients with a median age 66 (52-74) enrolled in the study, 18 had a suprapubic catheter, remaining 12 had median PFR 5.2 (2-10) mL/s. Stent migration was noted in two patients, these stents were replaced by new ones. Stone formation was diagnosed in one patient, a pneumatic-lithotripsy was performed. The median follow-up time was 28 (4-60) months following stent removal. Six cases needed further treatment after removal. The median PFR of remaining 24 patients was 20 (16-30) mL/s (P =.001). The objective cure rate was 24/30(80%), the Patient Global Impression of Improvements scores varied from 1 to 2, meaning subjective cure rate was 24/30(80%). For the six failed cases, according to patient preferences a lifetime RPS insertion was planned. With its minimally invasive nature, reversibility, and acceptable success and complication rates, incision of anastomosis and insertion of the RPS for a 1-year duration is a promising option for the treatment of recurrent vesicourethral anastomosis stricture. [ABSTRACT FROM AUTHOR]

To report our experience with 71 postphalloplasty urethral strictures in order to discuss the performance characteristics of different urethroplasty techniques in urethral stricture after phalloplasty. We conducted a retrospective chart review of 85 urethroplasties performed for stricture repair in 71 patients with phalloplasty for gender affirmation between August 2017 and May 2020. Stricture location, urethroplasty type, complication rate, and recurrence rate were recorded. The most common stricture type was distal anastomotic (40/71, 56%). The most common initial repair type was excision and primary anastomosis (EPA) (33/85, 39%), followed by first-stage Johanson urethroplasty (32/85, 38%). The stricture recurrence rate after initial repair of all types was 52% (44/85). The recurrence rate of stricture after EPA was 58% (19/33). The recurrence rate after staged urethroplasty was 25% (2/8) for patients who successfully completed a first and second stage. 30% (3/10) of patients who completed a first stage and opted out of a second stage required a revision to achieve successful lifetime voiding from the surgical urethrostomy. EPA after phalloplasty has a high failure rate. Nontransecting anastomotic urethroplasty has slightly lower failure rate, and staged Johanson-type surgeries have the highest success rates after phalloplasty. [ABSTRACT FROM AUTHOR]

Placement of a temporary urethral stents after urethrotomy is a safe procedure with satisfactory results. Complications were unremarkable in 85% of our cases. A stent indwelling time longer than 6 mo provides better outcomes. Recent years have seen the development of a new generation of temporary urethral stents as an adjuvant option after direct vision internal urethrotomy (DVIU). Despite some early promising results, large series addressing their safety and outcomes are still lacking. To report complications and outcomes from the largest series of patients receiving a temporary bulbar urethral stent to date. We performed a retrospective analysis of bulbar urethral stenting procedures after DVIU in seven centers. Patients either refused urethroplasty or were not fit for surgery. The stents were removed after at least 6 mo in place unless complications requiring earlier removal occurred. DVIU with a cold knife or laser is performed, followed by stent placement. At the end of the treatment period, the stent is removed under cystoscopy with gripping forceps. All patients underwent postoperative follow-up (FU) for assessment of complications while the stent was in place. After removal, the FU schedule consisted of office evaluation at 6 mo and 12 mo, and then annually. Failure was defined as any treatment for urethral stricture after stent removal. A total of 49% of the patients experienced complications. The most frequent were discomfort (23.8%), stress incontinence (17.5%), and stent dislocation (9.8%). Some 85% of the adverse events observed were Clavien-Dindo grade <3. The overall success rate at median FU of 38.2 mo was 76.9%. The success rate was significantly lower if the stent was removed before 6 mo (53.3% vs 79.7%; p = 0.026). Temporary urethral stents may be a safe choice with satisfactory results in patients not undergoing urethroplasty. A stent indwelling time shorter than 6 mo provides worse outcomes that are comparable to those with DVIU alone. We assessed complications and outcomes after placement of a temporary narrow tube in the urethra after surgery to widen a narrowing of the urethra. The treatment is safe and easily reproducible with satisfactory results. Further studies are needed to confirm our findings. [ABSTRACT FROM AUTHOR]

Hepaticojejunostomy anastomotic stricture (HJAS) is an adverse event after pancreatoduodenectomy (PD) which can result in jaundice and/or cholangitis. With endoscopy, HJAS can be managed. However, few studies report the specific success and adverse event rates of endoscopic therapy after PD. Patients with symptomatic HJAS, who underwent an endoscopic retrograde cholangiopancreatography at the Erasmus MC between 2004-2020, were retrospectively included. Primary outcomes were short-term clinical success defined as no need for re-intervention <3 months and long-term <12 months. Secondary outcome measures were cannulation success and adverse events. Recurrence was defined as symptoms with radiological/endoscopic confirmation. A total of 62 patients were included. The hepaticojejunostomy was reached in 49/62 (79%) of the patients, subsequently cannulated in 42/49 (86%) and in 35/42 patients (83%) an intervention was performed. Recurrence of symptomatic HJAS after technically successful intervention occurred in 20 (57%) patients after median time to recurrence of 7.5 months [95%CI, 7.2–NA]. Adverse events were reported in 4% of the procedures (8% of patients), mostly concerning cholangitis. Endoscopic treatment for symptomatic HJAS after PD has a moderate technical success rate and a high recurrence rate. Future studies should optimize endoscopic treatment protocols and compare percutaneous versus endoscopic treatment. [ABSTRACT FROM AUTHOR]

• We described that biliary reconstruction for multiple graft bile duct didn't have higher incidence of biliary complications compared to biliary reconstruction for single graft bile duct under our polices. • Moreover, biliary reconstruction using high biliary radicals for multiple graft bile ducts was not associated with a higher incidence of biliary complications under our strategies and that could be a safe option during living donor liver transplantation. • Dunking with mucosal eversion technique could be replace unification ductoplasty in cases with two close spaced ducts or two orifices located on the same hilar plate. Multiple graft duct openings are associated with a high incidence of biliary complications (BCs), and biliary reconstruction for multiple graft bile ducts (BDs) remains a surgical challenge during living donor liver transplantation (LDLT). In particular, biliary reconstruction using "high biliary radicals (HBR)" of recipients for multiple graft BDs has a high probability of BCs. Herein, we analyzed outcomes by retrospectively reviewing 283 patients who underwent right lobe LDLT from January 2013 to September 2019. In total, 112 LDLT procedures using grafts with multiple BDs have been performed under our policies. In recent cases with 2 orifices located on the same hilar plate, we did dunking with a mucosal eversion technique instead of ductoplasty. When 2 orifices are located far apart on different hilar plates, we attempted to perform separate duct-to-duct anastomosis (DDA) using HBR of the recipient instead of hepaticojejunostomy. Among patients with multiple graft BDs, 20 underwent ductoplasty, 50 were treated using dunking with mucosal eversion technique, and 40 underwent separate DDA using HBR (HBR group). The incidence rates of biliary leakage and stricture were 8.9% and 10.7% in the multiple BD group, respectively, congruent with the outcomes of the single BD group. In subgroup analysis, we compared clinical outcomes between the HBR and single BD groups; the incidence of BCs in the HBR group was 15.0%, comparable to that of the single BD group. In conclusion, multiple graft BDs do not negatively impact the BC rate compared with single-graft BD when applying our technique to prevent BCs. [ABSTRACT FROM AUTHOR]

To demonstrate a technique for minimally invasive endoscopic management of posterior urethral strictures, including those at the bladder neck and vesicourethral anastomosis. Herein, we have included endoscopic video footage from 3 patients with posterior urethral strictures, including 1 at the bladder neck, 1 at the vesicourethral anastomosis, and 1 in the bulbomembranous urethra. In each patient, we perform a direct visualization internal urethrotomy (DVIU) with incisions at the 5 and 7 o'clock positions to widen the urethral lumen, followed by injection of 2 mg mitomycin C (MMC) in a total volume of 5 mL sterile water. Herein, we describe our technique for the endoscopic management of posterior urethral strictures, including those in the prostatic urethra and bladder neck. MMC injection, in conjunction with traditional DVIU, adds minimally to the complexity and length of the procedure but may substantially improve long-term surgical outcomes. Bladder outlet obstruction due to stenosis or stricture of the posterior urethra is a common urologic diagnosis whose etiology can often be traced to prior urethral manipulation or iatrogenic trauma. While Americal Urological Assicuation (AUA) guidelines state that dilation or direct visualization internal urethrotomy (DVIU) should be offered for bulbar strictures measuring less than 2 cm in length, recent evidence suggests that DVIU with or without MMC injection may have utility in the management of bladder neck or vesicourethral anastomotic contractures. We have found that DVIU with subsequent MMC injection is a viable minimally invasive approach for the treatment of posterior urethral strictures. While more data are needed to better understand the long-term success rates of these procedures, this approach should be considered for patients with a bladder outlet obstruction secondary to a short stricture of the posterior urethra, bladder neck, or vesicourethral anastomosis. [ABSTRACT FROM AUTHOR]

1) To describe the authors' technique of anterolateral thigh (ALT) phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort. Following IRB (Institutional Review Board) approval, retrospective chart review identified all patients undergoing primary three-stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split-thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications. Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split-thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least 1 urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%). ALT phalloplasty with split-thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender-affirming phalloplasty. [ABSTRACT FROM AUTHOR]

To report the technique and outcomes of tissue expansion (TE) for generating additional penile skin for urethroplasty and/or skin coverage during primary or redo hypospadias repair in penoscrotal transposition (PST) patients with a proximal hypospadias. Proximal hypospadias and PST patients with a lack of penile skin, congenitally or after failed repair, who underwent TE assisted reconstruction were reviewed. TE were placed under the penile shaft and expanded skin was used for tubularized incised plate repair. Success was defined as urethral advancement to the corona or more distal with tension free skin coverage. A total of 24 patients underwent reconstruction including 16 as part of primary repair and for redo repairs in 8. Nine patients experienced expander extrusion and posturethroplasty complications occurred in 43.8% of primary repairs and 75.0% of redo repairs; a urethrocutaneous fistula was most common (n = 8). Overall, success was achieved in 87.5% of patients with postoperative meatal locations almost all coronal (45.8%) or glanular (50.0%). Proximal hypospadias reconstruction is challenging, and complications are not infrequent. TE is a useful alternative for complex patients with a skin paucity such that cutaneous coverage would be difficult following urethroplasty. Although the complication rate was 43.8% for primary repair, TE generated sufficient residual skin for success after additional reconstruction. For redo repair early use is most beneficial as there is more expandable skin. The pseudocapsules provide vascularized coverage to reinforce the urethra while there is sufficient skin to minimize the need for a skin graft for penile coverage. [ABSTRACT FROM AUTHOR]

To synthesize existing evidence to evaluate the outcomes of different urinary catheter removal timing (early vs late) after urethroplasty. We performed a comprehensive search of PubMed, Embase, the Cochrane Library, and Web of Science from inception to August 7, 2022. Articles were initially screened by title, abstract, and subsequently by a full paper review before being included in the final analysis. All comparative studies that assessed the association between urethral catheterization duration and frequency of extravasation and recurrence rate in patients who underwent urethroplasty were included in the analysis. Exclusion criteria were case reports, case series, letters to editors, and non-English studies. The risk of bias was assessed using the Newcastle-Ottawa Scale. Of the 439 relevant records in the literature databases, 5 studies involving 634 patients were included. In all 5 studies, the extravasation rate was not significantly different between the early and late catheter removal groups. Among the 3 studies that reported recurrence rates, the recurrence rate was low, with no statistically significant difference between the early and late catheter removal groups. Wound and urinary tract infections were among the most common complications, with a higher rate in patients with late catheter removal. Early catheter removal following urethroplasty does not increase the rate of extravasation or recurrence during long-term follow-up. The existing evidence can serve as the foundation for additional research with a larger sample size. [ABSTRACT FROM AUTHOR]

To determine which patient-reported symptoms are associated with satisfaction after urethroplasty. From 2011 to 2018, patients were offered enrollment in a prospective study assessing patient-reported outcomes after urethroplasty. Outcomes were assessed preoperatively and 6-months postoperatively including patient satisfaction, voiding function (International Prostate Symptom Score), erectile function (International Index of Erectile Function 5) and ejaculatory function (ejaculatory component of brief sexual function inventory). Additionally, penile curvature/appearance, genitourinary pain, postvoid dribbling, and standing voiding function were also evaluated using either 3 or 5 point Likert scales. Stricture recurrence was defined as the inability to easily pass a 16Fr flexible videocystoscope. Multivariable binary logistic regression was used to examine the associations between outcomes and patient satisfaction. A total of 387 patients completed the study with a mean age of 49.5 years and a mean stricture length of 4.5 cm. Location was bulbar (59.4%), penile (19.6%), posterior (13.7%) and pan-urethral (7.2%). At 6-months, 96.1% of patients were stricture-free, 81.6% reported being satisfied with surgery and 8% were unsatisfied. On multivariable binary logistic regression, improvement in International Prostate Symptom Score (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.1-1.2, P =.04), new erectile dysfunction (OR: 0.5, 95% CI: 0.2-0.9, P =.04), new penile curvature (OR: 0.4, 95% CI: 0.2-0.9, P =.03) and improved standing voiding function (OR: 1.3, 95% CI: 1.1-1.5, P =.004) were associated with patient satisfaction. Cystoscopic success (P =.60), change in pain score (P =.14), postvoid dribbling (P =.69), change in penile length (P =.44), and ejaculatory dysfunction (P =.51) were not. Improved voiding function, patient-reported penile curvature, new erectile dysfunction and improved standing voiding are independently associated with patient satisfaction after urethroplasty and should be incorporated into any patient-centered approach to urethral stricture management. [ABSTRACT FROM AUTHOR]

To report our experience and outcomes using a novel robotic technique for the simultaneous repair of rectovesical fistula (RVF) with vesicourethral anastomotic stricture (VUAS) after radical prostatectomy (RP). Between 2019 and 2021, four consecutive patients who underwent robotic-assisted simultaneous repair of RVF with concurrent VUAS after RP were retrospectively reviewed. Baseline characteristics and perioperative outcomes were examined and reported. Complications were graded using the modified Clavien-Dindo classification system and the European Association of Urology Complications Panel Assessment and Recommendations. Four cases with a median age of 68.5 (63.3-72.3) years were treated. Interposition omentum flaps were used in all our cases. One case had perineal urethral mobilization to reach healthy urethral margins and tension-free vesicourethral anastomosis. Surgeries were uneventful, with no intraoperative complications reported. Median operative time, estimated blood loss, and length of hospital stay were 370 (291.3-453) minutes, 255 (175-262.5) mL, and 2.5 (2-3) days, respectively. Median Jackson-Pratt drains, Double-J stents and Foley catheter removal days were 6 (6-10), 38 (32-43), and 30 (27-41) days, respectively. No postoperative complications were reported. The median follow-up time was 16.25 (12-26) months, and no fistula recurrence was shown. Robotic-assisted laparoscopic repair could represent an effective approach for the simultaneous repair of RVF with concomitant VUAS. More studies and management standardization are needed to assess the role of the robotic platform in the simultaneous repair of RVF with VUAS after radical prostatectomy. [ABSTRACT FROM AUTHOR]

Urethral stricture disease is a commonly presenting problem to the urologist. Any condition that damages the urethral epithelium or underlying spongy tissue has the potential to cause a stricture. Patients with a urethral stricture can present either acutely or chronically with a range of urinary symptoms. An understanding of urethral stricture disease and a systematic approach to the history and investigations will enable clinicians to manage patients appropriately. This article aims to give an overview, appropriate for surgeons in their early years of training, on the aetiology, presentation and investigation of urethral stricture disease, as well as a basic understanding of the principles of management. [ABSTRACT FROM AUTHOR]

The Glanular-Frenular Collar (GFC) technique has evolved since it was first described in 2017. The technique involves reconstruction of the septum glandis , which has been overlooked in the history of hypospadias, and formation of the frenulum, creating the ventral wall of the glanular urethra without dissecting the glans, leaving room for the formation of the navicular fossa. We present a case of distal hypospadias corrected with the GFC technique and demonstrate the important steps of the surgical technique. The aesthetic result corresponded to the normal anatomy of the glans and frenular triangle, and the functional result showed a free and wavy shape of urine that resembled the normal flow from the urethra. In the normal anatomy of the penis, the wings of the glans are separated ventrally by the septum glandis and the frenulum. The navicular-shaped glanular urethra and its vertical, elliptical opening are covered by the fibroelastic septum glandis, unlike the penile urethra, which is surrounded by the corpus spongiosum. Reconstruction of hypospadias should include the formation of a septum glandis , frenulum, and navicular fossa. The GFC technique demonstrates the importance of a dual surgical approach for glanular and penile urethra reconstruction. [ABSTRACT FROM AUTHOR]

To determine if there are histologic differences relative to tobacco exposure in buccal mucosa. Substitution urethroplasty outcomes may be worse in tobacco users and we investigate if the buccal graft is inherently damaged due to chronic tobacco exposure. Subjects undergoing substitution urethroplasty with buccal graft harvest were prospectively consented in this IRB approved study. Subjects with poor dentition were excluded. A detailed tobacco use history was obtained. Cotinine testing was performed day of surgery to confirm or exclude active tobacco use. Trimmed portions of harvested graft were sent for tissue processing. Standard hematoxylin and eosin staining was performed. A single blinded pathologist performed analysis of the slides. Using a scale of none, mild, moderate, or severe slides were analyzed for cytologic atypia, architectural complexity, inflammation, and keratinization. Evidence of vascular damage was noted and the type of inflammation if present was classified. Twenty-five buccal grafts were analyzed. No evidence of vascular damage or cytologic atypia were noted in any grafts. While mild architectural complexity and mild inflammation, typically lymphocytic, were noted in several of the buccal mucosa sections, this did not appear to correlate with tobacco exposure. The majority of grafts demonstrating increased keratinization correlated with significant tobacco exposure, but this was not consistently noted in all those with tobacco use. Buccal mucosa in patients with tobacco exposure did not show significant histologic alterations. Outcomes of substitution urethroplasty may be more impacted by persistent systemic exposure causing local ischemia as opposed to the graft tissue itself. [ABSTRACT FROM AUTHOR]

Objective: To assess the incidence of genital pain in patients with urethral stricture and examine the impact of urethroplasty. Genital pain is a common and challenging urological condition and potentially associated with urethral stricture.Methods: From 2011-2019, patients were offered enrollment in a prospective single-center study assessing patient-reported genital pain pre- and 6-months posturethroplasty. Genital pain was assessed with the question, "Do you experience genital (scrotum or penis) pain?" answered on a five-point scale ["Never" (1), "Occasionally" (2), "Sometimes" (3), "Most of the Time" (4) or "All of the Time" (5)]. Responses of 3, 4, or 5 were considered clinically significant. Wilcoxon signed-rank test was used to compare pre- and postoperative states and logistic regression was used to evaluate the association between genital pain and clinical variables.Results: Of the 387 patients completing enrollment, 36.4% (141/387) reported genital pain preoperatively. Patients with panurethral stricture reported higher rates (57.1%) of pain (Odds Ratio 2.93, 95%CI 1.32-6.50; P = .008). Posturethroplasty, pain scores improved with an incidence of 14.2% (P < .0001). In patients reporting preoperative pain, 88.7% (125/141) experienced improvement, 8.5% were unchanged and 2.8% reported worsening pain. On logistic regression, patients with penile strictures (O.R. 0.24, 95%CI 0.06-0.91; P = .04), hypospadias (O.R. 0.14, 95%CI 0.02-0.88; P = .04), and staged reconstruction (O.R. 0.22, 95%CI 0.05-0.90; P = .04) were less likely to report improvement.Conclusion: Genital pain is common in patients with urethral stricture and improves in the majority of patients undergoing urethroplasty but less so in patients with penile strictures, hypospadias and staged reconstruction. [ABSTRACT FROM AUTHOR]

There has been rapid evolution in management of urethral strictures in the last 3 decades. From the era of dilatation, we have moved to urethral reconstruction. Reinvention of buccal grafts changed the outcomes of urethroplasty. Barbaglis dorsal onlay popularised stricture management across the globe. Kulkarni described a single stage surgery for panurethral stricture. Advances have taken place, and we have moved from transecting to the non-transecting approaches. We describe the various advances in urethral reconstruction in the last decade. [ABSTRACT FROM AUTHOR]

• Management of pediatric patients with pelvic fracture urethral injury is challenging and associated with controversy. • There are choices between immediate primary re-alignment and delayed urethroplasty via suprapubic cystostomy. • Both methods had no advantage nor disadvantage in statistical analysis however, it may be advantageous to consider PR in some practical settings. The management of pediatric patients afflicted with pelvic fracture urethral injury (PFUI) remains a topic of ongoing debate and controversy within the realm of urology. There is persistent discourse concerning the optimal timing for intervention, specifically between immediate primary realignment (PR) and delayed urethroplasty via suprapubic cystostomy (SCDU). This study was undertaken with the objective of conducting a systematic review of the existing body of evidence, with a focus on comparing the outcomes associated with PR and SCDU as interventions for PFUI among pediatric population. A systematic search across databases (PubMed, ScienceDirect, Web of Science and Cochrane Library) was conducted without time or language limitations. Both medical subject heading and free text terms as well as variations of keywords were searched. Randomized controlled trials (RCTs), nonrandomized comparative studies and single-arm case series were included. Data were narratively synthesized considering methodological and clinical heterogeneity. The risk of bias of each included study was assessed. From 1,776 identified articles, 5 studies encompassing 95 PR and 180 SCDU pediatric patients met our eligibility criteria. All studies were non-randomized comparative studies. In general, included studies were of moderately quality. Follow-up durations ranged from 3 to 204 months. Meta-analysis demonstrated that PR and SCDU had similar stricture rates (OR = 0.63, [95 %CI 0.29–1.36], p = 0.24), similar rates of urinary incontinence (OR = 0.65, [95 %CI 0.28–1.48], p = 0.3), and similar rates of ED (OR = 0.59, [95 %CI 0.23–1.53], p = 0.28). This study demonstrated that primary realignment procedure did not yield superior outcomes in terms of stricture formation, urinary incontinence, and rates of erectile dysfunction compared to SCDU in pediatric populations with PFUI. It is noteworthy that the predominant inclusion of non-randomized retrospective studies in this analysis introduces a potential for bias. Consequently, there is a pressing requirement for further high-quality research, notably prospective studies and randomized controlled trials, to bolster the robustness of the existing evidence base. [ABSTRACT FROM AUTHOR]

Objective: To review and report data on transformation to urethral carcinoma after urethroplasty for urethral stricture disease. Primary urethral carcinoma is a rare entity, and guidelines lack high quality data from which to cite. Urethroplasty is a highly effective treatment for urethral stricture disease, though in rare cases complications may include development of urethral carcinoma.Methods: A systematic PubMed search was performed to identify all articles describing patients with urethral carcinoma after urethroplasty. Data were collected on the following parameters: patient age and sex, indication for urethroplasty, presentation of cancer, imaging, pathology, presence of metastasis, intervention, and outcome.Results: The final cohort included fourteen patients, 13 from previously published cases and one from our institution. The median patient age at presentation was 60, most had endoscopic management prior to urethroplasty, and the majority presented with decreased urinary stream. All patients developed squamous cell carcinoma of the urethra. Patients underwent radical resection, lymph node dissection, chemotherapy, or radiotherapy, often in combination. A majority of patients had died at the time of case report.Conclusion: Development of urethral squamous cell carcinoma, particularly after urethroplasty, is a rarely encountered process. Patients and urologists must have a high index of suspicion and investigate symptoms such as fistula or lower urinary tract symptoms, even if these occur many months or even years after buccal mucosa graft . By compiling previously reported cases and adding an additional case to the literature, we hope that familiarity with this entity will lead to earlier recognition and diagnosis of disease. [ABSTRACT FROM AUTHOR]

Background: Single-layer ACell Cytal matrix (ACell Inc, Columbia, MD) is a commercially available, acellular scaffold derived from porcine bladder epithelial basement membrane and tunica propria. We describe our initial experience using Cytal as corporal graft in pediatric patients who underwent correction of ventral curvature in proximal hypospadias repair.Methods: A retrospective review of a single-institution, 4 surgeon hypospadias database was performed between January 2020 and December 2021. Outcomes assessed were postoperative recurrent ventral curvature, corporal diverticulum, scarring on corporoplasty site on physical exam, and parental reports of atypical adverse effects.Results: Ten males underwent correction of ventral curvature with Cytal as corporal graft for correction of ventral curvature were identified. All completed planned operations. Median age was 18.6 months (IQR 14.6-27.0). Median follow up was 14.1 months (IQR 8.9-16.5). Mean ventral curvature after degloving was 80 ± 50 degrees. All patients had straight erections. Nine of the 10 patients had straight erections verified at a subsequent artificial erection test at least 6 months from the corporoplasty (90%). The remaining patient underwent a double face onlay-tube-onlay transverse island preputial flap as a single-stage hypospadias repair and did not require any additional procedures. He had straight erections per parental history. None developed corporal diverticulum or demonstrated induration at site of corporoplasty on physical exam. There were no parental reports of atypical adverse systemic effects.Conclusion: In the short term, single-layer Cytal is effective as corporal graft for correction of ventral curvature in proximal hypospadias repairs without incurring additional donor site morbidity. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To describe the novel gullwing technique for artificial urinary sphincter (AUS) placement. The transcorporal technique for AUS placement is beneficial in patients with 'fragile urethras' (previous failed AUS, urethroplasty or history of radiation) however limitations include insufficient lateral and ventral urethral support in addition to potential cinching during corporotomy closure which, in the absence of additional grafting may restrict our ability to conserve internal corporal capacity and limit options for future preservation of erectile function via penile prosthesis placement. The gullwing variation of the technique offers the potential to circumvent these disadvantages.Materials and Methods: This case describes the gullwing variation of transcorporal AUS placement in a complex patient with a history of abdominopelvic trauma and prior failed AUS placements secondary to urethral erosion.Results and Conclusion: Transcorporal AUS placement in patients with prior urethral compromise has been shown to result in lower revision and erosion rates. The gullwing modification of the technique is a novel variation providing improved circumferential urethral protection and, with the addition of corporal grafting, aims to enable the preservation of the three-dimensional corporal volume necessary for ease of subsequent penile prosthesis implantation. However, studies assessing the long-term functional outcomes and durability of this technique are needed. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the results and related factors of tubularized incised plate (TIP) urethroplasty at two institutions.Methods: This was a prospective cohort analytical study conducted over a period of 12 months. All patients who underwent TIP urethroplasty in the specified period were studied. Quantitative and qualitative data of the intrinsic parameters of the penis were obtained and patients were followed for an average period of 14.72 ± 3.67 months (range 9-21months) after surgery.Results: One hundred twenty-nine patients (N = 129) were included in the study. The mean age at surgery was 50.93 months. The mean glans size and pre-incised urethral plate width were 14.34 mm and 8.38mm respectively. The post-operative results were satisfactory with the meatus in a glanular position in 122(94.6%) patients. Overall, 49 patients (38%) developed complications. Eighteen patients (14%) developed early complications whereas forty-two (32.6%) patients had late complications. UCF and Meatal stenosis occurred in 27 (20.9%) & 14 (10.9%) patients respectively. Seven patients developed recurrent hypospadias and dehiscence of glans occurred in eight patients (6.2%).Conclusion: TIP can be used to repair for all types of hypospadias in the absence of severe penile curvature. It has more complication rate in proximal than distal hypospadias. Distal hypospadias were the most common type of hypospadias corrected with TIP. UCF and meatal stenosis were the most common complication followed by glans dehiscence and recurrent hypospadias. Glans size, age at surgery, plate width, location of meatus and stretched penile length were the most determinant factors for the outcome. [ABSTRACT FROM AUTHOR]

Objective: To determine the utility of post-operative imaging after ureteroneocystostomy and whether long-term symptom or radiographic surveillance aided in the detection of recurrent obstruction.Materials and Methods: Adult patients were identified who underwent a ureteroneocystostomy with or without psoas hitch or Boari flap between January 2012 and June 2021. Patients who underwent a bilateral procedure, had active malignancy or immediate failure, or did not have 6 months of follow-up with 2 imaging studies were excluded. Using the initial imaging study after stent removal, patients were categorized into normal and equivocal groups according to predefined radiologic criteria. Patients were followed longitudinally to determine whether they subsequently developed radiographic evidence of obstruction. Follow up visits were reviewed for patient symptoms suggestive of post-operative obstruction, defined as flank pain, hematuria, or pyelonephritis.Results: One hundred and twelve patients met criteria. Normal and equivocal initial imaging was seen in 99 and 13 patients, respectively. At a mean radiologic follow-up of 32 months, stricture recurrence was identified in 3 patients with normal initial imaging. No patients with initial equivocal imaging demonstrated recurrent obstruction at mean radiologic follow-up of 29 months. All patients with recurrent stricture presented with symptoms of obstruction. Of patients who developed symptoms after ureteroneocystostomy, 13.6% had recurrent stricture.Conclusion: Asymptomatic patients after ureteroneocystostomy who had either normal or equivocal post-operative imaging did not benefit from additional radiologic testing in this cohort. All patients that demonstrated failure presented with symptomatic obstruction that warranted imaging. Surgeons may consider restricting surveillance imaging to symptomatic patients after the initial post-operative period. [ABSTRACT FROM AUTHOR]

Objective: To determine the long-term success of ventral inlay buccal-mucosal graft urethroplasty (Vi-BMGU) for female urethral strictures (FUS).Materials and Methods: We performed a retrospective analysis of prospectively maintained data on patients who underwent Vi-BMGU between May 2016 and January 2020 with a minimum follow-up of 2 years. The primary outcome was the long-term success after 2 to 5 years of surgery. Patients were followed with American Urological Association (AUA) symptom score, uroflowmetry, and post-void residual (PVR) urine measurement. Failure (recurrence) was defined by an increase in the AUA symptoms score by 3 on subsequent follow-up visits and maximum flow rate (Qmax) <12 cc/s and inability to calibrate with an 18 Fr catheter.Results: Twenty-one patients were included. The Median follow-up was 42 months (range: 24-64 months). The AUA symptom scores, Qmax, and PVR, improved in all except 3 patients. The median AUA score fell from 27 (range 18-34) at diagnosis to 9 (range 6-24), at the last follow-up. Similarly, the median PVR values decreased from 138 ml (34-290) to 24 ml (19-360) and the mean Qmax improved from 7.7 ± 2.2 ml/s to 22.6 ± 5 ml/s. None experienced urinary incontinence. There were 2 failures, 1 at 6 months and the other at 24 months. The overall success rate was 90.5 %. Success rates on life table analysis were 95%, 85%, 85%, 85%, and 85% after 1, 2, 3, 4 and 5 years respectively.Conclusion: The 95% success at 1 year and 85% sustained success at 2 to 5 years of follow-up establishes the long-term success of Vi-BMGU. [ABSTRACT FROM AUTHOR]

Objective: To describe a novel single-port, endorobotic technique for harvesting rectal mucosa grafts (RMGs) for urethral reconstruction.Methods: A 57-year-old man with prior transurethral procedures developed recurrent obstructive voiding symptoms. Urethrography revealed a panurethral stricture, meatus to the bulbomembranous junction. It was decided to proceed with surgical repair. Owing to the stricture's length, available oral mucosa would require additional material, and repair with a single rectal mucosa graft was offered instead. Single-port (SP) endorobotic approach offered ideal access for transanal harvest. With the patient placed in a modified lithotomy position, a GELPOINT Path transanal access platform was inserted through the anal canal. Pneumorectum was established at 12 mmHg with an AirSeal CO2 insufflator. A Da Vinci SP surgical system was docked, equipped with Maryland bipolar forceps and a monopolar spatula. After injection of ORISE gel, endorobotic submucosal dissection began posteriorly proximal to the dentate line.Results: Proceeding cranially through the rectal submucosa, a 21 ✕ 3 cm strip of mucosa was obtained with appropriate hemostasis. The resulting graft was thoroughly thinned. The robot was undocked, and the patient repositioned to high lithotomy. The patient underwent a penis-inverting, dorsolateral approach augmentation urethroplasty. With an indwelling catheter placed, the patient was discharged on postoperative day 2 with no postoperative complications.Conclusion: Transanal rectal mucosal dissection with a single-port endorobotic approach can be an enticing and minimally invasive harvesting technique to provide substitution grafts for long-segment urethral reconstruction. [ABSTRACT FROM AUTHOR]