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Penile inversion vaginoplasty is the most common technique used for gender affirming genital surgery in the treatment of gender dysphoria among transwomen. As vaginoplasty becomes more widely available, the management of associated complications has become its own field. There is a relative dearth of literature on surgery for complications following vaginoplasty. This review illustrates surgical technique and management options for patient reported complaints and complications following vaginoplasty. The goal of this manuscript is 2-fold (1) to introduce community surgeons to common postoperative issues they may encounter and (2) provide a systematic operative approach to complications for reconstructive surgeons who see transgender patients regularly., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To describe the urologic sequalae of several rare congenital neuromuscular diseases., Methods: We retrospectively reviewed medical records at Gillette Specialty Healthcare (2014-2018) of patients presenting to urology clinic with lower urinary tract symptoms and select rare congenital diseases: muscular dystrophy, spinal muscular atrophy, and Rett syndrome., Results: Muscular dystrophies (n = 19) are X-linked myogenic disorders characterized by progressive muscle wasting and weakness. Men present to the urologist at variable ages, typically with complaints of functional incontinence and normal cystometrograms; we manage them with oral anticholinergic medications, condom catheter, or suprapubic catheter. Spinal muscular atrophy (n = 6) is a rare autosomal recessive disease characterized by degeneration of the anterior horn cells in the spinal cord and motor nuclei in the lower brainstem leading to progressive muscle weakness and atrophy. Patients typically present with nephrolithiasis and urinary retention in late adolescence/early adulthood, but timing varies. Filling cystometrograms have been normal. We allow passive retention with intermittent catheterization and creation of catheterizable channels, when indicated. Rett syndrome (n = 5) is a rare, noninheritable genetic condition affecting females characterized by a brief period of normal development followed by loss of speech and purposeful hand use; there are characteristic behaviors. Patients present in early adulthood with complaints of urinary retention. We manage retention with permissive retention or sphincter chemodenervation., Conclusion: Several congenital neuromuscular conditions can cause lower urinary tract symptoms when these individuals become adults. We have discussed the clinical characteristics and management of select neurogenic and myogenic bladder conditions seen in adults with congenital conditions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To examine the utility of the Neurogenic Bladder Symptom Score (NBSS) in adults with cerebral palsy (CP)., Methods: Patients participated in a structured intake which included bladder management. Patients (or caregivers, if patients unable) completed NBSS and SF-Qualiveen twice over a 2-week period. Validity was determined using Cronbach's alpha and correlation testing between NBSS, intake, and SF-Qualiveen. Reliability was determined using test-retest method and intraclass correlation coefficients., Results: Fifty-four patients were included. Thirty-six patients (67%) used a wheelchair; 35 patients (66%) required a caregiver to complete questionnaires. Median NBSS subdomain scores were 12 of 29 for incontinence, 9 of 22 for storage and/or voiding, 2 of 23 for consequences and 1 of 4 for quality of life (QOL). Lower scores reflect fewer symptoms. Reliability was high (intraclass correlation coefficients = 0.90). There was a moderate correlation (R = 0.70) between NBSS QOL and SF-Qualiveen. Bladder management method, as determined by the NBSS, was indwelling catheter in 4, intermittent catheterization in 6, voiding into a toilet in 33, and missing in 11. Importantly, there was no option for voiding into a diaper, which was common in this population., Conclusion: For adults with CP, the NBSS has high reliability and statistically, it demonstrated appropriate validity, but it has limitations. Its face validity is questionable given that diapers were not an option. The validity of caregiver completion needs further assessment. The NBSS may have a floor effect for detecting urinary consequences or QOL, reflected by consistently low scores in these subdomains. The development of a specific urinary symptom and/or QOL tool for adults with CP is needed., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To propose a simple classification system for buried penis repairs and present an analysis of perioperative data based on category., Methods: Patients undergoing buried penis repair at a single institution were examined. Classification was as follows: Category I-penile unburying with local flap; II-skin graft; III-scrotal surgery; IV-escutcheonectomy; V-abdominal panniculectomy. Complex repairs were Category III or above. Success was defined as an unburied penis without additional unburying surgery., Results: Between 2007 and 2017, 64 patients underwent repair with 44 (69%) considered complex. Patients undergoing complex repairs had a higher body mass index (median 48 vs 36 kg/m 2 , P < .01). A total of 30 patients (47%) had urethral strictures, with no association to buried penis complexity (P = .43). High-grade complications (Clavien ≥ 3) occurred in 10 patients (23%) in the high-complexity group with none in the low-complexity group (P = .02). Seven of 10 (70%) of high-grade complications were wound related. Successful unburying was seen in 58 patients (91%). All failures occurred in the high-complexity group. Median follow-up was 209 days., Conclusion: Buried penis repairs are highly successful. We propose a classification based on surgical complexity. Patients requiring complex repairs have higher body mass index and increased risk of high-grade complications. While urethral strictures are found in nearly half of patients, there is no association with the severity of disease. Ongoing modifications of technique and perioperative care may improve outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To describe outcomes of bone anchoring of penile implant in a neophallus with an accompanying video focusing on operative technique and salient tips for surgeons performing these procedures. Penile prosthesis insertion allows individuals with a neophallus to achieve erectile function. Lack of corporal bodies to accommodate cylinders makes anchoring of any prosthesis challenging. Anchoring the device to the pubic bone is one strategy to achieve proximal stabilization., Methods: A single-institution, retrospective chart review of 10 neophallus patients undergoing penile prosthesis placement from 2006 to 2015 was done. The pubic symphysis is exposed and corticotomy created for placement of the rear tip extender of the implant using a Stryker TPS bone drill. Anchoring sutures through the corticotomy defect, rear tip, and proximal cylinder seat the implant. The remainder of the implantation procedure mirrors that used in native tissue., Results: The overall perioperative complication rate was 20%, with a mean follow-up of 49 months. Seventy percent of the patients required reoperation, with a mean of 1.4 prosthesis revision surgeries per patient. Primary causes of revision included infection, poor fixation of the rear tip, and prosthesis failure. Despite high revision rates, 80% of the patients have fully functioning prosthesis as of last follow-up. Limitations include retrospective study design and the small patient cohort., Conclusion: Penile prosthesis placement in the neophallus is feasible and effective. A bone-anchored rear tip is an option to provide proximal stabilization. Continued efforts to minimize the need for revisions are ongoing and necessary., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To identify risk factors for ureteral injury during hysterectomy and to assess outcomes of concurrent minimally invasive vs converted to open repairs., Methods: We queried the American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2013 to identify abdominal hysterectomy (AH), minimally invasive hysterectomy (MIH), or vaginal hysterectomy. Ureteral injury was identified based on intraoperative or delayed management. Multivariate logistic regression was performed to assess the effect of hysterectomy approach on risk of ureteral injury while controlling for covariates. For patients with ureteral injury during MIH, we compared 30-day outcomes following minimally invasive vs converted open repairs., Results: There were 302 iatrogenic ureteral injuries from 96,538 hysterectomies, with 0.18%, 0.48%, and 0.04% from AH, MIH, and vaginal hysterectomy, respectively. Patients who underwent MIH were younger and had decreased comorbidities compared to patients who underwent AH (all P < .001). MIH resulted in lower overall complications (6.6% vs 14.8%, P < .001) but higher ureteral injury rate (0.48% vs 0.18%, P < .001) compared to AH. On multivariate analysis, the minimally invasive approach was associated with increased risk of ureteral injury (odds ratio 4.2, P < .001). Patients undergoing minimally invasive ureteral repairs (89%) during MIH had shorter operating room time and length of stay but similar overall perioperative complications compared to those with converted open repairs (11%)., Conclusion: Using a large national series, we show that the minimally invasive approach for hysterectomy is an independent risk factor for iatrogenic ureteral injuries. During MIH, concurrent minimally invasive ureteral repairs resulted in comparable 30-day outcomes compared to converted to open repairs., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To examine the risk factors and outcomes of BI, a rare complication of abdominopelvic surgery., Methods: We queried the National Surgical Quality Improvement Program database to identify intraoperative bladder injury (BI) defined by the Current Procedural Terminology code for cystorrhaphy from 2005 to 2013. Propensity-score matching balanced the differences between patients with BI and the controls. The factors matched included age, body mass index, race, modified frailty index, and procedure category., Results: There were 1685 cases of BI in 1,541,736 surgeries (0.11%). Although 49.5% of surgeries were performed in an open fashion, this approach accounted for 69.3% of BI (P < .001). Prior to matching, mortality rates and morbidity were increased for the BI group (P < .001). Moreover, age, recent chemotherapy or radiation or steroid history, and smoking were among the risk factors for BI (all P < .05). Resident involvement increased the odds of BI and complications after BI, but decreased the risk of readmission (all P < .05). After matching, 30-day mortality was no longer increased for patients with BI (P < .001). Patients with BI requiring repair did have increased median length of stay (6 days [interquartile range {IQR}: 3-11] vs 5 [IQR: 2-9]; P < .001) and operative time (203 min [IQR: 140-278] vs 134 [IQR: 86-199]; P < .001). BI patients were more likely to undergo reoperation (7.7% vs 5.3%; P = .005). Urine infection, sepsis, and bleeding were more likely in the BI group compared with the matched controls (all P < .001). Delayed repair was rare., Conclusion: We present the largest national series assessing iatrogenic BI and subsequent repair. BI increases 30-day complications, reoperation, and length of stay but does not increase 30-day mortality compared with matched controls. More complex surgical cases and increased baseline comorbidity were risk factors for BI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To examine 30-day outcomes of robotic-assisted and pure laparoscopic ureteral reimplantation (LUR) vs open ureteral reimplantation (OUR) in adult patients for benign disease., Methods: We identified adult patients undergoing LUR or OUR by urologists between 2006 and 2013 using the American College of Surgeons National Surgical Quality Improvement Program database, excluding those with concomitant partial cystectomy or ureterectomy. Multivariable regression modeling was used to assess for the independent association of minimally invasive surgery (MIS) with 30-day complications, reoperations, or readmissions., Results: Of 512 patients identified, 300 underwent LUR and 212 underwent OUR. Baseline characteristics including age, race, body mass index, and cardiovascular comorbidities were similar between LUR and OUR (all P > .05). Patients who underwent LUR had higher median preoperative serum creatinine (1.1 mg/dL vs 1.0 mg/dL, P = .03), increased presence of a resident (51% vs 34%, P < .01), and shorter hospitalization (1 [interquartile range 0-3] days vs 4 [interquartile range 3-6] days, P < .01) compared to patients who underwent OUR. LUR had lower overall complications (9% vs 28%, P < .01), especially with regard to transfusions (1% vs 11%, P < .01), superficial wound infections (0% vs 5%, P < .01), and urinary tract infections (5% vs 11%, P = .03). On multiple regression analyses, MIS was an independent predictor of lower overall complication rate (odds ratio [OR] 0.24 [0.14-0.40], P < .01), but was not predictive of readmission (OR 0.93 [0.44-1.98], P = .16) or reoperation (OR 2.09 [0.90-4.82], P = .10)., Conclusion: In the largest current series assessing the impact of MIS on adult ureteral reimplantation, data from the National Surgical Quality Improvement Program demonstrate that LUR results in decreased 30-day complications., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To compare outcomes after retropubic sling (RPS) in women with and without Valsalva voiding., Methods: Women who underwent RPS for stress incontinence from 2010 to 2014 were identified and their baseline characteristics were examined. Valsalva voiding was defined as abdominal straining throughout voiding on preoperative urodynamics. Sub-analysis of those with Valsalva included a subset with detrusor underactivity on urodynamics. Follow-up was at 1, 3, 6, and 12 months. Primary outcomes were rates of subjective success, revisions, complications, and voiding dysfunction. Secondary measures were Urogenital Distress Inventory (UDI-6) score, Incontinence Impact Questionnaire (IIQ-7) score, post-void residual, and pad use., Results: Subjects (n = 141) analyzed included 75 Valsalva voiders (VV) and 66 non-Valsalva voiders. At baseline, there were no differences in age, race, comorbidity, post-void residual, pad use, UDI-6, or capacity. Postoperatively, there were no differences in rates of passing initial void trial, need for clean intermittent catheterization, revisions, complications, or voiding dysfunction. No differences in pad use, UDI-6, or IIQ-7 were seen at 6 or 12 months. Within VV, no differences between patients with and without detrusor underactivity were seen for any primary or secondary outcomes (all P > .05)., Conclusion: In patients who void with Valsalva, RPS appears to be safe and effective. Between VV and non-Valsalva voiders, there were no differences in rates of subjective success, revisions, or complications, even in patients with Valsalva voiding without appreciable detrusor contraction., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To examine the national trends of simple prostatectomy (SP) for benign prostatic hyperplasia (BPH) focusing on perioperative outcomes and risk factors for complications., Methods: The National Inpatient Sample (2002-2012) was utilized to identify patients with BPH undergoing SP. Analysis included demographics, hospital details, associated procedures, and operative approach (open, robotic, or laparoscopic). Outcomes included complications, length of stay, charges, and mortality. Multivariate logistic regression was used to determine the risk factors for perioperative complications. Linear regression was used to assess the trends in the national annual utilization of SP., Results: The study population included 35,171 patients. Median length of stay was 4 days (interquartile range 3-6). Cystolithotomy was performed concurrently in 6041 patients (17%). The overall complication rate was 28%, with bleeding occurring most commonly. In total, 148 (0.4%) patients experienced in-hospital mortality. On multivariate analysis, older age, black race, and overall comorbidity were associated with greater risk of complications while the use of a minimally invasive approach and concurrent cystolithotomy had a decreased risk. Over the study period, the national use of simple prostatectomy decreased, on average, by 145 cases per year (P = .002). By 2012, 135/2580 procedures (5%) were performed using a minimally invasive approach., Conclusion: The nationwide utilization of SP for BPH has decreased. Bleeding complications are common, but perioperative mortality is low. Patients who are older, black race, or have multiple comorbidities are at higher risk of complications. Minimally invasive approaches, which are becoming increasingly utilized, may reduce perioperative morbidity., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To compare pathological characteristics, treatment patterns, and survival in patients with ductal adenocarcinoma (DC) compared to those with acinar adenocarcinoma (AC)., Materials and Methods: Using the National Cancer Database, we identified patients diagnosed with clinically localized (cN0, cM0) pure DC (n = 1328) and AC (n = 751,635) between 1998 and 2011. High-risk AC was defined as Gleason 8-10. Demographic, treatment, pathological, and survival characteristics of patients were compared., Results: Compared to patients with Gleason 8-10 AC, those with DC presented with lower mean prostate-specific antigen (10.3 vs 16.2 ng/mL, P <.001), had similar rates (11.7% vs 11.5%, P = .8) of clinical extra-capsular extension (stage ≥ cT3), and were more likely to undergo prostatectomy (54% vs 36%, P <.001). Compared to patients with Gleason 8-10 AC undergoing prostatectomy, those with DC had more favorable pathology: stage ≥ T3 (39% vs 52%, P <.001), fewer positive lymph nodes (4% vs 11%, P <.001), and fewer positive margins (25% vs 33%, P <.001). On Kaplan-Meier analysis, patients with DC had similar 5-year survival (75.0%, 95% confidence interval [CI] [71.7-78.9]) compared to those with Gleason 8-10 AC (77.1%, 95% CI [76.6%-77.6%], P = .2). On Cox multivariable analysis, patients with Gleason 8-10 AC had a similar risk of death compared to those with DC (hazards ratio = 0.92, 95% CI [0.69-1.23], P = 6)., Conclusion: In this large contemporary population-based series, patients with DC of the prostate presented with lower prostate-specific antigen, had more favorable pathological features, and similar overall survival compared to men with Gleason 8-10 AC., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To examine the outcomes of endoscopic procedures for bladder neck contracture (BNC) in the orthotopic neobladder (ONB) after radical cystectomy focusing on success rates for patients who require multiple treatments., Materials and Methods: Patients who underwent treatment for cystoscopically confirmed BNC in an ONB from 2007 to 2014 were studied. Treatment information included procedure type, use of adjuvant clean intermittent catheterization (CIC), and follow-up procedures. Procedures followed by additional interventions were categorized as failures. Success was defined as no additional surgical procedure with at least 1 year of follow-up. Procedures were classified by a number of prior endoscopic treatments., Results: Seventy-one patients underwent 155 individual endoscopic procedures (146 urethrotomy, 3 dilation, and 6 transurethral resection of bladder neck). All patients were male without prior radiation. Median follow-up after initial endoscopic treatment was 26.8 months (interquartile range: 16.6-51.7), and time to recurrence was 3.5 months (1.6-6.3). Success was experienced for 50 of 136 individual procedures (37%) after excluding 19 procedures for inadequate follow-up. Success rates remained 25%-43% even after multiple prior interventions. Adjuvant CIC was associated with a higher success rate (14/24 or 58%) compared to procedures without CIC (36/112 or 32%, P = .02). Successful outcomes were seen in 50 of 71 patients (73%) with 2 patients requiring ONB removal., Conclusion: Individual endoscopic treatments of BNC in the ONB were met with 37% success. The rate did not decrease with subsequent procedures. Adjuvant CIC improved the outcomes. Overall, a successful outcome was achieved for most patients, but the majority required more than one procedure., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To examine the epidemiology and timing of penile fracture, patterns of urethral evaluation, and risk factors for concomitant urethral injury., Materials and Methods: The National Inpatient Sample (2003-2011) was used to identify patients with penile fractures. Clinical data included age, race, comorbidity, insurance, hospital factors, timing, hematuria, and urinary symptoms. Rates of formal urethral evaluation (cystoscopy or urethrogram) and urethral injury were calculated. Multivariate logistic regression was used to identify predictors of urethral evaluation and risk factors for urethral injury., Results: A weighted population of 3883 patients with penile fracture was identified. Presentations during weekends (37%) and summers (30%) were overrepresented (both P <.001). Urethral evaluation was performed in 882 patients (23%). Urethral injury was diagnosed in 813 patients (21%) with penile fracture. There was an increased odds of urethral evaluation with hematuria (odds ratio [OR] = 2.99; 95% confidence interval [CI], 1.03-8.73; P = .045) and a decrease for Hispanics (OR = 0.42; 95% CI, 0.22-0.82; P = .011). Older age (32-41 years: OR = 1.84; 95% CI, 1.07-3.16; P = .027; >41 years: OR = 2.25; 95% CI, 1.25-4.05; P = .007), black race (OR = 1.93; 95% CI, 1.12-3.34; P = .018), and hematuria (OR = 17.03; 95% CI, 3.20-90.54; P = .001) were independent risk factors for urethral injury., Conclusion: Penile fractures, which occur disproportionately during summer and weekends, were associated with a 21% risk of urethral injury. Urethral evaluations were performed in a minority of patients. Even in patients with hematuria, 55% of patients underwent formal urethral evaluation. On multivariate analysis of patients with penile fracture, hematuria as well as older age and black race were independently associated with concomitant urethral injury., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To study the epidemiology, risk factors, and outcomes of rhabdomyolysis (RM) after major urologic surgery., Materials and Methods: The National Inpatient Sample (2003-2011) was used to identify patients who underwent radical prostatectomy, radical or partial nephrectomy, or radical cystectomy. Demographics included age, sex, race, and comorbidities. Factors examined included bleeding, hospital teaching status, minimally invasive technique, and development of RM. Multivariate logistic regression was used to identify independent risk factors of RM. Outcomes of mortality, acute kidney injury (AKI), length of stay, and charges in patients with RM were compared with those of controls., Results: A weighted population of 1,016,074 patients was identified with 870 (0.1%) developing RM, which was significantly more likely for radical or partial nephrectomy and radical cystectomy patients compared with radical prostatectomy patients. On multivariate analysis, independent risk factors for RM included younger age, male sex, diabetes, chronic kidney disease, obesity, and bleeding. Race, minimally invasive technique, and teaching status were not associated with RM when controlling for other factors. Patients with RM experienced increases in mortality, AKI, length of stay, and hospital charges., Conclusion: Rhabdomyolysis is a rare complication after urologic surgery. Risk factors include male sex, younger age, diabetes, chronic kidney disease, obesity, and perioperative bleeding. Patients who develop RM have a higher risk of AKI, mortality, prolonged hospital stay, and increased charges., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To present our operative approach and outcomes with buccal mucosal graft urethroplasty for anastomic stricture in the neophallus., Methods: All patients who underwent buccal mucosal graft urethroplasty by a single surgeon for urethral stricture in a neophallus between March 1998 and June 2013 were identified. Urethroplasties were performed using 1-stage ventral onlay buccal mucosal graft after incision of the stricture., Results: Ten patients were included in analysis. One patient underwent creation of neophallus after trauma, whereas all others were performed as gender reassignment. In all patients, strictures were located at the anastomosis between the native and the neourethra. Mean age was 39 years (range, 26-56 years). Mean stricture length was 3.6 cm (range, 2-6 cm). Median follow-up was 9.5 months (range, 2.7-84 months). At last follow-up, all the first 3 patients had stricture recurrence, whereas 5 of the next 7 patients remained free of stricture (overall success rate, 50%). A total of 11 follow-up procedures were performed for recurrent strictures in these patients, including 8 internal urethrotomies, 1 suprapubic tube placement, and 2 repeat urethroplasties. The only perioperative complication was a patient who experienced mild rhabdomyolysis, which resolved with supportive measures., Conclusion: Experience with urethral strictures in the neophallus is limited, and management is complex. Buccal mucosal graft urethroplasty may be more effective than endoscopic management, but failure remains common. Modifications in surgical approach and experience may improve outcomes., (Copyright © 2015 Elsevier Inc. All rights reserved.)