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This study aimed at comparing surgical outcomes and patient-reported donor site morbidity between lingual mucosal graft (LMG) and buccal mucosal graft (BMG) through a meta-analysis of comparative studies. A systematic literature search was performed in January 2019 including non-randomized comparative studies and randomized controlled trials (RCT). The assessed data included urethroplasty outcomes, complications, and donor site morbidities such as pain, bleeding, swelling, numbness, difficulty speaking, difficulty eating, mouth opening, and difficulty with tongue protrusion. A total of 632 patients (LMG 323, BMG 309) from 12 comparative studies (four RCTs and eight non-randomized) were included in the meta-analysis. Overall pooled effect estimates revealed no significant difference on reported surgical outcomes and operative stricture-related complications. The LMG group reported a higher proportion of patients with difficulty speaking (RR 6.96, 95% CI 2.04–23.70) and difficulty with tongue protrusion (RR 12.93, 95% CI 3.07–54.51) within 30 days post-op. In comparison, the BMG group had significantly more incidence of early post-procedural donor site swelling (RR 0.39, 95% CI 0.25–0.61) and numbness within 30 days post-op (RR 0.48, 95% CI 0.23–0.97) and 3–6 months (RR 0.52, 95% CI 0.30–0.90) post-op. The evidence suggests no overall significant difference between LMG and BMG with regard to urethroplasty outcomes at 1-year follow-up. While patients undergoing LMG urethroplasty have a higher chance of experiencing difficulty with speech and difficulty with tongue protrusion within 1 month of surgery, the BMG group is more likely to experience early donor site swelling and mouth opening difficulty within 30 days post-op, as well as oral numbness for up to 6 months.

Adult acquired buried penis (AABP) can present with concomitant Lichen Sclerosus (LS), a chronic dermatosis that may affect surgical outcomes. Our aim was to evaluate outcomes of patients undergoing AABP repair with and without LS. A retrospective cohort study was performed for AABP repair patients at a single institution from 1/1991 to 12/2017. Patient characteristics and surgical and peri-operative outcomes, including success, erectile function, and complications, were collected. Sixty-seven AABP patients with mean follow-up of 16.1 ± 20.4 months were identified. Overall surgical success was 91%. Overall surgical complication rate was 50.7% (23.9% Clavien-Dindo ≥ 3). Forty-two (62.7%) patients had concomitant LS. A higher proportion of patients with LS required a STSG (90% vs 60%, p = 0.005). There was no difference in surgical success (90.5% vs 92.0%, p = 0.999), overall complication rate (57.1% vs 40.0%, p = 0.212), Clavien-Dindo ≥ 3 complications (23.8% vs 24.0%, p = 0.999) or early complications (35.7% vs 32.0%, p = 0.797) between patients with and without LS, respectively. However, a higher proportion of patients with LS experienced late complications (33.3% vs 8.0%, p = 0.020), which were mainly related to wound healing. Satisfaction with erectile function was higher among patients with LS (59.5% vs 320%, p = 0.043). AABP patients with LS behave somewhat differently than their non LS counterparts. They are more likely to require skin graft during surgical treatment. Though surgical success and complications are similar, they do experience a higher rate of late complications from impaired wound healing. Work on improving wound healing in this population should be considered.

INTRODUCTION AND OBJECTIVE:There are few options besides diversion and SP tube for patients with urethral strictures that are non-operable. Urethral balloon dilators are a frequently overlooked opt...

Objective To compare the postprocedural oral pain scale and other patient reported oral morbidities for nonclosure vs closure of buccal mucosal graft (BMG) harvest sites through systematic review and meta-analysis of comparative studies. Methods A systematic literature search was performed in September 2018. Nonrandomized comparative studies were summarized and randomized controlled trials were evaluated according to the Cochrane Collaboration recommendations. The outcomes assessed were: pain, perioral numbness, mouth opening tightness, and impairment of oral intake. Standardized mean difference, and relative risk with corresponding 95% confidence intervals were extrapolated. Effect estimates were pooled using the inverse variance method with a random-effects model. Subgroup analysis was performed according to the shape of the BMG harvested. PROSPERO registry (CRD42016043502). Results A total of 269 patients from 4 randomized controlled trials were included for meta-analysis. Overall pooled effect estimates on the reported pain score assessed on postprocedural day 1, day 3-7 and 6 months, have shown no significant difference between the closure and nonclosure treatment groups. Subgroup analysis showed that rectangular shaped BMG harvest sites that were not closed had lower pain scores (standardized mean difference−0.90, 95% confidence interval −1.70, −0.10) on postoperative day 1. No reported short or long-term oral morbidities required further surgical intervention in either treatment group. Conclusion The evidence suggests that at 6-month follow-up, there is no overall significant difference between nonclosure and closure of BMG harvest sites. However, among rectangular shaped BMG, not closing the harvest site may lead to less immediate postoperative pain when compared to closure of the harvest site.

Supplemental digital content is available in the text., Objectives This randomized, multicenter, placebo-controlled, phase IV study assessed the efficacy and tolerability of onabotulinumtoxinA in patients with overactive bladder. Methods Patients were randomized 1:1 to onabotulinumtoxinA 100 U or placebo. Assessments over 12 weeks included: change from baseline in urinary incontinence (UI) episodes/day; proportions of patients who achieved 100% and 50% or greater reductions in UI episodes/day; proportion of patients using no incontinence pads in the previous 24 hours; and changes from baseline in micturition frequency, nocturia, urgency UI, Incontinence-Quality of Life, King’s Health Questionnaire, International Consultation on Incontinence Questionnaire—UI Short Form scores and time to request retreatment. Results Significant reductions in UI episodes/day were seen with onabotulinumtoxinA versus placebo within week 1 posttreatment (−2.9 vs −2.0, P = 0.005) through week 12 (coprimary endpoint: −3.5 vs −1.6, P < 0.001). Significantly more onabotulinumtoxinA-treated patients achieved 100% (coprimary endpoint) and 50% or greater reductions in UI episodes/day. Decreases in other urinary symptoms were also seen within 1 week with onabotulinumtoxinA that continued through at least week 12. More onabotulinumtoxinA-treated versus placebo-treated patients required no incontinence pads at weeks 1 to 12, and greater improvements in quality of life measurements were seen. Time to request retreatment was significantly longer with onabotulinumtoxinA versus placebo (30.0 weeks vs 13.1 weeks; P < 0.001). No unexpected safety signals were observed. Urinary tract infection was the most commonly observed adverse event. Conclusions Urinary symptom and quality of life improvements were observed with onabotulinumtoxinA within 1 week of treatment and were sustained for at least 12 weeks.

Aims The SUCCESS trial is a phase III study of the Vesair® balloon in the United States for female stress urinary incontinence (SUI). The purpose of this manuscript is to present the 3 month primary efficacy and tolerability outcome data. Methods The SUCCESS trial is a multi-center, prospective, single blind, randomized, sham-controlled study. Subjects were randomized on a 2.33:1 basis to either Vesair balloon placement or placebo. The primary efficacy endpoint was a composite of both a >50% reduction from baseline on 1 h provocative pad weight test and a ≥10-point improvement in symptoms on the Incontinence Quality of Life Survey (I-QOL) questionnaire assessed at the 3 month study visit. Results A total of 221 subjects were randomized, including 157 treatment arm subjects and 64 controls. The 3 month composite primary efficacy endpoint was achieved in 42.1% of treatment group subjects compared with 28.1% of controls on intention-to-treat analysis (p = 0.046). Treatment arm subjects were significantly more likely to report at least a 50% reduction in incontinence frequency on 7-day voiding diary (55.2% vs 32.3%, P = 0.002, ITT) and more commonly reported their incontinence was improved on Patient Global Impression of Improvement in Incontinence (PGI-I) at 3 months compared with controls (58.0% vs 37.7%, P = 0.007, ITT). No device- or procedure-related serious adverse events nor unanticipated adverse events were reported and no cases of urinary retention were observed. All adverse events fully resolved following balloon removal. Conclusions In this phase three trial, the Vesair intravesical balloon achieved 3 month primary and secondary endpoints both objectively and subjectively.

Urethral reconstruction is a delicate surgery that requires intricate knowledge and skill to perform. Principles of reconstructive surgery must always be upheld to guide patient management and optimize functional outcomes. Proper equipment and instruments are important tools to adequately evaluate the ca se at hand and preserve tissue health.

The AdVance transobturator male sling (Boston Scientific, Marlborough, MA) is a synthetic sling used for the treatment of male stress urinary incontinence (SUI). Its use was first described by Rehder and Gozzi in 2007 in Austria [1], and since has widely been accepted as a treatment for mild to moderate post-prostatectomy incontinence (PPI) and male SUI [2].

To determine predictors for surgical complications and assess patient satisfaction after surgical treatment of Adult-Acquired Buried Penis (AABP). A retrospective review was performed on all patients diagnosed with AABP who underwent surgical treatment at a single institution from January 2013-December 2017. Patient demographics and peri-operative data were extracted. Univariate and multivariate regression analyses were performed to identify predictors for surgical complications. Patients’ post-operative satisfaction was likewise assessed for factors such as successful outcome, post-operative erection quality, and complications related to the surgery. Twenty-four patients of median age 61.5 years (IQR 54–67) with median follow-up of 12 months (IQR 3.25–29) were included. Overall success was 87.5% (21/24). Complications occurred in 15 (62.5%) patients with 7 (29%) Clavien–Dindo category ≥ 3. Based on regression analyses, body mass index (BMI) ≥ 40 (HR 25; 95% CI 1.45–431.81) and tobacco smoking (HR 14.6; 95% CI 1.15–199.98) were identified as independent predictors of overall complications. Concomitant performance of abdominal panniculectomy was associated with Clavien–Dindo category ≥ 3 (HR 28; 95% CI 2.4–326.74) complications. Patient satisfaction was associated with surgical success (p

OBJECTIVE To determine the long-term outcome of transobturator sling for male stress urinary incontinence (SUI) clustered according to preoperative SUI severity, and to identify predictors of treatment success durability and failure occurrence in long-term follow-up. METHOD A nonconcurrent study was conducted on all transobturator male sling cases performed from August 2006 to June 2012 by a single surgeon. Preoperative SUI severity was clustered into mild (≤2 ppd), moderate (3-4 ppd) or severe (≥5 ppd). Success was defined as complete dryness with 0 pads used (cured), and a patient with ≥50% improvement, satisfied without further procedures needed. Otherwise it was considered a treatment failure. Clinical variables significantly associated with long-term treatment success were determined. Time-to-event (Kaplan-Meier) and Multiple-Cox regression analysis were performed to determine predictors of long-term treatment outcome. RESULTS A total of 215 patients (mild-59, moderate-94, and severe-62) with a mean follow-up of 56.4 ± 41.6 months were included. On long-term follow-up, 150 (69.8%) patients-maintained treatment success and 96 (44.7%) were dry. The long-term outcome success clustered according to SUI severity as mild, moderate, and severe was 84.7%, 72.3%, and 51.6%, respectively. Kaplan-Meier with Log-rank test and Multiple Cox-regression determined that both concomitant urge incontinence and preoperative SUI severity were independent predictors of long-term durability of treatment success and failure occurrence. Preoperative SUI severity was the only predictor of long-term cure sustainability. CONCLUSION The time to event analysis with an average of ∼5 years postoperative follow-up has determined that the preoperative severity and presence of concomitant urge incontinence were independent predictors for long-term outcome.

INTRODUCTION AND OBJECTIVES:Surgical correction of adult acquired buried penis (AABP) typically results in excellent outcomes. However, complication rates are high. Our objective is to report our i...

In recent pre-clinical studies, biomaterials and bladder tissue engineering have shown promising outcomes when addressing the need for bladder tissue replacement. To date, multiple clinical experiences have been reported. Herein, we aim to review and summarize the reported clinical experience of biomaterial usage and tissue engineering of the urinary bladder. A systematic literature search was performed on Feb 2019 to identify clinical reports on biomaterials for urinary bladder replacement or augmentation and clinical experiences with bladder tissue engineering. We identified and reviewed human studies using biomaterials and tissue-engineered bladder as bladder substitutes or augmentation implants. The studies were then summarized for each respective procedure indication, technique, follow-up period, outcome, and important findings of the studies. An extensive literature search identified 25 studies of case reports and case series with a cumulative clinical experience of 222 patients. Various biomaterials and tissue-engineered bladder were used, including plastic/polyethylene mold, preserved dog bladder, gelatine sponge, Japanese paper with Nobecutane, lypholized human dura, bovine pericardium, amniotic membrane, small intestinal mucosa, and bladder tissue engineering with autologous cell-seeded biodegradable scaffolds. However, overall clinical experiences including the outcomes and safety reports were not satisfactory enough to replace enterocystoplasty. To date, several clinical experiences of biomaterials and tissue-engineered bladder have been reported; however, various studies have reported non-satisfactory outcomes. Further technological advancements and a better understanding is needed to advance bladder tissue engineering as a future promising management option for patients requiring bladder drainage.

Urethral stricture disease in spinal cord injured (SCI) patients presents a challenging clinical scenario. Determining the appropriate course of management requires consideration of the unique issues of these patients, and unfortunately there is sparse published literature. The goals of treatment should be determined before the treatment modality is chosen. Endoscopic management options such as direct visual internal urethrotomy (DVIU), although less invasive, have a very high recurrence rate compared to urethral reconstruction or urinary diversion. Catheterization, whether clean intermittent catheterization (CIC), suprapubic catheter (SPC), or indwelling catheter (IDC), is often problematic. Urethral strictures in SCI patients are usually best treated with urethral reconstruction or urinary diversion. However, urethral reconstruction is associated with a significant rate of reoperation and subsequent necessity for urinary diversion; therefore, urinary diversion may be most appropriate in many patients. Detailed discussion and consideration of unique patient factors as well as patient preferences are important components of preoperative counseling.

Despite the emergence of different devices in the treatment of postprostatectomy urinary incontinence, the AMS 800 (American Medical Systems, Minnetonka, MN) remains the gold standard for the treatment of stress urinary incontinence in men. We reviewed the current literature regarding the indications, surgical principles, outcomes, and complications of artificial urinary sphincter placement for stress urinary incontinence after prostatectomy. Despite all the available information, heterogeneous data, different success definitions, and the lack of high-quality prospective studies with long-term follow-up, it is difficult to compare outcomes between studies. In spite of these, the perineal implantation of a single cuff artificial urinary sphincter has withstood the test of time.

Introduction Penile amputation is a rare type of external genital trauma. It may arise from accidental trauma, assault or self-inflicted mutilation. As with all trauma, initial management focuses on assessment and resuscitation of the patient. When available, hypothermic preservation of the detached penis should be undertaken. Aim This review serves to compile the current available information on etiology and management of penile amputation injuries, with focus on functional and cosmetic results. Main Outcome Measures Main outcome measures were penile cosmetics, viability, and sensation; urethral patency and graft survival, functionality. Methods A literature search using Medline, PubMed (U.S. National Library of Medicine and the National Institutes of Health), and abstracts from scientific meetings was performed from 1980–2013. Results Due to the rarity of penile amputation injuries, no randomized trials exist. Likewise, available published series on management of this condition are comprised of a small number of patients. Conclusions Penile amputation is rare but challenging. Current microreplantation procedures have a uniformly good result with a minimum number of post-operative complications. When microreplantation cannot be performed, older corporal reattachment techniques may be offered. When phallic reconstruction is required, a microsurgical free forearm flap phalloplasty may be performed to restore the patient with an acceptable cosmetic and functional phallus. Virasoro R, Tonkin JB, McCammon KA, and Jordan GH. Penile amputation: Cosmetic and functional results. Sex Med Rev 2015;3:214–222.

To present mid-term outcomes from an international, multi-institutional cohort of patients undergoing vessel-sparing excision and primary anastomosis urethroplasty for the reconstruction of the anterior urethra.From June 2003 to December 2011, 68 patients underwent vessel-sparing anterior urethral reconstruction at five different international institutions using the vessel-sparing technique described by Jordan et al. (J Urol 177(5):1799-1802, 2007).Patients' age range was from 3 to 82 years (mean 51.2). Stricture length ranged from 1 to 3 cm (mean 1.78). After a mean follow-up of 17.6 months, 95.6 % of patients had a widely patent urethral lumen. Three patients failed the procedure, requiring either direct vision internal urethrotomy or urethral dilation, after which all were free of symptoms and did not require further instrumentation. Complications were minimal and as expected following open urethroplasty.Preservation of blood supply is a noble pursuit in surgery; however, it can be technically difficult and often requires more time and effort. This vessel-sparing technique for anterior urethral reconstruction is reproducible and appears to be reliable in this international cohort. Larger studies and longer follow-up are needed to support these encouraging results.

Objectives The "Stress Incontinence Control, Efficacy and Safety Study" (SUCCESS) is a phase III study of the Vesair Balloon in women with stress urinary incontinence who had failed conservative therapy, and either failed surgery, were not candidates for surgery, or chose not to have surgery. The safety and efficacy of the balloon at 12 months is reported for those participants in the treatment arm who elected to continue with the SUCCESS trial beyond the primary end point at 3 months. Methods The SUCCESS trial is a multicenter, prospective, single-blinded, randomized, sham-controlled study. Participants were randomized on a 2.33:1 basis to either Vesair Balloon placement or placebo. The primary efficacy end point was a composite of both a greater than 50% reduction from baseline on 1-hour provocative pad weight test and an at least 10-point improvement in symptoms on the Incontinence Quality of Life questionnaire assessed at the 3-month study visit. Patients in the treatment arm who opted to continue in the trial were followed up prospectively up to 12 months. Results A total of 221 participants were randomized, including 157 in the treatment arm and 64 in the control arm. Sixty-seven participants in the treatment arm (42.7% of participants enrolled) were evaluated at 12 months, with 56.3% achieving the composite end point and 78.7% having greater than 50% reduction in pad weight from baseline in a per-protocol analysis. In an intent-to-treat analysis treating all participants who did not continue with the balloon as failures, 24% of the participants achieved the composite end point and 33.6% had a greater than 50% reduction in pad weight from baseline. Treatment-related adverse events in this group included dysuria (40.1%), gross hematuria (36.9%), and urinary tract infection (26.1%). Conclusions In this phase III trial, symptom relief was maintained for those participants who continued therapy for 12 months. The balloon was found to be safe with no device- or procedure-related serious adverse events reported. Additional studies are warranted to determine which patient populations are more tolerant of the balloon and to assess the efficacy and safety of its longer-term use. Additional screening methods, including screening patients for balloon tolerability, are warranted to reduce participant withdrawals.

The AdVance sling (American Medical Systems, Minnetonka, MN, United States of America) is a synthetic transobturator sling, which is a safe and effective minimally invasive treatment for mild to moderate stress urinary incontinence (SUI) in male patients. This article provides a step-by-step description of our technique for placement of the AdVance male sling, including details and nuances gained from surgical experience, advice for avoidance of complications and discussion on management of complications and sling failures. Patient selection is very important, including exclusion and preoperative treatment of urethral stenosis and bladder dysfunction. Previous pelvic radiation is a poor prognostic factor. In brief, the steps of sling placement are: (I) mobilization of the corpus spongiosum (CS); (II) marking and mobilization of the central tendon; (III) passage of the helical trocar needles exiting at the apex of the angle between the CS and inferior pubic ramus; (IV) fixation of the broad part of the sling body to the CS at the previous mark; (V) cystoscopy during sling tensioning; (VI) placement of a Foley urethral catheter; (VII) Subcutaneous tunnelling of the sling arms back toward the midline; (VIII) wound closure. The most common early postoperative complication is urinary retention but long-term retention is extremely rare. Management of sling failures include placement of an artificial urinary sphincter, repeat AdVance sling, urethral bulking agent or ProACT device.

Bladder neck stenosis (BNS) and posterior urethral stenosis (PUS) are uncommon but problematic complications of treatment for localized prostate cancer. Overall, BNS is less common following minimally invasive radical prostatectomy than open. Patients who develop PUS following radiation therapy (RT) (especially salvage RT) pose a greater challenge and tend to present longer after treatment. Regardless of etiology, treatment begins conservatively with endoscopic management but quickly progresses to more aggressive intervention if refractory. Urethral stents have been used with acceptable results. In patients who fail conservative therapy after radical prostatectomy (RP), open reconstruction should be considered. After RT, patients may ultimately benefit from urinary diversion or salvage prostatectomy. After treatment, many patients will require implantation of artificial urinary sphincter (AUS) for management of incontinence. Patient counseling prior to treatment selection for initial prostate cancer therapy is important; complications, future management, and potential for return to normal quality of life vary widely.

Objective To review extended patient outcomes after male transobturator sling placement for stress urinary incontinence. Methods A retrospective review of a prospectively maintained database for patients with at least 12 months of postoperative follow-up after AdVance male sling placement was performed. Success was defined as a dry safety pad or less (cured) or >50% improvement in pads used per day and patient satisfaction (improved). Patients requiring repeat continence procedures were considered failures. Results We reviewed data from 102 patients with a minimum of 12 months of follow-up (mean ± standard deviation 36.2 ± 16.5 months). The mean age at surgery was 66.1 years, and 86.4% had previously undergone a prostatectomy. At 12 months, 24 months, and final follow-up, success rates were 74%, 63%, and 62%, respectively. Although cure rates also declined over time, 40% of patients experienced a durable cure with no complaints of wet pads at final follow-up. Complications were minimal and similar with previous reports. Multivariate Cox regression analysis revealed detrusor overactivity and an elevated detrusor pressure and peak flow negatively predicted being cured using sling placement. Conclusion AdVance sling placement continues to represent a viable option in the treatment of male stress incontinence. Although a decrease in efficacy over time was observed, a substantial portion of patients can expect a durable cure.

We reviewed the current literature on lichen sclerosus as it related to urethral stricture disease using MEDLINE and PubMed (U.S. National Library of Medicine, National Institutes of Health) up to the current time. We identified 65 reports, 40 of which were considered relevant and form the basis of this review. Lichen sclerosus is now the accepted term, and balanitis xerotica obliterans is no longer acceptable. This common chronic inflammatory skin condition, mainly affecting the genitalia, remains an enigma, with uncertain etiology, varied presentation, and multiple treatments. In the early stages of the condition, a short course of steroids may be beneficial for some patients. If persistent, patients need long-term surveillance because of the potential development of squamous cell carcinoma. If diagnosed early, lichen sclerosus can be controlled, preventing progression. But once the disease has progressed, it is very difficult to treat. Surgical treatment by circumcision can be curative if the disease is treated early when still localized. Once progression to urethral involvement has occurred, treatment is much more difficult. Meatal stenosis alone is likely to require meatotomy or meatoplasty. Treatment of the involved urethra requires urethroplasty. Single-stage and multiple-stage procedures using oral mucosa have both been reported to give acceptable results, but the use of skin, genital or nongenital, is not recommended, because being skin, it remains prone to lichen sclerosus. With extensive disease, affecting the full length of the urethra, consideration should be given to perineal urethrostomy. A significant number of patients may prefer this simpler option.

The AdVance Transobturator Male Sling (American Medical Systems, Minnetonka, MN, USA) is a minimally invasive bulbourethral sling, which has been shown to be safe and efficacious in the treatment of men with mild-to-moderate stress urinary incontinence, particularly in the post-prostatectomy cohort. This chapter discusses the mode of action, preoperative patient selection and evaluation, surgical technique, postoperative care, outcomes, complications, and salvage maneuvers, regarding utilization of the AdVance sling. Several theories exist regarding the mode of action of the sling in effecting continence. The sling has also been used for the treatment of other types of stress urinary incontinence, such as in neurogenic incontinent patients though with caution. Previous radiation and detrusor overactivity seem to be negative predictive factors of sling success. In general, complications are minimal. Sling failures can be managed by repeat sling insertion in some cases or insertion of an artificial urinary sphincter.

urologists perceive preoperative positive urine culture rate to be > 25%. 71% order a urine culture preoperatively in all despite UA result, and 32% do so 1 week prior. Regardless of catheter status, 41.8% use a urine bacteria threshold of 10K CFU/mL to initiate treatment preoperatively. Ideal duration of treatment was 7 days in 35%, 5 days in 26%, and < 3 days in 26%. 58.8% would not post-pone surgery if preferred duration was not me. 15% repeated a urine culture preoperatively after treatment, and 35% would empirically treat with antimicrobials if a urine culture was not performed. The majority of experts administer 2 antimicrobials at time of urethroplasty with 42% preferring Aminoglycoside + Penicillin regardless of the urine culture. 18-24% of experts continue IV antimicrobials for longer than 24 hours. 61% administer oral antimicrobials until postoperative catheter removal (2-3 weeks). The majority give additional antimicrobials at catheter removal. CONCLUSIONS: There is substantial variability in antimicrobial administration for urethroplasty. Concern of over use of antimicrobials is based on the extensive use of antibiotics preoperatively and postoperatively. Opportunity and obligation exists to improve antimicrobial stewardship. Randomized trials are requisite to establish guidelines for judicious yet effective regimen(s).

Objective To review our experience with penile revascularization for patients with bilateral occlusion of the deep internal pudendal arteries after pelvic fracture urethral injury (PFUI). Materials and Methods We identified 17 patients who had undergone penile revascularization with end-to-side anastomosis of the deep inferior epigastric artery to the dorsal penile artery from July 1991 to December 2010. Success was defined as achieving erections sufficient for intercourse with or without pharmacologic assistance. Results All patients had had a PFUI causing arterial insufficiency and erectile dysfunction not responsive to pharmacologic intervention. Of the 17 patients, 4 (24%) underwent revascularization before and 13 (76%) after PFUI repair. The mean age at revascularization was 32.7 years (range 17-54). At an average follow-up of 3.1 years, the surgery was successful in 14 of the 17 patients (82%). In patients with erectile dysfunction as an indication for surgery, successful erections were achieved in 11 of 13. For those who underwent revascularization to prevent ischemic stenosis of the urethral repair, 3 of 4 achieved successful erections, and all subsequent urethral surgeries were successful. The penile duplex ultrasound parameters showed clinically and statistically significant improvements after revascularization. No operative complications developed. The average hospital length of stay was 4.7 days. Four patients experienced early postoperative complications, including an abdominal wall hematoma requiring evacuation in one, penile edema in two, and a superficial surgical site infection in one. No late complications occurred. Conclusion Penile arterial revascularization in select patients can allow for successful treatment of PFUIs and the refractory erectile dysfunction caused by them.

Rectourethral Fistula (RUF) is an unusual entity with severe consequences to patients. Radiation induced RUF is an infrequent complication following prostate cancer treatment. Evaluation and management of radiation induced RUF is not uniform. A variety of alternatives are offered to manage RUF, including but not limited to the transanal, transrectal approach (York-Mason), pure perineal and combined abdomino-perineal approaches. It is of utmost importance that the genitourinary reconstructive surgeon be familiar with the etiology, anatomy and options to treat RUF. Treatment strategies must be tailored with consideration toward the etiology of the fistula and to the patient status.

The AdVance ® transobturator sling, an innovative sling developed to correct postprostatectomy stress urinary incontinence, acts by repositioning the urethral sphincter complex back into the pelvis. Optimal placement of the sling on the urethral bulb is ensured by following a recommended surgical technique. Postoperative pain resolves spontaneously or is easily controlled with analgesics. Patients must comply with postoperative care instructions, that is, no strenuous exercise in the immediate postoperative period to avoid sling slippage. It is also feasible to conduct implantation of an inflatable penile prosthesis in men with erectile dysfunction at the same time as the AdVance ® sling. The subsequent placement of an artificial urinary sphincter is not compromised in men who have previously received the AdVance ® sling.

Purpose: We report our experience and long-term followup of patients undergoing excision and primary anastomotic reconstruction for anterior urethral strictures.Materials and Methods: From July 1986 to May 2006 the charts of 260 patients who underwent excision with primary anastomosis at our center for bulbar urethral stricture were reviewed. Patient age ranged from 14 to 78 years (mean 38.4), stricture length ranged 0.5 to 4.5 cm (mean 1.9). Patients who had surgery within the last 5 years were contacted by telephone if their 6-month postoperative cystoscopic evaluation was patent and they had not visited the clinic afterward.Results: After a mean followup of 50.2 months 257 patients (98.8%) were symptom-free and required no further procedures. Recurrent stricture occurred early in 2 patients and late in 1 patient. Two patients opted for intermittent dilations, and a single direct visual internal urethrotomy was performed in 1 patient 4 years postoperatively. One of the patients who elected dilation subs...

Introduction Outcomes following penile prosthesis implantation in patients with a history of total phallic construction are not well described. Aim The aim of this study was to evaluate outcomes following neophallus penile prosthesis placement. Methods Retrospective review penile prosthesis placement in patients with prior total phallic construction. GORE-TEX® (Gore Medical, Flagstaff, AZ) sleeve neotunica construction was utilized in all patients. Main Outcome Measure Success defined as patient sexual activity with a functioning prosthesis. Results Thirty-one patients underwent neophallic prosthesis implantation at a mean 35.6 years of age. Prosthesis placement occurred at an average 56.3 months following phallic construction and follow-up was a mean of 59.7 months. Malleable prostheses were placed in 21 patients and inflatable in 10; implants were bilateral in 94%. Six percent experienced operative complications including a bladder injury (1) and phallic flap arterial injury (1). Postoperative complications occurred in 23% at a median 5.5 months following placement. Five prostheses were explanted secondary to infection or erosion and two additional required revisions. Of the explanted prosthesis two were later replaced without further complication. Eighty-one percent of patients were sexually active following prosthesis placement. Conclusions Penile prosthesis placement is possible in patients with prior penile reconstruction/phallic construction. Although complications rates appear to be elevated in this population compared with historic controls of normal anatomic men, the majority of patients in this series were sexually active following prosthesis placement. This demonstrates the utility of prosthesis implantation in these difficult patients.

To evaluate the outcome of patients treated with a salvage AdVance male sling after a failed primary transobturator sling placement.Retrospective review of patients treated at our center with a primary and subsequent salvage AdVance sling. Success was defined as a dry safety pad or no pads (cured), or50% improvement in pads used per day and patient satisfaction (improved). Early primary sling failures (6 months) were compared with late (≥6 months) failures with regard to continence outcomes.We identified 18 patients who underwent a salvage AdVance sling placement at our institution. Overall success was 72% at 6 months postoperatively and 56% at a mean follow-up of 17.5 months, including 50% and 39% of patients who were dry at those same time periods. Patients failing late after their primary sling (n = 8) enjoyed improved outcomes with salvage sling placement compared with patients who failed early (n = 10) after the primary sling. At 6 months, more patients in the late primary failure group were cured (75% vs. 30%; P = .031). These improved cure rates remained significant through final follow-up with cure rates of 63% and 20%, respectively (P = .041).Salvage AdVance male sling is a viable treatment option after a failed primary sling procedure, especially in patients who demonstrated a prolonged efficacy period before primary sling failure.

Male urethral slings are becoming an accepted treatment for men with persistent post-prostatectomy incontinence (PPI) who do not desire, or are not candidates for artificial urinary sphincters (AUS). Initial and midterm results following AdVance sling placement have been encouraging, with success rates approaching 70–80 %. Patients with persistent or recurrent PPI following sling placement may be candidates for salvage treatments, depending on patient preference. After removal of the original mesh, repeat AdVance slings are placed in a similar manner to the primary procedure, other than being placed more distal on the corpus spongiosum. Patients competent and willing to operate an AUS may undergo AUS placement following failed AdVance. This is easily accomplished without removing the sling mesh, by placing the cuff around the spongiosum distal to the urethral sling. Early success rates following repeat AdVance placement has approached 70 %, and success following salvage AUS is expected to be similar to a primary AUS placement.

Objectives Tissue interposition is an important part of vesicovaginal fistula (VVF) repair that has been shown to improve success rates. The most common interpositional flap used during a transabdominal VVF repair is the omental flap; however, in some cases, it cannot be used. The urachus is a well-vascularized tissue that is easily mobilized for interposition. We describe our experience using a urachal flap in VVF repair. Methods Patients undergoing VVF repair at our center were identified, and a retrospective chart review was performed. Patients who underwent a transabdominal repair with interposition of a urachal flap were included. Results Thirteen patients were identified between 2005 and 2009. All were evaluated with a history, physical, upper and lower tract imaging, and cystoscopy. Median patient age was 49 years (range, 31-88 years). Fistula etiology was hysterectomy in 11 and prolapse repair in 2. Five patients presented with recurrent fistulas having failed previous repair. Of 13 patients, 12 had successful repairs with our described technique, including 4 patients who failed previous repairs. There was no recurrence of fistula after median follow-up of 6 months (range, 2 weeks to 4 years). Two patients had preoperative and postoperative complaints of stress urinary incontinence that was mild and did not require surgery. Conclusions Vesicovaginal fistulas can be a difficult challenge for the reconstructive surgeon. The urachal flap is a well-vascularized tissue flap that can be easily mobilized and interposed for VVF repair. Of 13 patients in this series, 12 were successfully repaired using this technique. We feel that further evaluation and usage of this tissue flap are indicated.

INTRODUCTION AND OBJECTIVES: Complex anterior urethral strictures provide a surgical challenge for the reconstructive urologist. Patients often present following multiple failed procedures with persistent voiding difficulty. Tissue substitution is often required for successful repair. Buccal mucosal graft (BMG) has become the tissue of choice given its excellent graft characteristics and low associated morbidity. The use of BMG in single staged urethroplasty has shown excellent success and durability, however the outcomes following its use in staged procedures for patients with extensive urethral strictures is not well documented. We present our outcomes following a staged BMG urethroplasty at a single institution. METHODS: Patients who underwent staged BMG urethroplasty between January 1, 1999 and August 8, 2011 were identified. A retrospective chart review was performed to collect clinical data including patient demographics, stricture etiology, and post-op complications following first and second stage procedures. Outcomes were assessed including durability of results, recurrence rates, and additional procedures required. RESULTS: Fifty-seven patients underwent a staged BMG urethroplasty during the designated time period. The average patient age was 41 years. Stricture etiology was hypospadias in 26 patients (46%) followed by lichen sclerosus in 16 patients (28%) with unknown etiology in the remaining patients. The average stricture length was 7.5 centimeters. Eighty-five percent of patients had undergone at least one attempt at a prior repair, 71% had 2 prior repairs and 48% had 3 prior repairs. Following the first stage procedure 11 (20%) patients elected not to undergo a second stage procedure. Complete follow-up was available in 42 patients (74%). There were 7 major complications (12%) including fistula development in 4 patients, penoscrotal tethering in 2 patients and meatal stenosis in 1 patient. The majority of the complications were successfully treated with an additional procedure. Three other patients required additional procedures including conversion to a perineal urethrostomy, a suprapubic tube and urethral dilation. The overall success rate was 76% defined as patients who required no further procedure at an average follow-up of 25 months. CONCLUSIONS: Substitution urethroplasty is often necessary to treat complex anterior urethral strictures such as those seen in hypospadias cripples and in patients with lichen sclerosus. The staged BMG is an effective treatment for these patients with acceptable complication rates. Further follow-up is required to confirm durability.

Patients with voiding dysfunction, such as overactive bladder (OAB) syndrome and non-obstructive retention, who have failed conservative treatment are candidates for sacral nerve stimulation (SNS). Sacral nerve stimulation was originally described by Tanagho and Schmidt.1 Medtronic received United States Food and Drug Administration (FDA) approval for Interstim in July 1998 for urge incontinence. To proceed with full implant, patients were initially tested with a percutaneous nerve evaluation (PNE). The percutaneous permanent tined lead (PPTL) was released in 2002 and is now the most commonly used procedure performed prior to a patient receiving a permanent implant.2 The advantage of the PPTL over PNE is higher implantation rates 88% versus 46%.3 Richard and colleagues used an interesting approach looking at the PNE as an adjunct to the PPTL and the implanted pulse generator implant. They performed a retrospective chart review of 106 patients who underwent 116 PNEs. Of these 116 patients, 62 (53%) had a successful PNE. Of these successful cases, 57 (92%) went on to an implant. Using the PNE allowed them to pre-select patients for PPTL, which increased their overall success.4 The authors address noteworthy considerations in their approach to SNS. The most worthwhile is the use of a 60% goal for symptom improvement compared to the standard 50%, which was an initial arbitrary goal. Some may argue we should consider an even higher improvement rate, possibly 70%. The authors astutely point out that the placebo success rate for anticholinergics can be as high as 60%, clearly explaining why some patients do not improve even after a full implant. Considering the significant expense of the product, elimination of the placebo effect would decrease cost, improve efficacy and prevent unnecessary procedures. Additionally, the authors discuss the prospect that using this three-stage approach may reduce the overall cost of SNS, as the cost of the PPTL staged approach is significantly less than a PNE. This may reduce the general cost to society; however, with the lower success rate of PNE, one cannot help but wonder if treatment is being withheld from some patients who are suffering. The authors should be commended for reviewing their data and trying to identify cost-efficient and more efficacious methods of providing care for their patients. A large multi-centre trial evaluating cost and efficacy would be optimal, but unfortunately improbable. As new treatment modalities enter the market, we must continue to assume the responsibility to weigh their costs and benefits to achieve the best outcomes for the greatest number of patients.