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We sought to evaluate long-term surgical urinary and bowel management in cloacal exstrophy (CE) in a multi-institutional study.We performed a cross-sectional study of people with CE and covered variants managed at five participating institutions. Those with1 year follow-up or born with variants without hindgut involvement were excluded. Primary outcomes were methods of urinary and bowel management. Urinary management included: voiding via urethra, clean intermittent catheterizations (CIC), incontinent diversion and incontinent in diaper. Bowel management included: intestinal diversion (colostomy/ileostomy) and pull-through (with/without MACE). We evaluated three age groups: children (10 years), older children (10 to18) and adults (≥18). We assessed if management varied by age, institution or time (born≤2000 vs.2000).A total of 160 patients were included (40% male). Median follow-up was 15.2 years (36% children, 22% older children, 43% adults). While 42% of children were incontinent in diapers, 73% of older children and adults managed their bladder with CIC, followed by incontinent urinary diversion (21%) (p 0.001, Table). CIC typically occurred after augmentation (88%) via a catheterizable channel (89%). Among older children and adults, 86% did not evacuate urine per urethra and 28% of adults had an incontinent urinary diversion. No child or adult voided per urethra. Age-adjusted odds of undergoing incontinent diversion was no different between institutions (p = 0.31) or based on birthyear (p = 0.08). Most patients (79%) had an intestinal diversion, irrespective of age (p = 0.99). Remaining patients had a pull-through, half with a MACE. The probability of undergoing bowel diversion varied significantly between institutions (range: 55-91%, p = 0.001), but not birth year (p = 0.85).We believe this large long-term data presents a sobering but realistic view of outcomes in CE. A limitation is our data does not assess comorbidities or patient-reported outcomes. Rarity of volitional urethral voiding in CE forces the question of whether is a potentially unachievable goal. We advocate thoughtful surgical decision making and thorough counseling about appropriate expectations, distinguishing between volitional voiding and urinary and fecal dryness.In this long-term, multi-institutional study of patients with CE, 94% of older children and adults manage their bladder with incontinent diversion or CIC. Nearly 80% of patients, regardless of age, have an intestinal diversion. Given that no patients were dry and voided via urethra and 86% of older patients do not evacuate urine per urethra, these data bring into question what functional goals are achievable when performing reconstructive surgery for these patients.

Cicatrix formation, which can form after neonatal circumcision to entrap the glans penis, presents a therapeutic challenge. Previous studies in the literature have described either using a topical steroid cream or stretching of the scar tissue with an instrument but not a combination of both modalities. In our experience, monotherapy has resulted in significant recurrence and/or need for further treatment. We present our successful experience that combines cicatrix stretching with a hemostat using local anesthesia in the office followed by several weeks of topical steroids with a minority of patients needing any additional therapy.

The absence of sperm in the ejaculate after vasectomy reversal is commonly caused by failure to recognize and subsequently bypass epididymal or proximal vasal obstruction at the time of vasectomy reversal. If intra-operative proximal obstruction is suspected, vasoepididymostomy (VE) is recommended rather than vasovasostomy (VV). We sought to calculate the associated risk of needing VE, rather than VV with time from original vasectomy (obstructive interval) using a large cohort of vasectomy reversal patients. We reviewed the electronic and paper vasectomy reversal database by a single surgeon from 1978 through 2012. We performed univariate analysis to identify variables that predicted the need for VE rather than VV, and then combined only significant univariates into our multi-variable analysis. 2697 total men underwent vasectomy reversal, and 239 were repeat procedures. Of the 5296 individual testes operated on, 1029 were VE. Significant variables that predicted the need for VE on univariate analysis included: age, obstructive time interval, vasectomy reversal after previous VV (repeat vasectomy reversal), and year the procedure was performed. On multi-variable analysis significant risk factors for VE were age above 50 (OR 1.36), repeat vasectomy reversal (OR 5.78), and greater obstructive time interval (OR 1.56). For every 3 years since original vasectomy, the risk of needing VE increases by 56%. There is a linear relationship between obstructive interval and need for VE. Men undergoing repeat vasectomy reversal have five times greater risk of requiring VE and men greater than 50 years of age are also at higher risk. Using these pre-operative predictors is helpful in identifying patients who will benefit from referral to an experienced surgeon who can perform VE.

Plication techniques are not a panacea for deformities associated with Peyronie’s disease or congenital curvature. However, they do provide certain advantages, both theoretic and real, over competing procedures such as grafting. Depending on the technique, plication procedures have minimal risk of de novo erectile dysfunction, minimal risk of injury to the dorsal neurovascular bundle, and may be used for a variety of angulation deformities, including multiplanar curvature and severe degrees of curvature. A variety of incisions may be used, including the classic circumcision with degloving but also ventral raphe, dorsal penile inversion, and penoscrotal. These may be helpful in preventing postoperative morbidity and in sparing the prepuce if desired. Plication may also be combined with procedures such as penile prosthesis for correction of residual curvature. Lastly, despite its complications, plication techniques are very well tolerated, are relatively simple to perform and result in the very high satisfaction rates.