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

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

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

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

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

Urethral stricture management guidelines are an important tool for guiding evidence-based clinical practice.To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of urethral strictures in females and transgender patients.The panel performed a literature review on these topics covering a time frame between 2008 and 2018 and used predefined inclusion and exclusion criteria for study selection. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on the review of the available literature and after panel discussion.Management of urethral strictures in females and transgender patients has been described in a few case series in the literature. Endoluminal treatments can be used for short, nonobliterative strictures in the first line. Repetitive endoluminal treatments are not curative. Urethroplasty encompasses a multitude of techniques and adaptation of the technique to the local conditions of the stricture is crucial to obtain durable patency rates.Management of urethral strictures in females and transgender patients is complex and a multitude of techniques are available. Selection of the appropriate technique is crucial and these guidelines provide relevant recommendations.Although different techniques are available to manage narrowing of the urethra (called a stricture), not every technique is appropriate for every type of stricture. These guidelines, developed on the basis of an extensive literature review, aim to guide physicians in selecting the appropriate technique(s) to treat a specific type of urethral stricture in females and transgender patients. TAKE HOME MESSAGE: Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. Management of urethral strictures in females and transgender patients is complex and a multitude of techniques are available. Selection of the appropriate technique is crucial and these guidelines provide relevant recommendations.

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

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

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

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

Purpose: We identified and characterized predictive factors associated with an unfavorable outcome of collagen injection therapy in post-radical prostatectomy incontinence.Materials and Methods: A total of 46 patients, 49 to 85 years old (mean age 67) and incontinent after radical retropubic prostatectomy, underwent a mean of 2.8 transurethral injections of collagen (mean cumulative volume injected 31 ml.). Preoperatively, all patients underwent fluoroscopic multichannel video urodynamics including determination of Valsalva's leak point pressure. Stress urinary incontinence was subjectively graded as 1 (0 to 1 pad per day), 2 (2 to 3 pads per day) and 3 (greater than 3 pads per day). Patient age, duration and severity of pretreatment incontinence, presence of detrusor instability and anastomotic strictures, number of injections, total volume of collagen delivered and the impact of a nerve sparing procedure plus adjuvant radiation therapy were assessed and correlated with treatment outcome.Results:...

Purpose: We determined the role and validity of visual erotic stimulation using RigiScan* *Dacomed, Minneapolis, Minnesota. monitoring as a more physiological and cost-effective diagnostic modality for primary noninvasive screening of psychogenic versus organic impotence. We also clarified the correlation between erotic and pharmacological erections, and their diagnostic usefulness in the clinical routine.Materials and Methods: A total of 76 impotent patients and 20 potent controls were entered into the study. A detailed medical and sexual history was obtained, and psychological evaluation and minimally invasive diagnostic studies were done, including a 15-minute visual erotic stimulation test, intracavernous pharmacological stimulation with 10 micro g. prostaglandin E1 and penile duplex ultrasound. Responses to each test were interpreted blindly and independently of each other, and of the results of the psychological evaluation. Visual erotic stimulation results were then correlated with the resu...

Purpose: We describe a variation of the ileal conduit that includes a nonrefluxing nipple valve designed to protect the upper urinary tracts.Materials and Methods: A total of 13 patients underwent urinary diversion with the nonrefluxing ileal conduit. The nonrefluxing nipple valve is created by intussuscepting the ileum into the conduit.Results: Followup ranged from 3 to 35 months. No patient demonstrated radiographic deterioration of the upper tracts or a clinically significant increase in serum creatinine level during followup.Conclusions: The nonrefluxing ileal conduit appears to be a viable treatment option in select patients with neurogenic bladder dysfunction.

Currently, the classical, time-honored ileal conduit as well as the stoma1 continent urinary diversions have given way to the increasingly frequent use of replacement cystoplasty. In 1852 Simon performed the first continent urinary diversion in a form of ureterorectal anastomosis on a paitent with ectopia vesicae’ and in 1913 Lemoine reported the first true clinical use of a rectal bladder.2 This and most of the following attempts would be tempered by a high surgical mortality rate. In 1951 Couvelaire reported the first clinical use of bladder substitution, which was followed by only sporadic reports on this method.3 Since Kock et a1 in 1982 reported on their pioneering experience with the use of an ileal segment for the construction of a continent reservoir: we have witnessed an explosion of interest in continent urinary reconstructions via the cutaneous and urethrally anastomosed forms. The number of variants currently average more than 40 worldwide.4-7 Bladder replacement by a variety of small and large bowel segments has become a standard method of reestablishing voiding per urethra. Typical causes for replacement cystoplasty, defined as total cystectomy followed by reconstruction, are bladder carcinoma (the leading cause in adults), surgically unreparable bladder exstrophy, undiversion and a diseased vesicourethral unit requiring total cystectomy.8 TO date, radical cystectomy remains the most effective method of treatment for invasive bladder carcinoma. Despite all of the advances in chemotherapy and radiotherapy, these modalities have still not been demonstrated to be equivalent to surgery in terms of survival, local or regional control, or quality of life. Major refinements in anesthetic procedures, the advent of the modern antibiotic era, and recent advances in surgical, urodynamic and metabolic knowledge have significantly decreased mortality and morbidity rates associated with cystectomy and urinary reconstruction. h y patient undergoing radical cystectomy will be confronted with the option of selecting 1 of 3 types of definitive urinary diversion: 1) the ileal or colon conduit, 2) a cutaneous continent reservoir and 3) a neobladder for orthotopic voidingg Option 3, hitherto reserved exclusively for men, has recently been performed successfully following radical cystectomy in the female patient.10-15 An intensive quest is underway to develop an orthotopic continent reservoir, resembling the natural bladder as close as possible, that is technically acceptable to surgeons and the most socially acceptable to patients. At the same time, it is important that any such bladder replacement procedure protects the upper urinary tract. This event is even more rewarding since followup is hoped to match normal life expectancy. Some disillusionment with long-term results of the ileal conduit, particularly in children, added to economic factors, particularly in Some third world countries where the cost of ostomy appliances is prohibitive, have also been responsible for this swing. We review what we believe to be only some of the most commonly used neobladders (bladder replacement in situ with the native urethra) to date, covering the most salient technical features. Basic physical and mathematical principles related to morphology and functional behavior of neobladders will be followed by a brief discussion of the rationale for recommending this type of procedure to post-radical cystectomy patients, probably regardless of gender. However, it should always be kept in mind that “urinary continence must not be achieved to the detriment of renal function” as stated by Bricker more than 4 decades ago.16 This statement still remains valid to date.

We established hemodynamic predictors of response to intracavernous pharmacotherapy.Specific characterization and quantification of hemodynamic abnormalities of the cavernous arterial inflow and corporeal veno-occlusive mechanism associated with failure to respond to intracavernous pharmacotherapy were performed retrospectively in 69 patients with nonendocrinological impotence. We investigated atherosclerotic vascular risk factors, duplex ultrasonography peak systolic and end diastolic velocities (10 micrograms. prostaglandin E1), and dynamic infusion cavernosometry and cavernosography parameters (60 mg. papaverine and 6 mg. phentolamine).The patients were stratified by severity of the various hemodynamic parameters encountered and mean dose required for response. Response subsequently was characterized as excellent (75% or greater rigid erections) in 36 patients, adequate (erections sufficient for intromission) in 17 and poor or absent in 16. Psychogenic, neurogenic and mild vasculogenic causes were noted in patients with an excellent response. The adequate responses included all 3 cases with mild to moderate vascular etiologies whereas patients with a poor or no response had only severe venogenic and combined arteriogenic and venogenic etiologies. Mean flow-to-maintain values plus or minus standard deviation of 9.7 +/- 3.7, 10.8 +/- 9.5 and 59.5 +/- 24.2 ml. per minute were demonstrated in the excellent, adequate and poor or no response groups, respectively. There was a good correlation between mean flow-to-maintain values and mean doses of our standard vasoactive solution (r2 = 0.88, p0.0001). Pharmaco-cavernosography demonstrated diffuse or pan-cavernous corporeal veno-occlusive dysfunction in the poor or no response group.Corporeal veno-occlusive dysfunction alone or combined with arterial disease is the specific hemodynamic abnormality causing nonresponse to intracavernous pharmacotherapy. Diffuse drainage, particularly involving the glans penis and corpus spongiosum, is greatly predictive of a poor or no response, reflecting the underlying cavernous smooth muscle myopathy and collagen degenerative alterations in these patients with end-organ failure.