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Phalloplasty in the female to male transgender patient is a complex operation aimed at creating a functional and aesthetic phallus, external genitalia, and perineum. Functional goals include standing micturition and sexual function with erogenous and tactile sensation as well as the ability to participate in penetrative intercourse. Functional genital reconstruction relies on creating of a fully lengthened urethra from local tissues as well as the provision for additional length via tissue transplantation. This manuscript will review techniques for the creation of perineal urethral segment as well as primary flaps available for the creation of neophallus. Particular emphasis is given to our preferred method of reconstruction: single-stage urethral lengthening with radial forearm flap phalloplasty including a review of surgical techniques and complications.

Objective To describe the infrapubic approach to penile prosthesis insertion in transmen after phalloplasty. Materials and Methods After verifying phalloplasty vascular pedicle anatomy and reliable micturition, patients may be considered for implant surgery. Specific modifications of the infrapubic approach to penile prosthesis insertion as well as individualization of commercially available implants are performed intraoperatively to help reduce the risk of postoperative complications. Results In our single surgeon series (MLC) using the infrapubic approach with these specific implants after phalloplasty, 17/107 (16%) patients from October 2017 to November 2020 required revision surgery after mean follow-up of 79.8 weeks. Conclusion Our infrapubic prosthesis insertion after phalloplasty technique with modifications to commercially available implants may help reduce the risk of postoperative complications.

PURPOSE Labia majora, the embryologic homologs of the scrotum, are ideal donor tissue for transgender scrotoplasty. The technique is detailed, and surgical outcomes are assessed for scrotoplasty using labia majora rotational advancement flaps. METHODS We retrospectively reviewed the outcomes of phalloplasty patients who underwent either primary or secondary labia majora flap scrotoplasty and perineal reconstruction from October 1, 2017, to December 1, 2019. Bilateral elevation and rotational flap advancement from the posterior to anterior position formed a pouch-like scrotum. Perineal reconstruction involved multilayered closure with apposition of the inner thigh skin. RESULTS The mean follow-up was 12.5 months (0.5-26 months). One hundred forty-seven scrotoplasties were performed. Of the 147 total scrotoplasty patients, 133 had labia majora flap scrotoplasty and perineal reconstruction with single-stage phalloplasty. Distal flap necrosis occurred in 6 patients (4.1%); 5 were ipsilateral to the groin dissection required for phalloplasty. Large (>1 cm diameter) perineoscrotal junction dehiscence occurred in 7 patients (4.7%). All wounds were managed conservatively except for 3 patients who developed urethrocutaneous fistulas at the perineoscrotal junction. All 3 patients required fistula repair. Two (1.4%) scrotal hematomas and 3 (2.0%) perineal hematomas were seen; all required operative intervention. CONCLUSIONS Labia majora flap scrotoplasty via the bilateral rotational advancement technique and perineal reconstruction can be safely performed during phalloplasty. Minor wound complications are common and frequently heal with conservative management. Wounds that do not heal may be associated with urethral complications. Hematomas are rare but usually require operative intervention.

An abnormal clinical Allen's test is not a definitive exclusion criterion for free radial forearm flap use. A surgical Allen's test may be useful to determine whether flap harvest is feasible in patients with an abnormal clinical Allen's test.

Labia majora, the embryologic homologs of the scrotum, are ideal donor tissue for transgender scrotoplasty. The technique is detailed, and surgical outcomes are assessed for scrotoplasty using labia majora rotational advancement flaps.We retrospectively reviewed the outcomes of phalloplasty patients who underwent either primary or secondary labia majora flap scrotoplasty and perineal reconstruction from October 1, 2017, to December 1, 2019. Bilateral elevation and rotational flap advancement from the posterior to anterior position formed a pouch-like scrotum. Perineal reconstruction involved multilayered closure with apposition of the inner thigh skin.The mean follow-up was 12.5 months (0.5-26 months). One hundred forty-seven scrotoplasties were performed. Of the 147 total scrotoplasty patients, 133 had labia majora flap scrotoplasty and perineal reconstruction with single-stage phalloplasty. Distal flap necrosis occurred in 6 patients (4.1%); 5 were ipsilateral to the groin dissection required for phalloplasty. Large (1 cm diameter) perineoscrotal junction dehiscence occurred in 7 patients (4.7%). All wounds were managed conservatively except for 3 patients who developed urethrocutaneous fistulas at the perineoscrotal junction. All 3 patients required fistula repair. Two (1.4%) scrotal hematomas and 3 (2.0%) perineal hematomas were seen; all required operative intervention.Labia majora flap scrotoplasty via the bilateral rotational advancement technique and perineal reconstruction can be safely performed during phalloplasty. Minor wound complications are common and frequently heal with conservative management. Wounds that do not heal may be associated with urethral complications. Hematomas are rare but usually require operative intervention.

The clinical need for magnified visualization during surgery spurred the evolution of microscope and microsuture technology. Innovative surgeons across various surgical specialties recognized the importance of utilizing and advancing these technologies. Operative microscopy allows human dexterity to perform beyond direct visual limitations. Microsurgery started in otolaryngology and ophthalmology, became popular in reconstruction and transplantation, and was then adopted in urology. Microsurgery in urology involves renal and penile revascularization, penile transplantation and free flap phalloplasty, testicular autotransplantation, reproductive tract reconstruction of the vas deferens and epididymis, varicocele repair, and sperm retrieval. By examining the peer reviewed and lay literature, this review discusses the history of microsurgery and its subsequent development as a subspecialty in urology.

Purpose: Phalloplasty is a critical step in female-to-male (transmale) gender confirming genital surgery. We examined outcomes between transmales who underwent phalloplasty with vaginectomy and full-length urethroplasty using the anterolateral thigh pedicled flap or the radial forearm free flap.Materials and Methods: We performed a single center, retrospective study of patients who underwent phalloplasty with vaginectomy and full-length urethroplasty using an anterolateral thigh pedicled flap or a radial forearm free flap from April 2013 to July 2016. All patients had at least 6 months of followup. Urethral and nonurethral complications were recorded. Complication rates were assessed using the OR of the anterolateral thigh pedicled flap and the radial forearm free flap groups.Results: Of the 213 patients 149 and 64 underwent radial forearm free flap and anterolateral thigh pedicled flap phalloplasty, respectively. Patients with a radial forearm free flap had a significantly higher body mass index than tho...

Objective To describe our technique for performing ring flap metoidioplasty in transgender men. Methods In a ring flap metoidioplasty, the urethra is created from bilateral anteriorly based labia minora and vestibular flaps. This technique is combined with Ghent scrotoplasty, vaginectomy (distal mucosal excision and proximal mucosal fulguration followed by cavity closure) and perineal masculinization. Suprapubic tube is placed for urinary diversion. To avoid disrupting the anteriorly based urethral pedicles, we do not perform monsplasty, division of the suspensory ligament, or resection of the labial folds adjacent to the penis at the time of ring flap metoidioplasty. Typically, resection of labial folds adjacent to the penis and testicular prosthesis insertion are performed 4-6 months after metoidioplasty. Results From November 2017 to June 2021, 52 patients underwent metoidioplasty with urethroplasty and concomitant vaginectomy by two surgeons (BF, MC). Median age was 30 years, and median follow-up was 22 months. Urethrocutaneous fistula developed in 7 (13%) patients, 1 of whom had spontaneous closure of the fistula. Urethral stricture occurred in 4 (8%) patients. Fistula repair and/or urethroplasty was required in 8 (15%) patients. Non urethral complications included bacteremia (1 patient) and venous thromboembolism (1 patient). Conclusion Ring flap metoidioplasty allows select patients to obtain masculine appearing genitals and the ability to void standing.

Gender dysphoria is estimated to occur in approximately 25 million people worldwide, and can have severe psychosocial sequelae. Medical and surgical gender transition can substantially improve quality-of-life outcomes for individuals with gender dysphoria. Individuals seeking to undergo female-to-male (FtM) transition have various surgical options available for gender confirmation, including facial and chest masculinization, body contouring, and genital surgery. The World Professional Association for Transgender Health guidelines should be met before the patient undergoes surgery, to ensure that gender-confirming surgery is appropriate and indicated. Chest masculinization and metoidioplasty or phalloplasty are the most common procedures pursued, and both generally result in high levels of patient satisfaction. Phalloplasty, with a resultant aesthetic and sensate phallus along with implantable prosthetic, can take upwards of a year to accomplish, and is associated with a considerable risk of complications. Urethral complications are most frequent, and can be addressed with revision procedures. A number of scaffolds, implants, and prostheses are now in development to improve outcomes in FtM patients.

Single-stage phalloplasty may be accomplished by having both the microsurgical and the reconstructive urology team operate simultaneously. Phalloplasty with pars pendulans urethroplasty is completed by the microsurgeons, and pars fixa urethroplasty, vaginectomy, scrotoplasty, and perineal reconstruction are performed by the reconstructive urologist. Some surgeons prefer separating phalloplasty from the urologic portions of the procedure. The single-staged approach is favored in patients whose ultimate goal is to have an aesthetic, sensate, and functional phallus and scrotum. Complications remain high but are predictably lower in higher-volume centers. Reconstructive urologists manage the urethral complications that develop.

Gender related genitourinary surgeries are vitally important in the management of gender dysphoria. Vaginoplasty, metoidioplasty, phalloplasty and their associated surgeries help patients achieve their main goal of aligning their body and mind. These surgeries warrant careful adherence to reconstructive surgical principles as many patients can require corrective surgeries from complications that arise. Peri-operative assessment, the surgical techniques employed for vaginoplasty, phalloplasty, metoidioplasty, and their associated procedures are described. The general reconstructive principles for managing complications including urethroplasty to correct urethral bulging, vaginl stenosis, clitoroplasty and labiaplasty after primary vaginoplasty, and urethroplasty for strictures and fistulas, neophallus and neoscrotal reconstruction after phalloplasty are outlined as well.

Gender-confirming surgery is a life-altering and medically necessary set of procedures for some people suffering from gender dysphoria. For transgender men, there are a variety of surgical interventions available for masculinization, including facial, chest, trunk, and genital surgeries. Facial and truncal masculinizations are rarely sought. Chest masculinization is the most common procedure in transgender men and consists of bilateral mastectomy through various approaches dependent on the breast size and laxity with minimal complications. Metoidioplasty and phalloplasty are the most common genital procedures (the radial forearm free flap phalloplasty being the most common) but have significant complication profiles. Up to 40% of those undergoing genital masculinization suffer from urethral fistula or stricture. Current advances consist of neurotization of the phallus and implant placement. Future studies on patient-reported outcomes and long-term follow-up are needed. This review contains 16 figures, 3 tables, and 62 references. Key Words: chest masculinization, gender affirmation, metoidioplasty, penile implant, phalloplasty, radial forearm free flap, scrotoplasty, transgender, urethral fistula, vaginectomy

Objective To report our successful experience in treating genital and perineal hidradenitis suppurativa (HS) and its sequelae including localized chronic lymphedema. We describe our method of diseased tissue resection and wound defect coverage with local flaps and split-thickness skin grafts (STSG). Methods From 2004 to 2012, we treated 6 patients with genital and perineal HS with radical resection of diseased tissue. Wound coverage was performed with skin flaps and/or STSGs. Results Two patients had enough normal neighboring skin for local flap coverage of their wound defect. Four others had more extensive disease requiring STSG coverage. Two patients with secondary penile skin lymphedema required STSG for penile shaft reconstruction. All patients achieved excellent cosmetic results. There was one recurrence that required repeat resection and wound coverage. No wound complications occurred at the STSG donor site. Successful STSG “take” on the scrotum and penis ranged from 90% to 100% (mean 98%). Wound complications from local flap closure were clinically insignificant and include small (≤2 cm) areas of wound breakdown with no evidence of infection in 3 patients (50%). Conclusion Genitoperineal HS is a debilitating and disfiguring disease that results in the need for repeated abscess drainage operations, chronically painful skin boils, and chronic foul-smelling infectious discharge. It can be associated with lymphedema of surrounding tissues, requiring removal of tissues not originally affected by the disease. The use of complete resection and reconstruction with skin flaps and grafts provides a viable treatment option for these patients.

We determined whether electrical stimulation of somatic afferent nerves in the foot could delay bladder filling sensations and increase bladder capacity in healthy humans without overactive bladder.Eight subjects underwent 90-minute foot stimulation using skin surface electrodes connected to a transcutaneous electrical nerve stimulator. The electrodes were attached to the bottom of the foot. Subjects completed a 3-day voiding diary, during which foot stimulation was applied on day 2. Stimulation parameters were pulse frequency 5 Hz, rectangular waveform pulse width 0.2 milliseconds and intensity 2 to 6 times the minimal stimulation current necessary to induce toe twitch. Stimulation intensity was set by each subject to a maximal level without causing discomfort. Subjects were provided with 500 to 1,000 ml of water to drink during stimulation.Average ± SE volume per void was 350 ± 22 ml during the 24 hours before foot stimulation. This voided volume increased to a mean of 547 ± 52 ml for up to 5 hours after stimulation (p0.01). Average voided volume returned to 363 ± 21 ml within 36 hours after stimulation. There were no adverse events.Foot stimulation can delay bladder filling sensations and significantly increase bladder capacity in healthy humans without overactive bladder. Although the study group was small, our results support moving forward with clinical trials of foot neuromodulation in patients with overactive bladder.

To evaluate the efficacy of augmenting ventral onlay buccal urethroplasty using a using a double-sided graft technique by adding a second, full-thickness skin graft (FTSG) dorsally in long strictures ≥4 cm, we hypothesized that a double-sided graft technique would improve surgical outcomes over buccal mucosal graft (BMG) ventral onlay urethroplasty alone.Retrospective chart review was performed comparing 15 patients who had undergone double-sided BMG + FTSG urethroplasty for long strictures ≥4 cm to a cohort group of 115 patients who had undergone BMG onlay urethroplasty for strictures of similar length. Comparisons of age, stricture lengths, time-to-failure, follow-up intervals, and failure rates were analyzed. Further analysis included age and stricture length matched control comparisons between BMG + FTSG patients to BMG only patients.Mean patient age, stricture length, and time to stricture recurrence were 44 years, 5.1 cm, and 10 months, respectively, in the BMG group. For the BMG + FTSG group, mean age was 52 years, stricture length 5.9 cm, and time to recurrence was 9 months. Overall, the BMG group had a decreased failure rate; 17% compared to 21%. Further analysis showed BMG ventral onlay had decreased failure rates for strictures 6 cm; 16% compared to 33%. However, for strictures ≥6 cm, the BMG + FTSG had a 0% failure rate compared to 24% in the BMG ventral onlay group (P = .005).Combined BMG and FTSG urethroplasty for very long bulbar urethral strictures ≥6 cm improve success rates compared to using BMG urethroplasty alone.

To evaluate the efficacy of transecting anastomotic urethroplasty (AU) and buccal mucosa graft (BMG) ventral onlay substitution urethroplasty (SU) in treating short bulbar urethral strictures.Sixty patients underwent either AU or SU for bulbar strictures of similar length with follow up of at least 12 months. Follow up included clinical history, uroflowmetry, and ultrasound post-void residuals (PVR) performed every 4 months for the first year and yearly thereafter.Out of 131 patients with short bulbar strictures, 40 were treated with BMG onlay SU and 20 had AU. Median follow up in the SU group was 57 months (IQR 27-76) and 120 months (IQR 109-130) in the AU group. The median stricture length was 3 cm (IQR 2.5-3.0) in the SU group and 1.3 cm (IQR 1-2) in the AU group (p0.001). The 3 year freedom from intervention was 93% in the SU group, and 85% in the AU group (p = 0.72).BMG onlay ventral urethroplasty has similar success rates to anastomotic urethroplasty for short bulbar urethral strictures. Due to the relatively fewer complications reported after substitution urethroplasty with BMG, it should be considered the treatment of choice for short bulbar urethral strictures.

Real-time tomographic reflection is a novel technique that uses a geometrically fixed arrangement of a conventional ultrasound transducer, a transducer-incorporated monitor, and a half-silvered mirror. This device, dubbed the Sonic Flashlight, generates a virtual anatomically scaled image, obviating the need for a separate monitor. It may therefore facilitate invasive procedures, such as percutaneous access to the kidney. This proof-of-concept study assesses the feasibility of this technique for renal imaging and concomitant needle puncture guidance.In a swine model with induced hydronephrosis, the Sonic Flashlight was used to visualize and guide needle access to the renal pelvis. Passage of a 7-inch, 18-gauge spinal needle was performed. Entry into the collecting system was confirmed by the aspiration of urine.The anechoic renal pelvis and hyperechoic needle tip could be seen with the Sonic Flashlight device. Successful access to the collecting system was obtained twice without dificulty. The sonographic image, appearing to emanate from the tip of the transducer, makes visualization and manipulation more intuitive. Furthermore, by placing the operator's eyes and hands in the same field as the sonogram, image-guided procedures are potentially easier to learn.The relatively shallow depth of penetration of the current device limits its clinical usefulness. A new Sonic Flashlight with a greater depth of penetration is in development.

Renal lymphangiomatosis is a disease characterized by abnormal formation of perirenal lymphatic vessels that fail to communicate with other retroperitoneal lymphatics; as a result, perirenal lymphatics dilate and form cysts. While typically an asymptomatic incidental finding, renal lymphangiomatosis rarely presents as flank or abdominal pain, ascites, impaired renal function, hypertension, hematuria, or proteinuria. Here we present the first known case of renal lymphangiomatosis found to spontaneously resolve following cardiac transplantation.

Adulthood buried penis is becoming an increasingly prevalent problem due to the rise in obesity. Weight loss and exercise may help overall health, but reconstructive surgery, especially in patients with scrotal lymphedema, cellulitis, abscess, or gangrene, is the primary treatment. We present a detailed description of our widely applicable surgical approach for management of these patients.

Introduction: Retroperitoneal fibrosis (RPF) can cause bilateral chronic obstruction of the ureters. Definitive surgical management includes ureterolysis with omental wrapping or ileal ureter substitution. We present a case of bilateral ureteral obstruction from RPF in a patient with a large abdominal aortic aneurysm (AAA) managed with bilateral ileal ureter substitution in the U-configuration. Case presentation: A 65-year-old man had medically refractory RPF with bilateral ureteral obstruction that failed ureteral stenting. He required bilateral nephrostomy tubes. Initially bilateral ureterolysis was considered, but given his large AAA and the proximity of the ureters to the aneurysm, ileal substitution was recommended. We attempted a “7” shaped configuration at first, but the natural lie of the ileal segment led us to perform a “U”-shaped substitution with the ends sewn to both renal pelvises and the middle portion sewn to the bladder dome. Postoperatively, the patient recovered well, and at two months followup, the patient has a stable serum creatinine and no hydronephrosis. He no longer requires ureteral stenting or nephrostomy tube drainage. Conclusion: Bilateral ileal ureter substitution is a viable option for patients with RPF induced hydronephrosis who fail conservative management. The U-shape is a novel configuration that may facilitate this procedure.

Urethral strictures in men often cause bothersome obstructive urinary symptoms and occasionally bladder dysfunction and even renal failure. Management of this disease differs depending on the location and length of the stricture, as well as the patient's overall health and goals. Most patients choose definitive reconstructive surgery since this offers the highest success rate compared to other treatments for urethral strictures.

To determine the involvement of opioid receptors in the inhibitory pudendal-to-bladder reflex, the effect of naloxone (0.01–1 mg/kg, i.v.), an opioid receptor antagonist, on the inhibition of bladder activity evoked by pudendal nerve stimulation was investigated in α-chloralose anesthetized cats. The inhibition of reflex isovolumetric bladder contractions induced by pudendal nerve stimulation (5–10 Hz) at intensity threshold (T) for producing complete inhibition was significantly suppressed by naloxone at a high dose (0.3 mg/kg). However, the inhibition elicited at higher intensities (1.5–3 T) was not changed. Naloxone (1 mg/kg) did not alter the frequency dependence of the inhibitory effect of pudendal stimulation. During cystometrograms (CMGs) pudendal nerve stimulation significantly increased bladder capacity to 155.1 ± 24.5% and 163.4 ± 10% of the control at stimulation intensities of 1 T and 1.5–3 T, respectively. After administration of naloxone (1 mg/kg), the bladder capacity during pudendal nerve stimulation at inhibition threshold (1 T) was not significantly different from control, but it was significantly increased at higher intensities (1.5–3 T). Naloxone alone markedly reduced bladder capacity to 43 ± 11.1% of the control, and pudendal stimulation completely reversed this facilitatory effect. This study revealed that activation of opioid receptors contributes to or facilitates the inhibitory pudendal-to-bladder reflex. The reduction in bladder capacity after naloxone treatment also indicates that endogenous opioid peptides mediate a tonic inhibition of micturition. Understanding the neurotransmitter mechanisms involved in the inhibitory pudendal-to-bladder reflex could promote the development of new treatments for bladder overactivity and incontinence.