Vaginoplasty tips and tricks

ABSTRACT Vaginoplasty is a commonly performed surgery for the transfeminine patient. In this review, we discuss how to achieve satisfactory surgical outcomes, and highlight solutions to common complications involved with the surgery, including: wound separation, vaginal stenosis, hematoma, and rectovaginal fistula. Pre-operative evaluation and standard technique are outlined. Goal outcomes regarding aesthetics, creation of a neocavity, urethral management, labial appearance, vaginal packing and clitoral sizing are all described. Peritoneal vaginoplasty technique and visceral interposition technique are detailed as alternatives to the penile inversion technique in case they are needed to be used. Post-operative patient satisfaction, patient care plans, and solutions to common complications are reviewed.

Early catheter removal after anterior anastomotic (3 days) and ventral buccal mucosal onlay (7 days) urethroplasty

INTRODUCTION: Physicians who perform urethroplasty have varying opinions about when the urinary catheter should be removed post-operatively, but research on this subject has not yet appeared in the literature. We performed voiding cystourethrogram (VCUG) on our anterior urethroplasty patients on days 3 (anastomotic) and 7 (buccal) in an effort to determine the earliest day for removal of the urethral catheter. MATERIALS AND METHODS: Retrospective chart review of 29 urethroplasty patients from October 2002 - August 2004 was performed at two reconstructive urology centers. 17 patients had early catheter removal (12 anastomotic and 5 ventral buccal onlay urethroplasty) and were compared to 12 who had late removal (7 anastomotic and 5 buccal). RESULTS: Of those with early catheter removal, 2/12 (17 percent) of anastomotic urethroplasty patients had extravasation, which resolved by the following week and 0/5 (0 percent) of the buccal mucosal urethroplasty patients had extravasation. Patients with late catheter removal underwent VCUG 6-14 days (mean 8 days) after anastomotic urethroplasty and 9-14 days (mean 12 days) after buccal mucosal urethroplasty. 0 percent of the anastomotic urethroplasty had leakage after the late VCUG and 1/5 (20 percent) of the buccal patients had extravasation after the VCUG. Recurrences were low in all patient groups. CONCLUSION: Catheter removal after anastomotic and buccal mucosal urethroplasty can be safely attempted on the 3rd and 7th post-operative days respectively, with a low rate of extravasation on VCUG. Eliminating the catheter as soon as possible should improve patient comfort without harming results and decrease the overall negative impact of surgery on the patient.

Extended complications of urethroplasty

INTRODUCTION: An extensive study of complications following urethroplasty has never been published. We present 60 urethroplasty patients who were specifically questioned to determine every possible early and late complication. MATERIALS AND METHODS: Retrospective chart review of urethroplasty patients between August 2000 and March 2004. An "open format" questioning style allowed maximal patient reporting of all complications, no matter how minor. RESULTS: 60 patients underwent 62 urethroplasties (24 anterior anastomotic, 19 buccal mucosal and 10 fasciocutaneous, 9 posterior anastomotic) with mean follow-up of 29 months. Early complications occurred in 40 percent, but only 3 percent were major (rectal injury and urosepsis). Early minor complications included scrotal swelling, scrotal ecchymosis and urinary urgency. Late complications occurred in 48 percent, but only 18 percent were significant (erectile dysfunction, chordee and fistula). Late minor complications included a feeling of wound tightness, scrotal numbness and urine spraying. Fasciocutaneous urethroplasty caused the most significant complications, and buccal mucus urethroplasty the least, while also resulting in the lowest recurrence rate (0 percent). CONCLUSIONS: Serious complications after urethroplasty (3 percent early and 18 percent late) appear similar to those reported elsewhere, but minor bothersome complications appear to occur in much higher numbers than previously published (39 percent early and 40 percent late). While all the early complications were resolved and most (97 percent) were minor, less than half of the late complications were resolved, although most (82 percent) were minor. These complication rates should be considered when counseling urethroplasty patients, and generally tend to support the use of buccal mucosal onlay urethroplasty as it had the lowest rate of serious side effects.

Resorbable extracellular matrix grafts in urologic reconstruction

PURPOSE: There is an increasingly large body of literature concerning tissue-engineering products that may be used in urology. Some of these are quite complex (such as multilayer patient-specific cell-seeded implants) yet the most simple and successful products to date are also the most uncomplicated: resorbable acellular extra-cellular matrices (ECMs) harvested from animals. ECMs have been used in a variety of difficult urologic reconstruction problems, and this review is intended to summarize this complex literature for the practicing urologist. METHODS: Medline search of related terms such as "SIS, small intestinal submucosa, ECM, extracellular matrix, acellular matrix and urologic reconstruction". Manuscripts missed in the initial search were taken from the bibliographies of the primary references. RESULTS: Full review of potential clinical uses of resorbable extra-cellular matrices in urologic reconstruction. CONCLUSIONS: Currently, the "state of the art" in tissue engineering solutions for urologic reconstruction means resorbable acellular xenograft matrices. They show promise when used as a pubovaginal sling or extra bolstering layers in ureteral or urethral repairs, although recent problems with inflammation following 8-ply pubovaginal sling use and failures after 1- and 4-ply SIS repair of Peyronie's disease underscore the need for research before wide adoption. Preliminary data is mixed concerning the potential for ECM urethral patch graft, and more data is needed before extended uses such as bladder augmentation and ureteral replacement are contemplated. The distant future of ECMs in urology likely will include cell-seeded grafts with the eventual hope of producing "off the shelf" replacement materials. Until that day arrives, ECMs only fulfill some of the requirements for the reconstructive urologist.

Successful management of stuttering priapism using home self-injections of the alpha-agonist metaraminol

Low-flow priapism can result in impotence if treatment is delayed, yet patients with recurrent priapism often suffer delay before therapy. We describe management of recurrent priapism using self-administered injections of intracavernosal metaraminol (AramineÖ, Merck), a long-acting vasoconstricting amine that is considered safer than epinephrine. The patient injects as often as once daily using 5-10 mg of drug. Our patient reports rapid detumescence and has not required emergency room visits since starting injections. He denies complications. Treatment of priapism using metaraminol has been suggested in the hospital setting; however, this is the first report of successful home self-administration of the drug.