Urethroplasty Methods for Stricture Repair After Gender Affirming Phalloplasty: High Failure Rates in a Hostile Surgical Field.

OBJECTIVE: To report our experience with 71 postphalloplasty urethral strictures in order to discuss the performance characteristics of different urethroplasty techniques in urethral stricture after phalloplasty. METHODS: We conducted a retrospective chart review of 85 urethroplasties performed for stricture repair in 71 patients with phalloplasty for gender affirmation between August 2017 and May 2020. Stricture location, urethroplasty type, complication rate, and recurrence rate were recorded. RESULTS: The most common stricture type was distal anastomotic (40/71, 56%). The most common initial repair type was excision and primary anastomosis (EPA) (33/85, 39%), followed by first-stage Johanson urethroplasty (32/85, 38%). The stricture recurrence rate after initial repair of all types was 52% (44/85). The recurrence rate of stricture after EPA was 58% (19/33). The recurrence rate after staged urethroplasty was 25% (2/8) for patients who successfully completed a first and second stage. 30% (3/10) of patients who completed a first stage and opted out of a second stage required a revision to achieve successful lifetime voiding from the surgical urethrostomy. CONCLUSION: EPA after phalloplasty has a high failure rate. Nontransecting anastomotic urethroplasty has slightly lower failure rate, and staged Johanson-type surgeries have the highest success rates after phalloplasty.

High Surgical Complication Rates after Silicone Implant Use for Improvement of Glans Ridge Appearance.

Background: Construction of the glans is an important aspect of gender-affirming phalloplasty. In these surgeries, the glans ridge is commonly constructed using the Norfolk technique or a similar technique. In cases of glans ridge flattening after creation, we generally recommend a redo/revision glansplasty, which is often curative. However, in situations when the glans ridge flattens again, we developed a silicone glans implant technique in an effort to create a satisfactory and lasting glans ridge. Methods: We conducted a pilot study of our first 12 glans implant cases. A retrospective chart review and brief, ad-hoc patient survey measured patient demographics, implant status, and patient satisfaction. Results: A total of 12 patients received a silicone glans implant between November 2017 and February 2020. One patient had the glans implant removed before the survey, and also could not be contacted. Three patients did not respond to the survey. Of the eight patients who responded, only five (5/8, 63%) patients still had the silicone implant at the time of the survey. The average satisfaction score was 3.25 (range 1 = very satisfied and 5 = very dissatisfied). Common complaints cited included dissatisfaction with implant appearance, as well as infection, discomfort, and pain. Conclusions: Patients and surgeons should be aware of the possibility of a novel silicone implant technique to create a glansplasty in those with failed/flattened previous glansplasty surgery. However, the technique is in development: patient satisfaction remains spotty and complication rates are high, although technical improvements may increase future success rates.

Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications.

BACKGROUND: Penile prostheses may be used as a component of genital gender affirmation surgery for the purpose of achieving penile rigidity after phalloplasty, and transgender individuals experience higher complication rates than cisgender individuals. AIM: To observe complications with transmasculine penile prosthesis surgery over time and across surgical conditions. METHODS: Retrospective chart review of all transmasculine patients with phalloplasty undergoing penile prosthesis placement between 4/14/2017 and 2/11/2020 (80 patients). OUTCOMES: Independent variables include implant type, previous genital surgeries, and simultaneous genital surgeries. Dependent variables include prosthesis infection and mechanical complication (device malfunction, dislodgement, erosion). RESULTS: There was an overall complication requiring surgery rate of 36% and infection rate of 20% (15/67 for inflatable prostheses and 1/13 for semirigid), with 14% (11/80) experiencing infection requiring removal. Differences in infection rates appeared insignificant across categories of previous surgery or with simultaneous surgery, but we did notice a markedly lower rate for semirigid prostheses compared to inflatable. There was a significant relationship between infection and case number, with the probability of infection decreasing over time. Device loss at 9 months was 21% overall. Preoperative conditions of the neophallus such as prior stricture correction and perioperative factors such as simultaneous clean and clean-contaminated procedures seemed to pose no additional increase in complication rates. CLINICAL IMPLICATIONS: Type and number of prior and simultaneous non-prosthetic surgeries should not be considered as a risk factor for penile prosthesis after phalloplasty for transmasculine patients, even those that are clean-contaminated STRENGTHS & LIMITATIONS: Our cohort size is large compared to currently available studies, although not large enough to generate sufficient power for group comparisons. We have reported every genital surgical step between phalloplasty and penile prosthesis placement and recorded complications with subsequent devices after failure. Patient-reported outcomes were not collected. CONCLUSION: We demonstrate that preoperative conditions of the neophallus, such as prior stricture correction, and perioperative factors, such as simultaneous clean and clean-contaminated procedures, seem to pose no additional increase in complication rates. Our data suggest that surgical experience may further decrease complications over time. B. L. Briles, R. Y. Middleton, K. E. Celtik, et al. Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications. J Sex Med 2022;19:641-649.

Nephrectomy After High-Grade Renal Trauma is Associated With Higher Mortality: Results From the Multi-Institutional Genitourinary Trauma Study (MiGUTS).

OBJECTIVE: To test the hypothesis that undergoing nephrectomy after high-grade renal trauma is associated with higher mortality rates. METHODS: We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS≤8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure <90 mmHg), and Glasgow Coma Scale (GCS). RESULTS: A total of 1181 high-grade renal trauma patients were included. Median age was 31 and trauma mechanism was blunt in 78%. Injuries were graded as III, IV, and V in 55%, 34%, and 11%, respectively. There were 96 (8%) mortalities and 129 (11%) nephrectomies. Mortality was higher in the nephrectomy group (21.7% vs 6.5%, P <.001). Those who died were older, had higher ISS, lower GCS, and higher rates of shock. After adjusting for patient and injury characteristics nephrectomy was still associated with higher risk of death (RR: 2.12, 95% CI: 1.26-2.55). CONCLUSION: Nephrectomy was associated with higher mortality in the acute trauma setting even when controlling for shock, overall injury severity, and head injury. These results may have implications in decision making in acute trauma management for patients not in extremis from renal hemorrhage.

Optimization of Second-stage Metoidioplasty.

OBJECTIVE: To describe a planned 2-staged metoidioplasty. Metoidioplasty is a genital gender-affirmation surgery aimed at creating a neophallus, scrotum (if desired), and flat male-type perineum (if desired) from natal tissues. It generally requires a planned second-stage to place testes prostheses, address complications, and perform additional surgical steps to maximally lengthen the phallus. The details of this procedure are sparsely mentioned in the literature. We found that phallus length can be optimized in the second-stage by applying surgical principles already established in the surgical treatment of adult acquired buried penis. MATERIAL AND METHODS: We conducted a retrospective chart review of patients after metoidioplasty between August 2015 and June 2020, and isolated those that underwent second-stage metoidioplasty. Each procedure was done by 1 of 4 surgeons in a single practice in 2 locations, San Francisco, CA, and Austin, TX. Details of procedures required, complications, and demographic information were recorded. RESULTS: Out of the 75 patients that had undergone metoidioplasty, 37 (37 of 75, 49%) underwent a second-stage metoidioplasty. Reduction of upper scrotal blocking tissue was the most common procedure performed during a second-stage metoidioplasty (31 of 37, 84%), followed by escutcheonectomy/penile lift (30 of 37, 81%), bilateral implant placement (20 of 37, 54%), chordee repair (13 of 37, 35%), and unilateral implant placement (1 of 37, 3%). 6 of the 37 patients (16%) developed major complications. 5 of the 37 (5 of 37, 15%) second-stage patients required a redo second-stage metoidioplasty. CONCLUSION: Second-stage metoidioplasties are commonly performed on patients to optimize results of phallic lengthening and release, and to repair complications that arise after single-stage metoidioplasty. Escutcheonectomy/penile lift, placement of scrotal implants, repair of chordee, and upper scrotal blocking tissue reduction are procedures that are often performed during a second-stage metoidioplasty.

Planned and Unplanned Delayed Anterolateral Thigh Flap Phalloplasty.

BACKGROUND: Pedicled anterolateral thigh (ALT) flap phalloplasty can be limited by inadequate perfusion. Vascular delay increases perfusion, as delay causes blood vessel formation by limiting the blood supply available to a flap before transfer. We hypothesized that delayed ALT flap phalloplasty would decrease rates of partial flap or phallus loss and other postoperative complications when compared with previously reported complication rates of undelayed single-stage ALT phalloplasty in our practice. METHODS: A retrospective medical record review was performed on all phalloplasty patients in our practice between January 2016 and September 2019. We found those patients who had completed delayed ALT flap phalloplasty with at least 6 months of delay and 12 months of follow-up. For these patients, we recorded postoperative complications, simultaneous surgeries, subsequent surgeries, and demographic characteristics. RESULTS: Five female-to-male transsexuals underwent delayed ALT flap phalloplasty (two were unplanned procedures, three were planned). Planned delay: The average time between Stage 1 and Stage 2 was 6.5 months. Complications for the planned delay cohort were as follows: partial loss of the neophallus not requiring repair (33%), urethral stricture requiring surgical repair (33%). Unplanned delay: The average time between Stage 1 and Stage 2 was 9.1 months. The following complication was seen in the unplanned delay cohort: urethral stricture requiring surgical repair (50%). CONCLUSIONS: Vascular delay of ALT flap phalloplasty is a successful emergency salvage procedure. Planned delay of ALT flaps provided similar results compared with those previously reported by our practice with standard single-stage approach.

Arteriovenous Fistula Rescues Radial Forearm Phalloplasty: A Case Report on Patients with Microvascular Obstruction.

Radial forearm free flap phalloplasty (RFFFP) is the most common surgery performed for genital reconstruction of female-to-male transgender patients. However, up to 19% require anastomotic re-exploration. The postoperative creation of an arteriovenous fistula (AVF) to bypass obstruction and salvage RFFFP was first reported in 1996 and has subsequently been reported by 1 high-volume center in Belgium. METHODS: Here, we present 2 cases in which intraoperative microvascular obstruction threatened the viability of the RFFF of transgender phalloplasty patients. In each patient, an AVF was created between the radial artery and cephalic vein in the distal flap either after being transferred out of the operating room, as has previously been described, or during initial operation. RESULTS: In both cases, the creation of a distal AVF salvaged the neophallus. Importantly, the patient that had been transferred out of the operating room before reintervention suffered partial flap necrosis compared with no flap loss in the patient who had an AVF created during initial surgery. One AVF was ligated 18 days postoperative, whereas the other was never formally closed. CONCLUSIONS: These cases demonstrate that AVF can be reliably used for RFFFP salvage both intraoperatively and for reintervention. They also suggest that earlier detection of persistent vascular compromise and utilization of AVF can further minimize flap loss. Finally, in contrast with the prior explanation of this technique, timing of AVF ligation may be less critical than previously described. Microsurgeons are reminded that this technique may save complicated flaps in the uncommon case of microcirculatory flap obstruction.

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.

Vaginoplasty tips and tricks.

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.

Clinical and Radiographic Factors Associated With Failed Renal Angioembolization: Results From the Multi-institutional Genitourinary Trauma Study (Mi-GUTS).

OBJECTIVE: To find clinical or radiographic factors that are associated with angioembolization failure after high-grade renal trauma. MATERIAL AND METHODS: Patients were selected from the Multi-institutional Genito-Urinary Trauma Study. Included were patients who initially received renal angioembolization after high-grade renal trauma (AAST grades III-V). This cohort was dichotomized into successful or failed angioembolization. Angioembolization was considered a failure if angioembolization was followed by repeat angiography and/or an exploratory laparotomy. RESULTS: A total of 67 patients underwent management initially with angioembolization, with failure in 18 (27%) patients. Those with failed angioembolization had a larger proportion ofgrade IV (72% vs 53%) and grade V (22% vs 12%) renal injuries. A total of 53 patients underwent renal angioembolization and had initial radiographic data for review, with failure in 13 cases. The failed renal angioembolization group had larger perirenal hematoma sizes on the initial trauma scan. CONCLUSION: Angioembolization after high-grade renal trauma failed in 27% of patients. Failed angioembolization was associated with higher injury grade and a larger perirenal hematoma. Likely these characteristics are associated with high-grade renal trauma that may be less amenable to successful treatment after a single renal angioembolization.

Intrasphincteric anastomotic urethroplasty allows preservation of continence in men with bulbomembranous urethral strictures following benign prostatic hyperplasia surgery.

PURPOSE: Injury to the external sphincter during urethroplasty at or near the membranous urethra can result in incontinence in men whose internal sphincter mechanism has been compromised by previous benign prostatic hyperplasia (BPH) surgery. We present outcomes of a novel reconstructive procedure, incorporating a recent anatomic discovery revealing a connective tissue sheath between the external sphincter and membranous urethra, which provides a surgical plane allowing for intrasphincteric bulbo-prostatic urethroplasty (ISBPA) with continence preservation. METHODS: Stricture at or near the membranous urethra after transurethral resection (TURP) or open simple prostatectomy (OSP) was reconstructed with ISBPA. The bulbomembranous junction is approached dorsally with a bulbar artery sparing approach and the external sphincter muscle is carefully reflected, exposing the wall of the membranous urethra. Gentle blunt dissection along this connective tissue plane allows separating the muscle away up to the prostatic apex, where healthy urethra is found for anastomosis. RESULTS: From January 2010 to August 2019, 40 men (18 after TURP and 22 after OSP) underwent ISBPA at a single institution. Mean age was 67 years (54-82). Mean stricture length was 2.6 cm (1-6) with obliterative stricture identified in 10 (25%). At a mean follow-up of 53 months (10-122), 36 men (90%) are free of stricture recurrence and 34 (85%) were completely dry or using one security pad. CONCLUSION: This novel intrasphincteric urethroplasty technique for stricture following BPH surgery is feasible and safe, allowing successful reconstruction with continence preservation in most patients. A larger series and reproduction in other centers is needed.

Current Management of Extraperitoneal Bladder Injuries: Results from the Multi-Institutional Genito-Urinary Trauma Study (MiGUTS).

PURPOSE: We studied the current management trends for extraperitoneal bladder injuries and evaluated the use of operative repair versus catheter drainage, and the associated complications with each approach. MATERIALS AND METHODS: We prospectively collected data on bladder trauma from 20 level 1 trauma centers across the United States from 2013 to 2018. We excluded patients with intraperitoneal bladder injury and those who died within 24 hours of hospital arrival. We separated patients with extraperitoneal bladder injuries into 2 groups (catheter drainage vs operative repair) based on their initial management within the first 4 days and compared the rates of bladder injury related complications among them. Regression analyses were used to identify potential predictors of complications. RESULTS: From 323 bladder injuries we included 157 patients with extraperitoneal bladder injuries. Concomitant injuries occurred in 139 (88%) patients with pelvic fracture seen in 79%. Sixty-seven patients (43%) initially underwent operative repair for their extraperitoneal bladder injuries. The 3 most common reasons for operative repair were severity of injury or bladder neck injury (40%), injury found during laparotomy (39%) and concern for pelvic hardware contamination (28%). Significant complications were identified in 23% and 19% of the catheter drainage and operative repair groups, respectively (p=0.55). The only statistically significant predictor for complications was bladder neck or urethral injury (RR 2.69, 95% 1.21-5.97, p=0.01). CONCLUSIONS: In this large multi-institutional cohort, 43% of patients underwent surgical repair for initial management of extraperitoneal bladder injuries. We found no significant difference in complications between the initial management strategies of catheter drainage and operative repair. The most significant predictor for complications was concomitant urethral or bladder neck injury.