Surgical management and outcomes of adult acquired buried penis with and without lichen sclerosus: a comparative analysis.

PURPOSE: Adult acquired buried penis (AABP) can present with concomitant Lichen Sclerosus (LS), a chronic dermatosis that may affect surgical outcomes. Our aim was to evaluate outcomes of patients undergoing AABP repair with and without LS. METHODS: A retrospective cohort study was performed for AABP repair patients at a single institution from 1/1991 to 12/2017. Patient characteristics and surgical and peri-operative outcomes, including success, erectile function, and complications, were collected. RESULTS: Sixty-seven AABP patients with mean follow-up of 16.1 ± 20.4 months were identified. Overall surgical success was 91%. Overall surgical complication rate was 50.7% (23.9% Clavien-Dindo ≥ 3). Forty-two (62.7%) patients had concomitant LS. A higher proportion of patients with LS required a STSG (90% vs 60%, p = 0.005). There was no difference in surgical success (90.5% vs 92.0%, p = 0.999), overall complication rate (57.1% vs 40.0%, p = 0.212), Clavien-Dindo ≥ 3 complications (23.8% vs 24.0%, p = 0.999) or early complications (35.7% vs 32.0%, p = 0.797) between patients with and without LS, respectively. However, a higher proportion of patients with LS experienced late complications (33.3% vs 8.0%, p = 0.020), which were mainly related to wound healing. Satisfaction with erectile function was higher among patients with LS (59.5% vs 320%, p = 0.043). CONCLUSION: AABP patients with LS behave somewhat differently than their non LS counterparts. They are more likely to require skin graft during surgical treatment. Though surgical success and complications are similar, they do experience a higher rate of late complications from impaired wound healing. Work on improving wound healing in this population should be considered.

Rectourethral Fistulas Secondary to Prostate Cancer Treatment: Management and Outcomes from a Multi-Institutional Combined Experience.

PURPOSE: Rectourethral fistula is a known complication of prostate cancer treatment. Reports in the literature on rectourethral fistula repair technique and outcomes are limited to single institution series. We examined the variations in technique and outcomes of rectourethral fistula repair in a multi-institutional setting. MATERIALS AND METHODS: We retrospectively identified patients who underwent rectourethral fistula repair after prostate cancer treatment at 1 of 4 large volume reconstructive urology centers, including University of California-San Francisco, University College London Hospitals, Lahey Clinic and Devine-Jordan Center for Reconstructive Surgery, in a 15-year period. We examined the types of prostate cancer treatment, technical aspects of rectourethral fistula repair and outcomes. RESULTS: After prostate cancer treatment 201 patients underwent rectourethral fistula repair. The fistula developed in 97 men (48.2%) after radical prostatectomy alone and in 104 (51.8%) who received a form of energy ablation. In the ablation group 84% of patients underwent bowel diversion before rectourethral fistula repair compared to 65% in the prostatectomy group. An interposition flap or graft was placed in 91% and 92% of the 2 groups, respectively. Concomitant bladder neck contracture or urethral stricture developed in 26% of patients in the ablation group and in 14% in the prostatectomy group. Postoperatively the rates of urinary incontinence and complications were higher in the energy ablation group at 35% and 25% vs 16% and 11%, respectively. The ultimate success rate of fistula repair in the energy ablation and radical prostatectomy groups was 87% and 99% with 92% overall success. CONCLUSIONS: Rectourethral fistulas due to prostate cancer therapy can be reconstructed successfully in a high percent of patients. This avoids permanent urinary diversion in these complex cases.

Continuing Medical Education and Maintenance of Certification.

INTRODUCTION: The ABMS (American Board of Medical Specialties) mandated maintenance of certification in 2000 for its 24 member boards. The ABU (American Board of Urology) initiated the maintenance of certification process in 2007. METHODS: A literature review using Medline® and a Google® search was performed using continuing medical education and maintenance of certification as search terms to identify pertinent literature. RESULTS: The relevant literature was reviewed, and a distillation of the controversial issues regarding continuing medical education and maintenance of certification was composed. CONCLUSIONS: The body of literature reviewed supports the conclusions that maintenance of certification serves as the most reliable vehicle to ensure lifelong learning and continuing medical education alone is not sufficient.

Penile Amputation: Cosmetic and Functional Results.

INTRODUCTION: Penile amputation is a rare type of external genital trauma. It may arise from accidental trauma, assault or self-inflicted mutilation. As with all trauma, initial management focuses on assessment and resuscitation of the patient. When available, hypothermic preservation of the detached penis should be undertaken. AIM: This review serves to compile the current available information on etiology and management of penile amputation injuries, with focus on functional and cosmetic results. MAIN OUTCOME MEASURES: Main outcome measures were penile cosmetics, viability, and sensation; urethral patency and graft survival, functionality. METHODS: A literature search using Medline, PubMed (U.S. National Library of Medicine and the National Institutes of Health), and abstracts from scientific meetings was performed from 1980-2013. RESULTS: Due to the rarity of penile amputation injuries, no randomized trials exist. Likewise, available published series on management of this condition are comprised of a small number of patients. CONCLUSIONS: Penile amputation is rare but challenging. Current microreplantation procedures have a uniformly good result with a minimum number of post-operative complications. When microreplantation cannot be performed, older corporal reattachment techniques may be offered. When phallic reconstruction is required, a microsurgical free forearm flap phalloplasty may be performed to restore the patient with an acceptable cosmetic and functional phallus. Virasoro R, Tonkin JB, McCammon KA, and Jordan GH. Penile amputation: Cosmetic and functional results. Sex Med Rev 2015;3:214-222.

International multi-institutional experience with the vessel-sparing technique to reconstruct the proximal bulbar urethra: mid-term results.

OBJECTIVE: To present mid-term outcomes from an international, multi-institutional cohort of patients undergoing vessel-sparing excision and primary anastomosis urethroplasty for the reconstruction of the anterior urethra. MATERIALS AND METHODS: From June 2003 to December 2011, 68 patients underwent vessel-sparing anterior urethral reconstruction at five different international institutions using the vessel-sparing technique described by Jordan et al. (J Urol 177(5):1799-1802, 2007). RESULTS: Patients' age range was from 3 to 82 years (mean 51.2). Stricture length ranged from 1 to 3 cm (mean 1.78). After a mean follow-up of 17.6 months, 95.6 % of patients had a widely patent urethral lumen. Three patients failed the procedure, requiring either direct vision internal urethrotomy or urethral dilation, after which all were free of symptoms and did not require further instrumentation. Complications were minimal and as expected following open urethroplasty. CONCLUSION: Preservation of blood supply is a noble pursuit in surgery; however, it can be technically difficult and often requires more time and effort. This vessel-sparing technique for anterior urethral reconstruction is reproducible and appears to be reliable in this international cohort. Larger studies and longer follow-up are needed to support these encouraging results.

Minimally invasive treatment of Peyronie's disease: evidence-based progress.

Peyronie's disease (PD) is often physically and psychologically devastating for patients, and the goal of treatment is to improve symptoms and sexual function without adding treatment-related morbidity. The potential for treatment-related morbidity after more invasive interventions, e.g. surgery, creates a need for effective minimally invasive treatments. We critically examined the available literature using levels of evidence to determine the reported support for each treatment. Most available minimally invasive treatments lack critical support for effectiveness due to the absence of randomised, placebo-controlled trials (RCTs) or non-significant results after RCTs. Iontophoresis, oral therapies (vitamin E, potassium para-aminobenzoate, tamoxifen, carnitine, and colchicine), extracorporeal shockwave therapy, and intralesional injection with verapamil or nicardipine have shown mixed or negative results. Treatments that have decreased penile curvature deformity in Level 1 or Level 2 evidence-based, placebo-controlled studies include intralesional injection with interferon α-2b or collagenase clostridium histolyticum.

Effect of a temporary thermo-expandable stent on urethral patency after dilation or internal urethrotomy for recurrent bulbar urethral stricture: results from a 1-year randomized trial.

PURPOSE: The long-term success rate of dilation and/or internal urethrotomy is low in cases of recurrent urethral stricture. We investigated the ability of the Memokath™ 044TW stent to maintain urethral patency after dilation or internal urethrotomy for recurrent urethral stricture. MATERIALS AND METHODS: A total of 92 patients with recurrent bulbar urethral strictures (mean length 2.7 cm) were treated with dilation or internal urethrotomy and randomized to short-term urethral catheter diversion (29) or insertion of a Memokath 044TW stent (63). The primary end point was urethral patency, as assessed by passage of a calibrated endoscope. Secondary end points included urinary symptoms and uroflowmetry parameters. Stents were scheduled to remain in situ for 12 months. RESULTS: The rate of successful stent insertion was 93.6% (59 of 63 patients). In stented patients patency was maintained significantly longer than controls (median 292 vs 84 days, p <0.001). Patency was reflected in significantly improved uroflowmetry and symptom scores. The stent was removed in 100% of patients. The most frequently noted side effects in stented patients were bacteriuria, hematuria and penile pain, which were usually mild and transient. There was no difference in sexual function between stented and control patients. Stent dislocation and occlusion were observed in 8 and 3 patients, respectively. CONCLUSIONS: Patients with recurrent bulbar urethral strictures treated with dilation or urethrotomy and a Memokath 044TW stent maintained urethral patency significantly longer than those treated with dilation or urethrotomy alone. The stent side effect profile was favorable. The stent was straightforward to insert and it was removed without difficulty even after long-term placement.

Outcome of penile revascularization for arteriogenic erectile dysfunction after pelvic fracture urethral injuries.

OBJECTIVE: To review our experience with penile revascularization for patients with bilateral occlusion of the deep internal pudendal arteries after pelvic fracture urethral injury (PFUI). MATERIALS AND METHODS: We identified 17 patients who had undergone penile revascularization with end-to-side anastomosis of the deep inferior epigastric artery to the dorsal penile artery from July 1991 to December 2010. Success was defined as achieving erections sufficient for intercourse with or without pharmacologic assistance. RESULTS: All patients had had a PFUI causing arterial insufficiency and erectile dysfunction not responsive to pharmacologic intervention. Of the 17 patients, 4 (24%) underwent revascularization before and 13 (76%) after PFUI repair. The mean age at revascularization was 32.7 years (range 17-54). At an average follow-up of 3.1 years, the surgery was successful in 14 of the 17 patients (82%). In patients with erectile dysfunction as an indication for surgery, successful erections were achieved in 11 of 13. For those who underwent revascularization to prevent ischemic stenosis of the urethral repair, 3 of 4 achieved successful erections, and all subsequent urethral surgeries were successful. The penile duplex ultrasound parameters showed clinically and statistically significant improvements after revascularization. No operative complications developed. The average hospital length of stay was 4.7 days. Four patients experienced early postoperative complications, including an abdominal wall hematoma requiring evacuation in one, penile edema in two, and a superficial surgical site infection in one. No late complications occurred. CONCLUSION: Penile arterial revascularization in select patients can allow for successful treatment of PFUIs and the refractory erectile dysfunction caused by them.

Assessment and initial management of urologic trauma.

This article discusses the appropriate assessment, initial management, timely referral to a urologist for abdominal, bladder, urogenital, and renal/renal collecting system injury. Appropriate laboratory and physical examinations, as well as radiologic imaging, are paramount to obtaining accurate diagnosis and to providing appropriate treatment.

Management of distal anterior urethral strictures.

Management of men with anterior urethral stricture disease is a relatively common issue faced by practicing urologists today. Anterior urethral strictures, which can be the result of congenital, idiopathic, iatrogenic or inflammatory causes, can affect patients of all ages and might present as some or all of the following disorders: difficulty with voiding, urinary tract infection, acute urinary retention and high bladder emptying pressures. A thorough understanding of the urethral anatomy and etiology of the stricture followed by effective treatment are crucial if successful outcomes for the patient are to be achieved. Historically, urologists viewed open repair as an option that should only be offered to patients who had failed to respond to repeated endoscopic treatments-the so-called reconstructive ladder. This dogma has, however, been scrutinized; urologists should be aware that this process may subject patients to repeated procedures with a low success rate, such as dilatation and internal urethrotomy, rather than one potentially curative operation, such as graft or flap urethroplasty.

Management of recurrent anastomotic stenosis following radical prostatectomy using holmium laser and steroid injection.

OBJECTIVE: To present our experience with the management of recurrent and resistant anastomotic stenosis following radical prostatectomy (RP) using transurethral laser incision of the stenotic area and injection of steroids. PATIENTS AND METHODS: Between January 1999 and April 2006, we evaluated 24 patients with anastomotic stenosis that would not allow the passage of the flexible cystoscope (17 F). Using the paediatric 7.5 F Olympus scope and a 550-microm fibre holmium laser, deep incisions were cut at the 3 and 9 o'clock positions at the bladder neck, and then triamcinolone was injected at the incision sites. Another session was then scheduled for office cystoscopy 6 weeks later, and if that showed evidence of annularity, another incision was made, as described above. RESULTS: All 24 patients had RP for localized disease, 21 were retropubic and two were perineal, and one laparoscopic. Five patients had adjuvant radiotherapy. The mean patient age was 64 years. Nineteen (79%) patients had previous attempts to open the bladder neck: eight patients had dilatation, eight patients had internal urethrotomy, five patients underwent transurethral resection of the bladder neck, and six patients had open surgical intervention. The procedure was done once in 17 patients, and twice in seven patients. After a mean (range) follow up of 24 (6-72) months, 19 patients (83%) had a well-healed and widely patent bladder neck. Of the 24 patients, 17 had urinary incontinence (UI) associated with the bladder neck contracture. An artificial urinary sphincter was implanted in 11 patients, three of which had to be explanted for malfunction in two, and erosion in one. CONCLUSION: Holmium laser bladder neck incision and steroid injection for anastomotic stenosis after RP had a success rate of 83% in this small series. It can be used safely as a primary treatment, or in some cases, for resistant and recurrent stenosis. It appears that insertion of an artificial sphincter can be done in patients with UI when the bladder neck remains patent for at least 8 weeks.

The use of intralesional clostridial collagenase injection therapy for Peyronie's disease: a prospective, single-center, non-placebo-controlled study.

INTRODUCTION: Peyronie's disease afflicts at least 3% of sexually active men over the age of 30. Many pharmacologic therapies have been tried, but to date, no systemic or local therapy has been proven to provide predictable and lasting results. AIM: This study was designed to assess the efficacy and safety of intralesional clostridial collagenase injection therapy in a series of patients with Peyronie's disease. METHODS: Twenty-five patients aged 21-75 years who were referred to a single institution with a well-defined Peyronie's disease plaque were treated with three intralesional injections of clostridial collagenase 10,000 units in a small volume (0.25 cm(3) per injection) administered over 7-10 days, with a repeat treatment (i.e., three injections of collagenase 10,000 units/25 cm(3) injection over 7-10 days) at 3 months. Primary efficacy measures were changes from baseline in the deviation angle and plaque size. Secondary efficacy end points were patient responses to a Peyronie's disease questionnaire and improvement according to the investigators' global evaluation of change. MAIN OUTCOME MEASURE: The primary efficacy measures were change in deviation angle and change in plaque size. Secondary end points were patient questionnaire responses and improvement according to the investigators' global evaluation of change. RESULTS: Significant decreases from baseline were achieved in the mean deviation angle at months 3 (P = 0.0001) and 6 (P = 0.0012), plaque width at months 3 (P = 0.0052), 6 (P = 0.0239), and 9 (P = 0.0484), and plaque length at months 3 (P = 0.0018) and 6 (P = 0.0483). More than 50% of patients in this series considered themselves "very much improved" or "much improved" at all time points in the study, and the drug was generally well tolerated. CONCLUSION: The benefits of intralesional clostridial collagenase injections in this trial lend support to prior studies supporting its use in the management of Peyronie's disease. A double-blind, placebo-controlled study is currently under development.

Long-term follow-up for reconstruction of strictures of the fossa navicularis with a single technique.

OBJECTIVE: To retrospectively review our experience with the ventral transverse skin island elevated on a dartos fascia flap. PATIENTS AND METHODS: In all, 45 patients were consecutively operated by the senior author using this technique from March 1987 to January 2006. The files of 35 patients were assessed for the study. Success was defined as a patent urethral calibre of >/=16 F that did not require further procedures. Follow-up consisted of, endoscopy with calibration, office visits, and telephone calls. This procedure was described in 1987 by Jordan. The overall outcome as well as indications after the follow-up period are presented. RESULTS: The overall success rate was 83% with a mean long-term follow-up of 10.2 years. All of the patients with a non-lichen sclerosus (LS)/balanitis xerotica obliterans (BXO) diagnosis had excellent results (23/23) with a mean follow-up of 10.2 years. LS/BXO recurred at the fossa or meatus in six of 12 patients. Seventeen patients (48%) were lost to follow-up, and three patients (9%) died from other causes. CONCLUSIONS: The ventral transverse penile skin island flap has proven to be effective, reliable, reproducible, and with good functional and aesthetic results in all fossa navicularis strictures with the exception of those strictures resulting from LS/BXO.