Jessica Delong

Objective To report 1-year results of the ROBUST II study investigating the safety and efficacy of a paclitaxel-coated balloon for the treatment of recurrent urethral strictures. Methods Subjects were adult men with a single anterior urethral stricture ≤ 3 cm in length and at least 2 prior stricture treatments. After treatment with the Optilume urethral drug-coated balloon (DCB), subjects were followed through 1 year. The primary safety endpoint was the rate of treatment-related serious complications at 90 days post-procedure. Efficacy outcomes included symptomatic assessments, erectile function measured using the International Index of Erectile Function (IIEF), Qmax, and anatomic success. Results Sixteen men with an average of 4.1 prior dilations were treated with the DCB. Anatomic success was achieved at 6 months in 73%. Average IPSS improved from 18.4 to 6.0 at 1 year (P < 0.001). Qmax improved from 6.9 mL/sec to 20.8 mL/sec (P < 0.001). There was no change in IIEF. Four su...

hospitalization in a woman with no prior anti-reflux surgery. She had a concomitant diagnosis of gestational HTN. Overall, UTIs occurred during 11/38 pregnancies (29%) in women with conservatively managed VUR and 2/32 pregnancies (6%) in women with a history of anti-reflux surgery (p[0.03). Gestational hypertension/pre-eclampsia, spontaneous abortion, and pre-term delivery were also more common among women who were conservatively managed (Table 1). CONCLUSIONS: In this small population of women with VUR, UTIs during pregnancy were more common among women who had undergone conservative, non-operative VUR management compared to those who had prior surgical correction. Interestingly, other adverse maternal and fetal outcomes were also more common in the conservatively managed group. Larger studies are needed to further investigate these trends in order to improve informed decision-making for families of girls with VUR.

OBJECTIVE To determine the response to a virtual educational curriculum in reconstructive urology presented during the COVID-19 pandemic. To assess learner satisfaction with the format and content of the curriculum, including relevance to learners' education and practice. MATERIALS AND METHODS A webinar curriculum of fundamental reconstructive urology topics was developed through the Society of Genitourinary Reconstructive Surgeons and partnering institutions. Expert-led sessions were broadcasted. Registered participants were asked to complete a survey regarding the curriculum. Responses were used to assess the quality of the curriculum format and content, as well as participants' practice demographics. RESULTS Our survey yielded a response rate of 34%. Survey responses showed >50% of practices offer reconstructive urologic services, with 37% offered by providers without formal fellowship training. A difference in self-reported baseline knowledge was seen amongst junior r...

This study aimed at comparing surgical outcomes and patient-reported donor site morbidity between lingual mucosal graft (LMG) and buccal mucosal graft (BMG) through a meta-analysis of comparative studies. A systematic literature search was performed in January 2019 including non-randomized comparative studies and randomized controlled trials (RCT). The assessed data included urethroplasty outcomes, complications, and donor site morbidities such as pain, bleeding, swelling, numbness, difficulty speaking, difficulty eating, mouth opening, and difficulty with tongue protrusion. A total of 632 patients (LMG 323, BMG 309) from 12 comparative studies (four RCTs and eight non-randomized) were included in the meta-analysis. Overall pooled effect estimates revealed no significant difference on reported surgical outcomes and operative stricture-related complications. The LMG group reported a higher proportion of patients with difficulty speaking (RR 6.96, 95% CI 2.04–23.70) and difficulty with tongue protrusion (RR 12.93, 95% CI 3.07–54.51) within 30 days post-op. In comparison, the BMG group had significantly more incidence of early post-procedural donor site swelling (RR 0.39, 95% CI 0.25–0.61) and numbness within 30 days post-op (RR 0.48, 95% CI 0.23–0.97) and 3–6 months (RR 0.52, 95% CI 0.30–0.90) post-op. The evidence suggests no overall significant difference between LMG and BMG with regard to urethroplasty outcomes at 1-year follow-up. While patients undergoing LMG urethroplasty have a higher chance of experiencing difficulty with speech and difficulty with tongue protrusion within 1 month of surgery, the BMG group is more likely to experience early donor site swelling and mouth opening difficulty within 30 days post-op, as well as oral numbness for up to 6 months.

Female urethral stricture disease is rare and has several surgical approaches including endoscopic dilations (ENDO), urethroplasty with local vaginal tissue flap (ULT) or urethroplasty with free graft (UFG). This study aims to describe the contemporary management of female urethral stricture disease and to evaluate the outcomes of these three surgical approaches.

Introduction: We aimed to investigate the safety and preliminary efficacy of the OptilumeTM paclitaxel-coated balloon for the treatment of recurrent urethral stricture. Methods: Men with bulbar urethral strictures ≤2 cm with 1–4 prior endoscopic treatments were enrolled at four study sites after Ethics Committee approvals. All subjects were treated with mechanical balloon dilation or direct visualization internal urethrotomy prior to drug-coated balloon treatment. Patients were evaluated at 2–5 days, 14 days, three, six, and 12-months post-treatment. The primary safety endpoint was serious complications through 90 days post-procedure. The preliminary efficacy endpoint was anatomic success, defined as urethral lumen ≥14 Fr at 12 months. Results: A total of 53 subjects were enrolled and treated; 46 completed the 12-month followup. Forty-three percent of men had undergone >1 previous dilation; the mean for the overall study population was 1.7 prior dilations. There were no serious a...

OBJECTIVE To determine the long-term outcome of transobturator sling for male Stress Urinary Incontinence (SUI) clustered according to pre-operative SUI severity, and to identify predictors of treatment success durability and failure occurrence in long-term follow-up. METHOD A non-concurrent study was conducted on all transobturator male sling cases performed from August 2006 to June 2012 by a single surgeon. Pre-operative SUI severity was clustered into mild (≤2 ppd), moderate (3-4 ppd) or severe (≥5 ppd). Success was defined as complete dryness with zero pads used (cured), and a patient with ≥50% improvement, satisfied without further procedures needed. Otherwise it was considered a treatment failure. Clinical variables significantly associated with long-term treatment success were determined. Time-to-event (Kaplan-Meier) and Multiple-Cox regression analysis were performed to determine predictors of long-term treatment outcome. RESULTS A total of 215 patients (mild-59, moderate-94, severe-62) with a mean follow-up of 56.4±41.6 months were included. On long-term follow-up, 150 (69.8%) patients-maintained treatment success and 96 (44.7%) were dry. The long-term outcome success clustered according to SUI severity as mild, moderate and severe was 84.7%, 72.3%, and 51.6%, respectively. Kaplan-Meier with Log-rank test and Multiple Cox-regression determined that both concomitant urge incontinence and pre-operative SUI severity were independent predictors of long-term durability of treatment success and failure occurrence. Pre-operative SUI severity was the only predictor of long-term cure sustainability. CONCLUSION The time to event analysis with an average of ∼5 years post-operative follow-up has determined that the pre-operative severity and presence of concomitant urge incontinence were independent predictors for long-term outcome.

INTRODUCTION AND OBJECTIVES: A novel liposomal formulation of bupivacaine is available as a 96-hour delayed release formulation. Given that patient reported pain from the Buccal Mucosal Graft (BMG) harvest site is worst in the first 1-2 days following surgery, infiltration of this medication has the potential to dramatically reduce post-operative pain in these patients. We aim to assess the efficacy and safety of liposomal bupivacaine infiltration on the BMG harvest site in alleviating pain by evaluating the post-operative pain score, narcotic requirement and associated morbidities. METHODS: After IRB approval, a single-blinded randomized controlled trial was conducted among adult patients with urethral stricture, that were evaluated suitable for substitution urethroplasty using BMG. Patients were randomized using computer generated allocation scheme to group 1 (liposomal bupivacaine) and group 2 (control). Patient demographic and peri-operative data were collected. Outcome assessed were: post-operative day 1 -2 narcotic use, converted as cumulative morphine equivalents on a 24-hour basis. A validated survey with 10-point visual analogue scale for evaluation of patient reported oral pain score, associated oral morbidities, and oral conditions on post-procedural day 1-3 and 1-month follow-up. Fisher-exact test and independent T-test was used to analyze the data with statistical significance set at 0.05 level. (Clinicaltrials.gov registration NCT03720223) RESULTS: A total of 50 eligible patients were enrolled, 7 were excluded according to predefined exclusion criteria (Group 1: 21, Group 2: 22). No significant baseline characteristics difference was noted between the treatment groups. Compared to group 2, a significantly lesser narcotic requirement was noted among the patients in group 1 on post-op day 1 (IV Morphine equivalent mean difference 8.58; 95%CI 1.59, 15.56, p=0.017). No significant between group difference was noted for narcotic requirements on post-op day 2. Likewise, no between group difference was noted for post-procedural oral pain score, and oral morbidities on post-op day 1 to 3, and at 1-month follow-up. For post-procedural oral conditions, a significantly higher number of patients in group 1 have reported oral numbness at post-op day 2 (14 (87.5%) vs 8 (44.4%); p=0.013), which was not sustained and equivalent to group 2 at 1-month follow-up. CONCLUSIONS: Our study showed that Liposomal bupivacaine infiltration to the BMG harvest site is safe and may adequately address the post-procedural oral pain, with noted significantly fewer narcotic requirements at post-op day 1. Although, higher incidence of oral numbness can be reported among these patients on post-op day 2, which was not long-lasting. Future studies may consider to evaluate the cost-effectiveness to determine suitability for routine use. Source of Funding: None

OBJECTIVE To compare the postprocedural oral pain scale and other patient reported oral morbidities for nonclosure vs closure of buccal mucosal graft (BMG) harvest sites through systematic review and meta-analysis of comparative studies. METHODS A systematic literature search was performed in September 2018. Nonrandomized comparative studies were summarized and randomized controlled trials were evaluated according to the Cochrane Collaboration recommendations. The outcomes assessed were: pain, perioral numbness, mouth opening tightness, and impairment of oral intake. Standardized mean difference, and relative risk with corresponding 95% confidence intervals were extrapolated. Effect estimates were pooled using the inverse variance method with a random-effects model. Subgroup analysis was performed according to the shape of the BMG harvested. PROSPERO registry (CRD42016043502). RESULTS A total of 269 patients from 4 randomized controlled trials were included for meta-analysis. Overall pooled effect estimates on the reported pain score assessed on postprocedural day 1, day 3-7 and 6 months, have shown no significant difference between the closure and nonclosure treatment groups. Subgroup analysis showed that rectangular shaped BMG harvest sites that were not closed had lower pain scores (standardized mean difference-0.90, 95% confidence interval -1.70, -0.10) on postoperative day 1. No reported short or long-term oral morbidities required further surgical intervention in either treatment group. CONCLUSION The evidence suggests that at 6-month follow-up, there is no overall significant difference between nonclosure and closure of BMG harvest sites. However, among rectangular shaped BMG, not closing the harvest site may lead to less immediate postoperative pain when compared to closure of the harvest site.

To evaluate the outcomes and factors affecting success of urethroplasty in patients with stricture recurrence after Urolume® urethral stent. Retrospective international multicenter study on patients treated with urethral reconstruction after Urolume® stent. Stricture and stent length, time between urethral stent insertion and urethroplasty, age, mode of stent retrieval, type of urethroplasty, complications and baseline and post-urethroplasty voiding parameters were analyzed. Successful outcome was defined as standard voiding, without need of any postoperative adjunctive procedure. Sixty-three patients were included. Stent was removed at urethroplasty in 61 patients. Reconstruction technique was excision and primary anastomosis in 14(22.2%), dorsal onlay buccal mucosa graft (BMG) 9(14.3%), ventral onlay BMG 6(9.5%), dorso-lateral onlay BMG 9(14.3%), ventral onlay plus dorsal inlay BMG 3(4.8%), augmented anastomosis 5(7.9%), pedicled flap urethroplasty 6(9.5%), 2-stage procedure 4(6.4...

METHODS: 15 transgender patients who were already living as females presented to our institution from 1/2016 to 10/2016, and underwent our previously defined RAPiV. Briefly, the RAPiv is performed in the low lithotomy position and the penis is degloved through a circumcision incision. An additional perineal incision is made to the bulbar urethra. The dissected penis, urethra, neurovascular bundle, glans and corpora are delivered through the perineal incision (Figure 1a). We spare the dorsal aspect of the tunica of the corpora cavernosa to reduce risk of glans necrosis. Four robotic ports were placed and the abdomen was insufflated (1b) and robot docked. Denonviller’s fascia is opened (1c) and the abdominal dissection is continued to the peritoneal one (1d), the neovagina is passed into robotic field (1e) and pexed to the anterior reflection of the posterior peritoneum (1f). The peritoneal reflection is then closed (1g). We then complete the labioplasty and clitoroplasty. RESULTS: The average operative time for RAPiV was 5.8 hours (5-7), 8/15 (53%) required mobilization of additional tissue flaps (4/15, 27%) or underwent concomitant abdominoplasty and skin graft harvest (4/15 27%) to supplement penile skin. EBL was 386cc (100600) and LOS was 3.7 (2-6). Average postoperative vaginal depth was 11.3cm (10.2-12.7). Two patients had complications, 1 dehiscence of labioplasty treated with conservative therapy and 1 had loss of neovagina depth and distal urethral stenosis secondary to wound infection requiring debridement. CONCLUSIONS: We have performed 15 cases utilizing our novel method for robot assisted penile inversion vaginoplasty. Under direct visualization the neovaginal canal is created. This technique achieves maximal vaginal length in a reproducible manner.

INTRODUCTION AND OBJECTIVES: Male stress urinary incontinence (SUI) is a common sequela of radical prostatectomy and occasionally benign prostatic hyperplasia surgery, causing significant impact on quality of life. The AdVance transobturator sling has been described as a safe and effective minimally invasive treatment for male SUI, but early postoperative urinary retention (EPUR) is not uncommon. This study evaluates the outcomes of patients who have EPUR after insertion of an AdVance transobturator male sling for treatment of SUI. Our hypothesis is that although EPUR can be concerning, it is usually transient and may be associated with favorable continence outcomes. METHODS: A review of all men with SUI treated with an AdVance transobturator sling by a single surgeon during the period of January 1, 2006 through August 1, 2016, was performed. Perioperative, continence and complication outcomes (including urinary retention, mesh erosion and reoperation) were assessed. Outcomes of men who experienced EPUR were compared with men who did not experience EPUR. Statistical analyses such as Chi Square test were performed in Microsoft Excel 2016. RESULTS: 257 men (mean age 68 years) underwent insertion of a transobturator sling for SUI during the study period. Mean follow up was 25 months; 5 men were lost to follow up. Overall, success rate was 84%, with 45% (114/252) of men reporting complete continence and 39% (98/252) reporting improvement only. Overall, the mean number of pads used per patient per day improved from 3.7 pre-sling to 1.3 post-sling insertion. 16% (41/252) of patients experienced EPUR which was treated with reinsertion of indwelling Foley urethral catheter and repeat void trial. Most cases of urinary retention resolved within weeks; one patient required explantation of the sling due to ongoing urinary retention beyond 3 months. In the group of patients who had EPUR, success rate was 98%, with 61% of men achieving complete continence and 37% reporting improvement only. By comparison, in the group of patients who did not have EPUR, success rate was 82%, with 42% of men reporting complete continence and 39% of men stating improvement only. The difference in continence success rate between the EPUR and no EPUR groups was statistically significant (p<0.05). CONCLUSIONS: Insertion of an AdVance transobturator sling for treatment of male SUI was complicated by EPUR in 16% of men. Most cases of EPUR were transient. The continence success rate in the group of men who experienced EPUR was significantly better than in the group of men without EPUR.

PurposeTo present our technique and outcomes for perineal urethrostomy augmented with a dorsal onlay buccal mucosa graft (BMG). Results from initial series and collaboration from an international center are included.MethodsA retrospective chart review of all adult patients who underwent urethral reconstruction with perineal urethrostomy utilizing a buccal mucosal graft between January 1, 2002 and January 1, 2013 was performed. All surgeries were performed by three surgeons using the same technique (GHJ, KAM, and RV). Success was defined as no need for additional treatment following definitive surgery.ResultsA total of 44 patients met inclusion criteria. Mean patient age was 60 (range 44–81) years. All strictures were pananterior. Etiologies included unknown in 16 (36%), failed hypospadias repair in six (14%), lichen sclerosus in ten (23%), iatrogenic in seven (16%), Fournier’s in three (7%), urethral cancer in one (2%) and penile cancer in one (2%). Mean follow-up was 45 (range 6–136) months. Overall success was 80%. Nine patients recurred, of which four had a successful revision, two are awaiting potential revision, and three are being managed with periodic dilations.ConclusionsBMG perineal urethrostomy is a valid alternative for complex urethral strictures due to lichen sclerosus, previous failed reconstructions or hypospadias cripples. Midterm results are encouraging for this novel technique.

Objectives: To describe the development of a genitourinary reconstructive fellowship curriculum and the establishment of the first genitourinary reconstructive and pelvic floor postgraduate training program in the Caribbean. Methods: In an effort to respond to the need for specialty-trained reconstructive urologists in the Dominican Republic, we developed an18-month fellowship program to train local surgeons. The process began with creation of a curriculum and partnership with in-country physicians, societies, hospitals, and government officials. We sought accreditation via a well-established local university, and fellowship candidates were selected. A database was maintained to track outcomes. Subjective and objective reviews were performed of the fellows. Results: The first fellow graduated in 2018, the second in 2020, and the third is currently in training. The curriculum was created and implemented. The fellowship has been successfully integrated into the health system, and the ...

To determine patient-perceived and clinical outcomes of the AdVance sling at 3 years follow-up in men with post-prostatectomy incontinence (PPI). Data was prospectively collected of men with PPI treated with the AdVance male sling between February 2008 and March 2010. Twenty-four-hour pad counts and weights and patient completed validated questionnaires were obtained pre-operatively and at 3 years. The primary outcome was improvement in pad count with secondary outcomes of questionnaire scores and patient perception of success. At a median follow-up of 39 months (IQR: 36-44), we identified 30 men meeting inclusion criteria who had the AdVance male sling placed for mild to severe PPI. Eighteen (60%) patients were cured (no pad usage or one pad for security) and an additional 4 (13%) showed improvement (≥50% reduction in pad usage). Eight (27%) patients failed: six patients underwent seven salvage procedures including urethral bulking with collagen (n = 1), Virtue perineal sling (n = ...

Partial nephrectomy is an effective surgical treatment for small renal masses. We compare a single surgeon's experience with consecutive laparoscopic and robotic partial nephrectomy to assess potential perioperative outcomes. A review of the literature is provided. A retrospective review was performed comparing 15 consecutive patients undergoing laparoscopic partial nephrectomy to the subsequent consecutive 13 patients undergoing robotic assisted partial nephrectomy for small renal tumors. All patients had normal contralateral kidney appearance on cross sectional imaging. A similar transperitoneal technique was employed for both cohorts. A 4-arm technique was used for the robotic cases using the da Vinci (Intuitive Surgical, Sunnyvale, USA) surgical system. Patient demographics, tumor characteristics, intraoperative, and postoperative data including tumor size, warm ischemia time, and estimated blood loss (EBL) were compared using Student t-test, Wilcoxon rank-sum, or Chi square...

To report patients' perceptions of urethral reconstruction outcomes by comparing the results from preoperative and postoperative symptom questionnaires and to propose a standardized method of follow-up that includes patient satisfaction questionnaires and objective cystoscopic evaluation to facilitate comparison of different urethral reconstructive techniques and outcomes among surgeons and institutions. Data were prospectively collected for 110 consecutive patients undergoing urethral reconstruction. Patient demographics, American Urological Association Symptom Score, quality of life score, International Index of Erectile Function score, flow rate, and postvoid residual urine volume were collected pre- and postoperatively. The patients were evaluated at 3 and 6 months postoperatively and then yearly. Flexible cystoscopy (17F) was performed at 6 months postoperatively. The Wilcoxon signed rank test and Mann-Whitney U test were used to compare the pre- and post-test distributions. One-way analysis of variance was used to compare the mean values among groups. The mean patient age was 47 years, and the mean stricture length was 4.9 cm. Of the 110 patients, 32 received anastomotic (29%), 60 onlay (55%), 7 staged (6%), and 11 fasciocutaneous flap (10%) urethroplasty. The median individual change comparing the pre- and postoperative data was an improvement of 11 for the American Urological Association Symptom Score (P <.0001), 4 for the quality of life score (P <.0001), and 0 for International Index of Erectile Function (P = .05). No unifying individual follow-up questionnaire or flow rate correlated with recurrence. Patients undergoing urethral reconstruction reported significant improvement in urinary bother and quality of life scores while maintaining or improving their erectile function. Cystoscopic evaluation can be a valuable component of the postoperative follow-up algorithm, providing a consistent data point for comparison and confirming the patency of repair. Standardization of the measured outcomes is critical to validate the reported urethral reconstructive outcomes.

To determine patient-perceived and clinical outcomes of the AdVance sling at 3 years follow-up in men with post-prostatectomy incontinence (PPI). Data was prospectively collected of men with PPI treated with the AdVance male sling between February 2008 and March 2010. Twenty-four-hour pad counts and weights and patient completed validated questionnaires were obtained pre-operatively and at 3 years. The primary outcome was improvement in pad count with secondary outcomes of questionnaire scores and patient perception of success. At a median follow-up of 39 months (IQR: 36-44), we identified 30 men meeting inclusion criteria who had the AdVance male sling placed for mild to severe PPI. Eighteen (60%) patients were cured (no pad usage or one pad for security) and an additional 4 (13%) showed improvement (≥50% reduction in pad usage). Eight (27%) patients failed: six patients underwent seven salvage procedures including urethral bulking with collagen (n = 1), Virtue perineal sling (n = 1), and artificial urinary sphincter (n = 5). There were 16 post-operative complications: 13 Clavien I, 2 Clavien II, and 1 Clavien IIIb. AdVance male sling is an effective treatment option for PPI evidenced by objective improvements in 24-hr pad count and pad weight and patient perceived success via validated questionnaires. Neurourol. Urodynam. 34:251-254, 2015. © 2013 Wiley Periodicals, Inc.