Tissue transfer techniques in reconstructive urology

Smile Incision-Modified Technique for Better Scrotal Outcome in Surgical Management of Penile Paraffinoma

INTRODUCTION

Penile augmentation with foreign material injection is used to increase penile length, girth, or both. Most of these individuals develop complications due to an abnormal mass formation known as penile paraffinoma. Multiple surgical techniques for restoring penile function and correcting near-normal penile shape have been developed, but prior techniques have some post-operative complications.

METHODS

We explained the smile incision-modified technique for penile paraffinoma reconstruction using illustrations to describe step-by-step procedures. This study aimed to describe our modified surgical technique for reconstruction to correct complications due to disastrous consequences of failed penile augmentation.

RESULTS

A total of 16 patients aged 28-66 years (mean: 44.25 ± 2.63) were operated with a smile incision-modified technique from January 2017 until December 2020 in Semarang Dr. Kariadi tertiary hospital. There were no intraoperative complications observed. We found hematoma in 3 patients in a 1-week follow-up. After 2 weeks of post-operative surgery, all patients had no skin dehiscence or necrosis. Cosmetic appearance and functional improvement after reconstruction were acceptable by all patients.

CONCLUSION

Penile paraffinoma reconstruction using the smile incision-modified technique was a feasible and effective technique to manage penile paraffinoma patients with good esthetic results and minor complications.

Glans Adipodermal Augmentation for Management of Neophallus Fat Atrophy After Penile Implant Insertion: Surgical Technique and Outcomes

OBJECTIVE

To describe our surgical technique and outcomes of glans augmentation with autologous adipodermal or acellular dermal matrix (ADM) interposition grafts for fat atrophy of the neophallus following penile implant insertion.

METHODS

We retrospectively reviewed the outcomes of glans augmentation in phalloplasty patients presenting with fat atrophy following penile prosthesis insertion. Glans augmentation is performed by making a small posterior coronal incision to preserve the shaft-to-glans dermal blood supply. A plane is made between the glans skin and the capsule of the distal penile implant cylinder. An adipodermal graft or ADM sheet graft is then sized to the glans dissection space and inserted, covering the implant capsule and filling the glans. The graft harvest site and posterior coronal incisions are then closed. The primary postoperative outcome was the recurrence of implant glans skin impingement or erosion.

RESULTS

From October 2017 through January 2023, 15 patients underwent glans augmentation after penile prosthesis insertion. The mean follow-up was 20 months. Adipodermal grafts were placed in 12 (80%) patients and ADM grafts in 3 (20%) patients. Two patients developed complications requiring surgical revision and 3 patients are considering a secondary glans augmentation, for a potential surgical revision rate of 33% (5/15). There were no wound infections, implant infections, or erosions.

CONCLUSION

Glans augmentation with adipodermal or ADM graft interposition between the glans skin and implant capsule improves the neophallus appearance and may help prevent future implant erosion in phalloplasty patients who develop fat atrophy after penile implant insertion.

Lessons learned from the first 15 years of penile transplantation and updates to the Baltimore Criteria

Since 2006, five penis transplants have been performed worldwide. Mixed outcomes have been reported, and two of the five penile transplants have required explantation. However, the long-term outcomes have been encouraging when compliance is implemented, whether standard induction and triple therapy maintenance, or single therapy maintenance. Follow-up monitoring of transplant recipients has enabled a synthesis of technical considerations for surgical success and has shown stable leukocyte counts and renal function after a donor bone-marrow-based immunomodulatory regimen followed by tacrolimus monotherapy as long as 3 years post-transplant, as well as continuous nerve regeneration of penile allografts 3 years post-transplant. Areas of uncertainty include the ethics of donor-recipient colour mismatch, surveillance for sexually transmitted infections and how to optimize patient compliance. Questions also remain with respect to the long-term immunological sequelae of penile tissue, functional outcomes, psychosocial implications and patient selection. Patient counselling should be modified to mention the possibility of long-term improvement in nerve regeneration and sufficient renal function with single-therapy maintenance, and to build a longitudinal dialogue and partnership between the patient and the multidisciplinary care team regarding the risks of sexually transmitted infection instead of surveillance.

Prospects and Challenges of Electrospun Cell and Drug Delivery Vehicles to Correct Urethral Stricture

Current therapeutic modalities to treat urethral strictures are associated with several challenges and shortcomings. Therefore, significant strides have been made to develop strategies with minimal side effects and the highest therapeutic potential. In this framework, electrospun scaffolds incorporated with various cells or bioactive agents have provided promising vistas to repair urethral defects. Due to the biomimetic nature of these constructs, they can efficiently mimic the native cells’ niches and provide essential microenvironmental cues for the safe transplantation of multiple cell types. Furthermore, these scaffolds are versatile platforms for delivering various drug molecules, growth factors, and nucleic acids. This review discusses the recent progress, applications, and challenges of electrospun scaffolds to deliver cells or bioactive agents during the urethral defect repair process. First, the current status of electrospinning in urethral tissue engineering is presented. Then, the principles of electrospinning in drug and cell delivery applications are reviewed. Finally, the recent preclinical studies are summarized and the current challenges are discussed.

Risk factors of penile resurfacing in re-operative hypospadias repair: A retrospective analytical study

INTRODUCTION

In re-operative hypospadias repair, scarred urethral plate, and deficient unhealthy penile skin are usually problematic. Difficulties are not only in urethroplasty but also in penile skin coverage. Penile skin coverage after urethroplasty with good viable skin decreases the complication rate and increases the satisfaction with repair. Studies reporting variables that increase the risks of the need for penile resurfacing in re-operative hypospadias are lacking.

OBJECTIVES

To determine the risk factors of the need for penile resurfacing techniques (PRSTs) in re-operative hypospadias.

STUDY DESIGN

A retrospective analysis of the redo hypospadias cases operated in-between January 2010 and December 2020 was done. Surgical data of the previous repairs, the indications for intervention, and the penile shaft coverage techniques at the time of the last repair were collected and analyzed. Patients' records were reviewed and categorized into two main groups. Group one include patients with simple skin closure, and group two include patients in whom penile resurfacing was done. Univariate analysis and Stepwise logistic regression measured the risk factors of the need for penile resurfacing techniques.

RESULTS

Out of 223 re-operative hypospadias, simple skin closure was done in 105 (group 1). Penile skin resurfacing (Byars flaps, Heineke-Mikulicz technique, and Z-Plasty) was in 55 (group 2a). In 63 patients (group 2b), scrotal flaps and skin grafts (split and full thickness) were the PRSTs. Patients ages, proximal hypospadias, number of prior surgery, one-stage repair, penile skin use in repair especially flap techniques, more than one complication in the same case, and unsatisfactory skin appearance increased the risk for PRSTs. Each previous repair increases the odds ratio of penile and non-penile resurfacing 1.9 and 3.2 folds respectively. One-stage repair increases odds of PRSTs 4 folds.

DISCUSSION

We analyzed the risk factors of the need for penile resurfacing techniques in the re-operative hypospadias cases. Step-wise logistic regression showed that the number of previous repairs and one-stage repair are the independent risk factors of penile resurfacing. Also, it showed that the number of prior surgeries is the only independent risk factor for non-penile skin resurfacing.

CONCLUSION

Number of previous repair is the independent risk factors of penile resurfacing and non-penile skin use in resurfacing. Previous repair in one-stage is an independent risk factor of the need for penile resurfacing.

Management of peno-scrotal wound defects in a tertiary hospital in North-Western Nigeria: a 20-year retrospective review

Background

Fournier’s gangrene and trauma to the external genitalia are the commonest causes of peno-scrotal wound defects in our environment. The management of these patients includes initial resuscitation and subsequent wound care with or without wound cover. The aim of this study is to document our experience in the management of peno-scrotal defects in a tertiary hospital of North-Western Nigeria.

Methods

This is a 20-year retrospective study of patients managed for peno-scrotal wound defects by the Urology Unit in the Department of Surgery of our hospital from January 2001 to December 2019. Data were collected from the patients’ case notes and entered into a proforma. Data were analysed using SPSS version 25.0.

Results

A total number of 54 patients with peno-scrotal wound defects were managed within the study period with the mean age of 46.27 ± 22.09 years and a range of six weeks to 107 years. The wound defects were sequelae of Fournier’s gangrene in 42 patients (77.8%) and traumatic in 12 patients (22.2%). Healing by secondary intention was achieved in 20 patients (37.0%). Direct closure was done in 17 patients (31.5%), skin graft in nine patients (16.7%), and advancement flap in eight patients (14.8%) depending on the location and size of the defects. Fourteen patients (26.0%) developed surgical site infection ± wound dehiscence and partial graft loss. The complication rate was higher in post-Fournier’s gangrene wound defects, but without statistical significance (p = 0.018).

Conclusion

Fournier’s gangrene and trauma to the external genitalia are the commonest causes of peno-scrotal wound defects in our environment. Smaller wound defects were healed by secondary intention, while larger defects required either direct closure or the use of advancement flap or skin grafting depending on the location and size of the wound. The study reported a higher post-repair complication in patients that had Fournier’s gangrene.

Meshed Versus Sheet Skin Graft for Scrotum and Perineal Skin Loss: A Retrospective Comparative Study

Background

A wide array of diseases can lead to skin defects of the male genitalia. Although reconstructive options have been debated in the literature, no study has compared the effectiveness of a meshed split-thickness skin graft (STSG) and a sheet STSG in perineal and scrotal wound coverage. In this study, we report our experience in a tertiary trauma center.

Methodology

In this retrospective study, we included cases with a skin defect of the male genitalia, for which genital reconstruction with a skin graft was performed at our hospital from December 2017 to February 2020. This study was approved by the institutional review board. The analysis was performed at 95% confidence interval using the Statistical Package for Social Science (SPSS) version 23.0 (IBM Corp., Armonk, NY, USA).

Results

A total of 27 patients were included in the study. The most common indication for genital reconstruction was Fournier’s gangrene (59.3%). In 15 (55.6%) patients, a meshed skin graft was utilized to cover the defect, whereas a sheet graft was utilized in 12 (44.4%) patients. Out of the 15 patients who underwent genital reconstruction with a meshed graft, 10 (66.6%) had complete graft take. On the other hand, out of the 12 (44.4%) patients who underwent genital reconstruction using a sheet graft, five (41.6%) had complete graft take. A statistically significant relationship was found between aesthetic and functional outcomes and the type of skin graft used. The satisfaction rate was higher among meshed skin graft recipients (86.2%) compared to sheet skin graft recipients (41.7%) (p = 0.014).

Conclusions

Based on our observational experience, we found that meshed STSG to cover male genital skin defects is safe with satisfactory cosmetic outcomes. Further prospective randomized studies are needed.

Reconstructive surgery of the scrotum: a systematic review

The term scrotoplasty embraces several techniques which aim to restore a normal scrotal appearance and function. We provide here a quick reference tool to allow the urologist to select the appropriate surgical strategy among the several available options. A comprehensive research was carried out on MEDLINE/PubMed to identify relevant studies concerning this topic, including a range of key words, e.g., scrotoplasty, ventral phalloplasty, scrotal reconstruction, scrotomegaly, penoscrotal web, scrotal lifting, scrotal reduction, scrotectomy, scrotal lymphoedema. Scrotal skin defects may be related with Fournier's gangrene, traumatic events, and surgery for genital cancers or peno-scrotal lymphoedema. The reconstructive management of these conditions is relatively reproducible in the hands of experienced urologists, if aware of the basics of scrotal surgery. Primary tension-free wound closure and local pedicled flaps typically allow optimal surgical outcomes for repairing most of these scrotal defects, with split-thickness skin grafts (STSGs) and/or distant flaps being required only when dealing with extensive skin losses. The demand for genitals' aesthetic surgery among adults is on the increase recently. Although the scientific evidence regarding this topic is scarce, reduction scrotoplasty and peno-scrotal webbing correction techniques are easy, safe and effective solutions to improve genital cosmesis, being carried out in isolation or in combination with penile prosthesis implantation. More robust scientific evidence is needed to achieve a uniformed consensus regarding the optimal surgical management in this broad field, and surgical innovation should continue to refine current reconstructive techniques.

Reconstruction of penile skin loss using a combined therapy of negative pressure wound therapy, dermal regeneration template, and split-thickness skin graft application

This study evaluates the use of acellular dermal matrix (ADM) in conjunction with negative pressure wound therapy (NPWT) and delayed split-thickness skin graft (STSG) application as an alternative to free tissue transfer for defect coverage of the penile shaft. Five patients with genital lymphedema and one with penile skin deficiency underwent penile shaft reconstruction with a two-stage surgical procedure. The first procedure aimed to the correction of skin defect and to neodermis regeneration through the use of an ADM (Integra®, Integra Lifesciences Corp., Plainsboro, NJ, USA) and NPWT. The second procedure 3 weeks later aimed to the covering of the skin defect with an unmeshed STSG. Both the Integra and skin graft showed completely taking at 7 days postop. No major complications occurred. At 6 months grafts gained sufficient elasticity to allow the sliding of the epidermis over the dermal layer, similarly the physiological penile shaft skin. Our results suggest that combined therapy might be an alternative to free tissue transfer for defect coverage of the penile shaft, leading to a good esthetic result, an optimal shaft coverage and providing adequate extensibility during erections. For best results we advise that in these cases urologists should collaborate with plastic surgeons.

Onlay Repair Technique for the Management of Ureteral Strictures: A Comprehensive Review

Ureteroplasty using onlay grafts or flaps emerged as an innovative procedure for the management of proximal and midureteral strictures. Autologous grafts or flaps used commonly in ureteroplasty include the oral mucosae, bladder mucosae, ileal mucosae, and appendiceal mucosae. Oral mucosa grafts, especially buccal mucosa grafts (BMGs), have gained wide acceptance as a graft choice for ureteroplasty. The reported length of BMG ureteroplasty ranged from 1.5 to 11 cm with success rates of 71.4%-100%. However, several studies have demonstrated that ureteroplasty using lingual mucosa grafts yields better recipient site outcomes and fewer donor site complications than that using BMGs. In addition, there is no essential difference in the efficacy and complication rates of BMG ureteroplasty using an anterior approach or a posterior approach. Intestinal graft or flap ureteroplasty was also reported. And the reported length of ileal or appendiceal flap ureteroplasty ranged from 1 to 8 cm with success rates of 75%-100%. Moreover, the bladder mucosa, renal pelvis wall, and penile/preputial skin have also been reported to be used for ureteroplasty and have achieved satisfactory outcomes, but each graft or flap has unique advantages and potential problems. Tissue engineering-based ureteroplasty through the implantation of patched scaffolds, such as the small intestine submucosa, with or without cell seeding, has induced successful ureteral regeneration structurally close to that of the native ureter and has resulted in good functional outcomes in animal models.

Autologous Flap Transfer for Esophageal Stricture Prevention After Endoscopic Submucosal Dissection in a Porcine Model

BACKGROUND

Esophageal stricture caused by endoscopic submucosal dissection for a mucosal defect that covers more than three quarters of the circumference of the esophagus has a high incidence. To date, no method for preventing such strictures has been widely recognized as effective in clinical practice.

AIMS

We examined whether esophageal stricture caused by circumferential endoscopic submucosal dissection could be prevented by autologous flap transfer.

METHODS

Six pigs (N = 6) underwent circumferential esophageal endoscopic submucosal dissection under general anesthesia. For animals in the flap group (N = 3), an autologous flap was constructed and then placed at the resection site and secured with metal clips. Animals in the control group (N = 3) underwent endoscopic submucosal dissection only. Endoscopy was performed 3 weeks postoperative to evaluate the effects of flap transfer.

RESULTS

Animals in the flap group gained more weight than animals in the control group. At 3 weeks postoperative, animals in the flap group developed clinically slight stricture; in these animals, an endoscope could be passed through the stricture with slight resistance. In contrast, in the control group, significant stricture was observed, and the stricture was difficult to cross with an endoscope.

CONCLUSION

Autologous flap transfer after circumferential esophageal endoscopic submucosal dissection is a novel approach that remarkably decreases the degree of esophageal stricture that arises.

Development of a novel indwelling catheter for urethral surgery

This study aimed to develop an indwelling catheter that can be used for urethral flushing, urethral secretion drainage, local urethral drug delivery, and urine drainage.We designed a new indwelling catheter type that has a balloon, 4 peripheral grooves, and a C-shaped groove on its surface. In addition, there is a flushing channel, a balloon channel, and a urine drainage channel in the catheter body. However, the most critical characteristic is that the flushing channel and the 4 peripheral grooves are connected with the C-shaped groove, and the flushing liquid can reach the C-shaped groove through the flushing channel and then flow out through the peripheral grooves, while the balloon channel leads to the balloon. Generally, our design is to add 4 peripheral grooves, a C-shaped groove, and a flushing channel to the indwelling catheter that is applied clinically nowadays.We designed a new type of indwelling catheter, which is multifunctional, and we had acquired a national patent in China. In theory, the new catheter type cannot only be used for urine drainage, bladder irrigation, but also for urethral flushing, urethral excretion drainage, and local urethral drug delivery at the same time.This new indwelling catheter can theoretically reduce catheter-associated urinary tract infection and facilitate urethral secretion drainage or flushing out, which is especially suitable for the treatment and nursing of patients who underwent urethral operation. However, the new catheter have not been produced and tested clinically, and this is our next step.

Refractory Urethral Stricture Management: Indications for Alternative Grafts and Flaps

PURPOSE OF REVIEW

Urethral strictures that are refractory to initial management present unique challenges to the reconstructive surgeon. Treatment trends have shifted as new tissue resources are becoming available. There is renewed interest in old methods as skill and technique have improved. We describe the scope of the surgical armamentarium available to develop creative approaches and successful outcomes.

RECENT FINDINGS

We discuss techniques to maximize the availability of oral mucosa, harvest and use of rectal mucosa, and developments in tissue engineering. Evolving methods to assess success of repair are also described. Urethral reconstruction for refractory urethral strictures requires proficiency with multiple methods as these strictures often require combining techniques for successful treatment.

Biofabrication and biomaterials for urinary tract reconstruction

Reconstructive urologists are constantly facing diverse and complex pathologies that require structural and functional restoration of urinary organs. There is always a demand for a biocompatible material to repair or substitute the urinary tract instead of using patient's autologous tissues with its associated morbidity. Biomimetic approaches are tissue-engineering tactics aiming to tailor the material physical and biological properties to behave physiologically similar to the urinary system. This review highlights the different strategies to mimic urinary tissues including modifications in structure, surface chemistry, and cellular response of a range of biological and synthetic materials. The article also outlines the measures to minimize infectious complications, which might lead to graft failure. Relevant experimental and preclinical studies are discussed, as well as promising biomimetic approaches such as three-dimensional bioprinting.

Advances in Surgical Reconstructive Techniques in the Management of Penile, Urethral, and Scrotal Cancer

This article reviews the most up-to-date surgical treatment options for the reconstructive management of patients with penile, urethral, and scrotal cancer. Each organ system is examined individually. Techniques and discussion for penile cancer reconstruction include Mohs surgery, glans resurfacing, partial and total glansectomy, and phalloplasty. Included in the penile cancer reconstruction section is the use of penile prosthesis in phalloplasty patients after penectomy, tissue engineering in phallic regeneration, and penile transplantation. Reconstruction following treatment of primary urethral carcinoma and current techniques for scrotal cancer reconstruction using split-thickness skin grafts and flaps are described.

Treatment of Urethral Strictures from Irradiation and Other Nonsurgical Forms of Pelvic Cancer Treatment

Radiation therapy (RT), external beam radiation therapy (EBRT), brachytherapy (BT), photon beam therapy (PBT), high intensity focused ultrasound (HIFU), and cryotherapy are noninvasive treatment options for pelvic malignancies and prostate cancer. Though effective in treating cancer, urethral stricture disease is an underrecognized and poorly reported sequela of these treatment modalities. Studies estimate the incidence of stricture from BT to be 1.8%, EBRT 1.7%, combined EBRT and BT 5.2%, and cryotherapy 2.5%. Radiation effects on the genitourinary system can manifest early or months to years after treatment with the onus being on the clinician to investigate and rule-out stricture disease as an underlying etiology for lower urinary tract symptoms. Obliterative endarteritis resulting in ischemia and fibrosis of the irradiated tissue complicates treatment strategies, which include urethral dilation, direct-vision internal urethrotomy (DVIU), urethral stents, and urethroplasty. Failure rates for dilation and DVIU are exceedingly high with several studies indicating that urethroplasty is the most definitive and durable treatment modality for patients with radiation-induced stricture disease. However, a detailed discussion should be offered regarding development or worsening of incontinence after treatment with urethroplasty. Further studies are required to assess the nature and treatment of cryotherapy and HIFU-induced strictures.