Genitourinary vascularized composite allotransplantation for gender affirmation in trans men: An anatomical feasibility study

PURPOSE

Gender affirmation in trans men requires multiple staged procedures. The final masculinizing step involves phalloplasty or metoidioplasty and further incorporation of penile and testicular prostheses. However, these are functionally suboptimal and associated with high complication rates. Therefore, we sought to investigate the anatomical feasibility of one-stage genitourinary vascularized composite allotransplantation (GUVCA) for such gender-affirming surgeries.

METHODS

Twenty fresh cadaveric dissections were performed to delineate the neurovascular anatomy of the proposed GUVCA. Specifically, in donors (n = 14), besides the penis and scrotum, the GUVCA included an inferior bladder patch with the urinary sphincter, prostate, seminal vesicles, as well as a strip of the pubic bone. In trans men recipients, osteotomies of the pubic bone to match that of the donor GUVCA were required. Five cadaveric GUVCA transplants were then performed to simulate one-stage gender affirmation surgery.

RESULTS

The GUVCA required (1) vascular anastomoses between the recipient's deep inferior epigastric, external pudendal, and superficial circumflex iliac (or superficial inferior epigastric) vessels to the donor's internal pudendal, external pudendal and genitofemoral vessels respectively; (2) neurosynthesis between the recipient pudendal and dorsal clitoral nerves to the donor pudendal and genitofemoral nerves; and (3) urinary bladder anastomosis at the bladder neck, upstream of the urinary sphincter. Average donor measurements (length (cm), diameter (mm)) were: external pudendal artery (2.5, 2.0) and vein (2.0, 3.5), internal pudendal artery (15.0, 4.0), pudendal (15.0, 3.0) and genitofemoral nerves (8.0, 2.0).

CONCLUSIONS

We have described the anatomical basis for a one-stage GUVCA in trans masculine genitourinary reconstruction.

Bladder tumour resection weight as a prognostic factor for recurrence and progression in patients with high-risk non-muscle invasive bladder treated with BCG

INTRODUCTION

Predicting outcomes of patients with high-risk non-muscle invasive bladder cancer (HR-NMIBC) is critical. Here, we evaluate whether bladder tumor resection weight might serve as a prognostic factor for recurrence and progression of HR-NMIBC patients treated with Bacillus Calmette-Guérin (BCG).

METHODS

In this retrospective, single-centre study in the UK, we analysed a consecutive cohort of HR-NMIBC patients who have received adequate intravesical BCG immunotherapy between 2009 and 2019. Univariable and multivariable Cox proportional hazards models were used to assess the association of resection weight and established predictors with recurrence and progression.

RESULTS

A total of 187 HR-NMIBC patients were analysed. The median resection weight was 1.4g (range: 0.2-28.5g). Within a median follow-up of 41 months, 58 (31%) tumors recurred and 19 (10%) progressed. Fifty-four patients (29%) died from any cause and 16 (9%) died from bladder cancer. Both the risk of recurrence (P = .007) and progression (P = .019) increased with rising resection weight. On the multivariable analysis, a resection weight of ≥ 2g and ≥ 3g conferred a 4.35-fold and a 9.03-fold increased risk of bladder cancer recurrence (P < .001) and progression (P < .001), respectively. The addition of resection weight improved the C index of multivariable standard prognostic models to a clinically significant extent (+ 3.8% for recurrence, + 4.3% for progression).

CONCLUSION

In our HR-NMIBC patient cohort treated with BCG, bladder tumor resection weight was associated with disease recurrence and progression. Its addition improves discrimination of standard prognostic factors. Measurement may therefore be considered for routine clinical practice.

Surgical and radiological predictive factors for ureteric stricture formation in patients treated with ureteroscopy for ureteric stones

BACKGROUND

Ureteric stricture is a potential complication of impacted ureteric stones. This study investigates surgical and radiological factors that could predict ureteric stricture formation after ureteroscopic treatment of impacted ureteric stones.

MATERIALS AND METHOD

Intraoperative and radiological data for patients who underwent ureteroscopic treatment of ureteric stones impaction over a 5-year period were reviewed retrospectively. Patients who had previous ureteroscopic treatment or strictures were excluded.

RESULTS

Between January 2014 and May 2019, 1,340 patients presented as emergency renal colic secondary to ureteric stones. A total of 297 ureteroscopy procedures were performed for impacted calculi. The mean age was 53 years. The stricture rate was 3.3%. Analysis of radiological and surgical factors revealed that the degree of hydronephrosis, residual fragments and intraoperative ureteric injury were significant predictors for stricture formation (p = 0.018, 0.01 and 0.02, OR = 10, 47 and 1776, respectively). None of the other factors significantly predicted ureteric stricture formation.

CONCLUSION

Our study found the presence of severe hydronephrosis, residual stone fragments after surgery and intraoperative ureteric injury are significant predictive factors for ureteric stricture formation. The high-risk patients should be monitored with routine postoperative renal ultrasound.

A single institution experience: Robotic-assisted laparoscopic renal calyceal diverticulectomies, heminephrectomy and bladder diverticulectomies

Introduction:

The use of a robotic surgical system has transformed modern urological surgeries. There is little reported, however, on the use of robotic surgical systems in the management of benign urological diseases. We aim to report our experience in robotic-assisted surgery in renal calyceal diverticulectomies, heminephrectomy and bladder diverticulectomies.

Methodology:

We retrospectively collected the data of patients who had robotic-assisted surgery in our institution from 1 January 2014 to 31 December 2019.

Results:

Over the last five years, our institution has performed over 1500 robotic-assisted urological surgeries. In this five-year period, four robotic surgeons have performed a total of 25 robotic assisted operations to treat benign urological diseases including three renal calyceal diverticulectomies, one heminephrectomy and two bladder diverticulectomies. All patients were satisfied with the outcomes of their surgery when reviewed at their follow up consultations.

Conclusion:

We report a very positive experience in using robotic surgical systems in managing our series of benign urological conditions in our hospital. We should not restrict the use of this tool to cancer surgery, but consider the technology in our surgical armamentarium for all aspects of our urological practice.

Surgical management of vesicoureteral reflux in adults

Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder into the upper urinary tract with or without upper-tract dilatation. This diagnosis is commonly made in childhood, affecting 1% of all births. In adults, its prevalence and incidence are not known. Presentation in adults could be with loin pain associated with voiding or a full bladder, recurrent urinary tract infections, a diagnosis carried over from childhood or an incidental finding. Most of the works on VUR have been done in the paediatric population. There are limited publications addressing VUR in adults. Unsurprisingly, the management of VUR in adults is extrapolated from the knowledge that we have gained from paediatric urology. Herein, we recap on the pathophysiology and review the surgical management of VUR in adults as published over the years.

A case of persistent haematospermia secondary to seminal vesicle calculi in an ageing male

Seminal Vesicle (SV) calculi are a rare pathology. Clinical presentation usually consists of nonspecific perineal pain and haematospermia. Adjuncts to aid diagnosis include US, MRI, and Vesiculography. This rare condition can be treated conservatively, however, surgical options are becoming more advanced with Vesiculoscopy now being the gold standard. Here, we present a case of a SV calculi treated conservatively.

Post vasectomy chronic pain: are we under diagnosing vasitis? A case report and review of the literature

Acute vasitis is a rare infection of the vas deferens. Clinical presentation and disease rarity can cause difficulty in correctly diagnosing this condition. Adjuncts to aid diagnosis can be used that include ultrasound scan (USS) or computed tomography. We report a unique case of acute vasitis following vasectomy, reversal and subsequent re-do vasectomy diagnosed using USS.

Dermatological manifestation of metastatic prostate cancer

A 59-year-old man presented to the urology department with increased urinary urgency, frequency, poor urinary flow and unintentional weight loss. He had a 25-year history of idiopathic urticaria episodes which had increased in frequency over the previous 2 months. On investigation, he was found to have a raised prostate-specific antigen level. He was investigated further with a multiparametric MRI, a local anaesthetic transperineal prostate biopsy, a CT scan of chest/abdomen/pelvis with contrast and a nuclear medicine bone scan. He was diagnosed with metastatic adenocarcinoma of the prostate and commenced on a luteinising hormone-releasing hormone antagonist and referred to oncology for further treatment. Since starting treatment, he has experienced no further episodes of urticaria.

Persistent hematospermia: seminal vesicle bleed

A 65-year-old gentleman, with no past medical problems and not on any anticoagulation was seen in the urology clinic with persistent hematospermia for the last few years. A thorough history and examination including a digital examination of the prostate was unremarkable. Bleeding from his female partner was also ruled out. Investigations such as prostate specific antigen (PSA) blood test, urine culture, semen culture, and flexible cystoscopy were performed, and these investigations were also within normal limits. Due to his persistent hematospermia even after masturbation, a magnetic resonance imaging (MRI) of his pelvis was performed to rule out any sinister intrapelvic pathology. His MRI pelvis revealed a right seminal vesicle haemorrhage which was the cause of his hematospermia. He was treated conservatively with the advice to abstain from ejaculation for a few months. More importantly, we have also reassured the patient.

Renal abscesses refractory to treatment: Have you thought of tuberculosis?

Urogenital tuberculosis is the commonest extrapulmonary tuberculosis after lymphadenitis, with the kidneys being the most frequently affected organ. The clinical manifestation of renal tuberculosis is frequently nonspecific, leading to many overlooked cases especially in a developed country. Herein, we report a case of renal tuberculosis in a 79-year-old Caucasian lady who presented with recurrent renal abscess refractory to antibiotics.

Level of evidence: Level 5

Cost awareness in urology: A nationwide survey

Introduction:

In the current economic climate with continuous expenditure reviews and financial constraints, clinicians should remain conscious of making cost-effective choices on consumables and medications. In this survey, we evaluated the cost awareness amongst UK urologists. This is an observational study in which urology clinicians were asked to estimate the cost of 10 commonly used medications and consumables in urology by completing a questionnaire.

Methodology:

The survey was primarily conducted at the BAUS Annual Meeting 2017 with subsequent responders at local hospitals and urological courses. The costs of consumables and medications were verified with the relevant companies and the 73rd edition of the British National Formulary.

Result:

There were 139 responders from across the UK (46 consultants, 64 training registrars, 13 trust grades doctors and 16 senior house officers (SHOs)). In total, 16 and 60% of all estimates were within ± 25% and ± 100% of the true cost of the items respectively. Approximately 97.1, 95.7 and 97.1% overestimated the cost of a 14Ch urethral catheter, Ciprofloxacin and Sildenafil, respectively; while 78.4 and 84.9% of responders underestimated the cost of a JJ ureteric stent and Solifenacin, respectively. On multivariate analysis, SHOs significantly overestimated the cost of urethral catheters, suprapubic catheterization kits and JJ ureteric stents compared to other clinician grades.

Conclusion:

Cost awareness among UK urologists is poor. Expensive items (e.g. JJ ureteric stent, Solifenacin) tend to be underestimated while inexpensive items (e.g. catheter, Ciprofloxacin, Sildenafil) tend to be overestimated. This lack of appreciation of value may have an impact on drug and consumable expenditure.

Level of Evidence:

Level 3

"Fungating" tumour? No, it's bacterial!

A fit and healthy 26-year-old woman presented to the general surgical team with epigastric pain and weight loss of 2 stones over 6 months. She has also a positive family history of ulcerative colitis. As her oesophagogastroduodenoscopy and colonoscopy were normal, a contrasted CT was requested, and it detected an inflammatory mass with fat streaking around her transverse colon. An intrauterine contraceptive device (IUCD) was noted. In light of the CT findings, she underwent a diagnostic laparoscopy. As the inflammatory mass was not separable from the transverse colon, a segmental transverse colectomy was proceeded. The histology revealed multiple actinomycosis abscesses in the mesentery. Subsequently, we learnt that her IUCD had been in situ for the last 7 years, and the source of actinomycosis abscesses is likely from her IUCD. The patient was recommended to have the coil removed and commenced on a 6 months course of amoxicillin.

Buried coin in the gastric mucosa

A 29-year-old man presented to the Accident and Emergency department with abdominal cramping following ingestion of a 50 p coin 2½ weeks prior to presentation. He had not observed it pass in his stools. An abdominal radiograph confirmed the presence of the 50 p coin in his stomach. Subsequently, he had an oesophagogastroduodenoscopy (OGD) performed with a failure to visualise the coin. 1½ weeks later, he returned to the department as he was still unable to observe its passing in his stools. A repeated abdominal radiograph and a CT of the abdomen and pelvis revealed that the coin was still in his stomach. A second OGD was performed once again with a failure to visualise the coin. It appeared that the coin had migrated into his gastric mucosa.

Cost Analysis and Service Delivery on Using Isiris α™ To Remove Ureteric Stents

Introduction Isiris α™ (Coloplast®) is an innovative single-use disposable flexible cystoscope with an integrated ureteric stent grasper designed specifically to remove ureteric stents. It allows clinicians to remove ureteric stents easily on the wards or in clinics without the need of arranging a routine and dedicated flexible cystoscopy appointment for patients. We evaluated Isiris α’s practical use and cost analysis against traditional reusable endoscopes. Method We compared the cost of removing ureteric stents using Isiris α™ in 10 patients prospectively versus traditional flexible cystoscopes in 10 patients retrospectively. The costs of the equipment, medications, reprocess machines, and utility costs were consulted from the relevant departments and companies. As for labour cost, we have sourced British Medical Association (BMA) and Royal College of Nursing (RCN) websites. Results From our study, it costs £260.65 and £123.41 on average to remove a ureteric stent using Isiris α™ and traditional flexible cystoscope respectively (p<0.001). Stent removal in the endoscopy department was delayed in 60% of patients, on average 6.4 days, compared to 0% of patients using Isiris α™ (p = 0.048). Conclusion Although Isiris α™ is shown to be a more expensive option to remove ureteric stents based on our analysis, it still provides clinicians flexibility and ease in removing ureteric stents in the outpatient clinic, reducing the pressure and demand for dedicated flexible cystoscopy slots in the endoscopy department.

Limberg flap in management of pilonidal sinus disease: systematic review and a local experience

OBJECTIVES

To review published evidence of Limberg flap (LF) use in pilonidal sinus disease (PSD). We also included our local experience of LF.

METHODS

Medline and Embase database were searched for the words 'pilonidal, sinus, Limberg, flap'. Non-English articles and those not-related to our scope of search were omitted. We included a retrospective study of patients underwent LF in our district hospital. Data including length of hospital stay, post-operative complications and recurrence were collected.

RESULTS

Literature review revealed 68 studies (22 case series, 35 comparative studies, nine RCTs and two meta-analyses). Recurrence rate was 0-7.4% in case series. Recurrence rate in comparative studies was 0-8.3%, compared to 4-37.7% for primary closure and 0-11% for Karydakis flap. RCTs showed that LF or its modification is superior to primary closure, with comparable results to Karydakis flap. About 26 patients included in the cohort study (16 male, average age 27 years). Six patients presented with recurrent disease. Post-operative length of hospital stay was four to seven days. Post-operative complication rate was 11.5% - [two partial wound dehiscence, one wound infection]. Recurrence rate was 7.7%. Average follow-up was 18 months.

CONCLUSIONS

Limberg flap presents a safe and effective method that can be offered for patients with primary or recurrent PSD.

A rare presentation of haematuria: hip prosthesis in the bladder

An 80-year-old woman presented to our department with visible haematuria and stage II acute kidney injury (AKI). She had stage IIB cervical cancer, for which she received chemotherapy and external beam radiotherapy in 2003. Four years later, she had a left dynamic hip screw for an extracapsular neck of femur fracture following a fall. In 2010, she underwent a right total hip replacement owing to osteoarthritis, and it was subsequently revised in 2012 owing to a right acetabular component failure. In this admission, her AKI improved with intravenous fluid administration and her haematuria settled following catheterisation with a three-way catheter and bladder irrigation with saline. She underwent a flexible cystoscopy which revealed that a part of her right hip prosthesis was in the bladder, having eroded through the right bony pelvis. However, she declined any surgical interventions.

Prostatic abscess: a rare complication of staghorn calculi

A staghorn calculus is a calculus accommodating the majority of a renal calyx extending into the renal pelvis. A conservative approach to its treatment may lead to high morbidity and mortality rates. Such morbidity usually manifests with renal failure, obstructed upper urinary tractand/or life-threatening sepsis. Prostatic abscesses have never been associated with staghorn calculi in the literature. We report a case of a 70-year-old man who presented with sepsis, which was found to originate from a complex prostatic abscess. The patient had no history of urinary tract infections or risk factors. The authors believe that the incidentally identified staghorn calculi promoted the growth of Proteus mirabilis which led to the development of the prostatic abscess. The patient underwent a transurethral resection and drainage of the abscess following a failed course of antibiotic therapy. This case also highlights the paucity of guidelines available in treating prostatic abscesses.

Devices to help combat stone retropulsion during ureteroscopic lithotripsy in 2016

Proximal migration of stones during ureteroscopic lithotripsy is a common problem that faces many urologists and reduces stone-free rates, which translates into higher costs and longer operative times. In a bid to increase stone-free rates, there are several anti-retropulsion devices on the market, to help urologists during ureteroscopic lithotripsy. We previously reviewed these anti-retropulsion devices and wish to update what is currently available on the market.

Survey on consenting practice and discussion of post-operative erectile dysfunction following rectal cancer surgery

Introduction:

Sexual dysfunction is a recognized complication of rectal cancer surgery, due to the close proximity of the pelvic autonomic nerves to the normal plane of dissection. The consenting process should therefore always include the risk of sexual and urinary dysfunction arising after such surgery. This survey was undertaken to assess the consenting practice, and to evaluate the frequency of use of phosphodiesterase Type 5 (PDE5) inhibitors to treat erectile dysfunction (ED) following rectal cancer surgery.

Methods:

All listed Association of Coloproctology of Great Britain and Ireland (ACPGBI) members were invited to participate in the electronic survey, which comprised six questions. By 8 weeks, 119 responses had been received.

Results:

There were 112 respondents (94.1%) who routinely discussed the risk of ED during the process of gaining consent for rectal cancer surgery. There were 104 respondents (87.3%) who documented ED on their consent form. There were 24 respondents (20.2%) who indicated that there was no stated percentage risk for ED; and there were 69 (58.0%) and 26 (21.9%) respondents who quoted there was a 0–25% and 26–50% risk of ED during the consent process, respectively. None were quoting > 50% risk of ED. There were 68 respondents (57.1%) who routinely enquired about ED during follow-up. There were 30 respondents (25.2%) who stated that they had experience in prescribing PDE5 inhibitors for their patients who suffer from ED: We had 25 of them who felt that patients benefited from using PDE5 inhibitors.

Conclusions:

The majority of colorectal surgeons routinely discuss and document the risk of ED when consenting for rectal surgery; however, most surgeons have no experience in prescribing PDE5 inhibitors. This is an area that requires further study and education.

Which Is Better? "Live" Surgical Broadcasts vs "As-Live" Surgical Broadcasts

INTRODUCTION

Recently, the role of "live" surgical broadcasts (LSB) as an educational tool to demonstrate surgical techniques at conferences has been challenged, with concerns surrounding the well-being and safety of the patient as well as the surgeon. There have been notions that "as-live" surgical broadcasts (ALSB), prerecorded unedited videos showing either the whole procedure or key features, may be educationally superior. Our study was hence conducted to determine which was deemed better by a diverse group of international urologists.

METHODS

All participants of the World Congress of Endourology held in October 2015 in London were invited to complete an electronic survey using the conference app regarding LSB demonstrations compared with ASLB, before the congress and again after the congress. Only ALSB videos were used in the congress.

RESULTS

Both pre- and postconference surveys showed that 76.9% and 78.2% of the participants, respectively, perceived that more teaching could be achieved in less time using ASLB. 52.8% and 60.3% of respondents indicated ALSB as being superior to LSB before and after the conference, respectively. Furthermore, 52.8% and 54.5% of respondents regarded ALSB videos as having more educational value than LSB before and after the conference, respectively.

CONCLUSION

There was little perceived difference between ALSB and LSB, showing that ALSB are at least noninferior as an educational tool. In view of the numerous ethical and logistical issues with LSB, we would advocate ASLB as the educational tool of choice for future surgical demonstration at conferences.

Prevascular femoral hernia and its relation with inferior epigastric vessels: a rare presentation of the femoral hernia sac

A 61-year-old man presented to the emergency department, with a 2-week history of a painful lump on his right groin. A diagnosis of an irreducible right femoral hernia was made. As such, an urgent operation was carried out on the same day, and the patient was found to have a rare prevascular femoral hernia in which the sac was lying over the femoral vessels and split by the inferior epigastric vessels into 2 components resembling 2 trouser limbs. The hernia sac presented in a different and challenging way that necessitated meticulous dissection and full orientation of the anatomy of the femoral triangle. Complete dissection and control of the inferior epigastric vessels, and complete reduction of the sac followed by repair with a prosthetic mesh plug were performed successfully. The patient was discharged home the next day.

Primary breast lymphoma presenting as non-healing axillary abscess

A 67-year-old woman with non-insulin dependent diabetes mellitus with a history consistent with a right axillary abscess, presented to her general practitioner (GP). A diagnosis of folliculitis was made and the GP started a course of flucloxacillin. Despite antibiotics, the patient's symptoms worsened and the abscess increased in size. This prompted her GP to perform an incision and drainage procedure of the abscess. The practice nurse subsequently oversaw the follow-up care of the wound. Two months after the incision and drainage, and after regular wound dressing, the patient was referred to the acute surgical team with a complicated, non-healing right axillary abscess cavity and associated generalised right breast cellulitis. There was no history of breast symptoms prior to the onset of the axillary abscess. The patient underwent wound debridement, washout and application of negative pressure vacuum therapy. Biopsies revealed primary breast lymphoma (B-cell). She underwent radical chemotherapy and is currently in remission.