Anderson, Katherine T.

Introduction: Endoscopic urethroplasty combines the minimally invasive benefit of endoscopic dilation or urethrotomy with the durability of open urethroplasty. Novel techniques in endoscopic urethroplasty have appeared through the years since the 1970s, including several techniques to hold free grafts against urethrotomy beds, such as grafts glued or sutured to a catheter, double-balloon catheter, and a novel balloon-graft carrying device along with transperineal sutures. 1 – 7 Ungerer et al. describe their endoscopic buccal graft urethroplasty using laparoscopic suturing instruments and a procedure-specific transurethral sheath. 8 In this video, we present our technique and early outcomes for transmeatal urethral surgery (TraMUS) for distal penile strictures. This technique applies to any stricture of the penile urethra where the distal aspect of a buccal mucosa graft (BMG) can be accessed transmeatally. Materials and Methods: The patient is prepped in the supine position. A 6 o’clock incision is made sharply using a nasal speculum with a scalpel, and an endoscopic cold knife set along the ventral plate of the urethra from the proximal end of the stricture to the meatus. Goal caliber is 26 French. The urethrotomy length is measured. A split-thickness BMG is deployed by passing a 26 French offset scope into the urethra. A Laborie needle is passed through the scope, through the mucosal edge of the urethrotomy, and out the penile skin. With each puncture, a 3-0 PDS free suture is passed through the needle, and the needle is removed to externalize the suture through the meatus. This is repeated until one pair of sutures exists on either side of the proximal urethrotomy. The equipment is removed and the transmeatal ends of each pair of sutures are passed through the proximal end of the graft from anti-mucosa to mucosa using a free needle and tied. The transcutaneous suture ends are pulled to parachute the graft into the urethra over the urethrotomy and then tied externally at the skin. The distal end of the graft is secured to the meatus with interrupted 4-0 Vicryl. Quilting sutures are placed along the graft using 3-0 Vicryl on skiied SH needles, similarly passing the needles through the urethra and out the skin with ends tied together, and then tying externally at the skin. Alternatively, quilting may be performed via the Laborie needle for more proximal placement. A Foley catheter is placed, and a compressive dressing is applied to the penis. The catheter remains for 2 weeks. Cystoscopy is performed at 4 months and 1 year to ensure patency. Results: Nineteen patients have been treated using TraMUS for distal penile strictures. Eighteen patients had at least 4 month of follow-up, with an average follow-up of 8 months (range 4–21 months). 2 failures are documented, in which we were unable to pass the 17 Fr flexible cystoscope. Median graft length was 5 cm (range 3–15 cm, IQR 4.9). Conclusions: TraMUS for distal penile strictures is a promising new technique for minimally invasive urethral reconstruction. The technique appears to be effective, and further data about outcomes are still needed. Patient Consent: Author(s) have received and archived patient consent for video recording/publication in advance of video recording of the procedure. Conflicts of Interest: The authors have no disclosures. Runtime of video: 8 mins 13 secs.

Introduction and Objectives: Urethral stricture disease is a challenging urologic problem with a high recurrence rate. Initial management is typically completed endoscopically (e.g., urethral dilation, direct visual internal urethrotomy); however, guidelines recommend against repeated endoscopic management. Currently, surgical urethroplasty or intermittent catheterization remains the only other option. We have demonstrated a minimally invasive approach to urethroplasty. In this video, we aim to demonstrate the techniques and early outcomes of transmeatal urethral surgery for short urethral strictures. Materials and Methods: We demonstrate the procedure in two different individuals with idiopathic bulbar urethral strictures less than 2 cm. The patient is prepped in dorsal lithotomy position. Under direct visualization via cystoscopy, the ventral place of the urethral stricture is first incised to a goal of 26 Fr lumen. Next, mucosal realignment is completed via LSI Solutions’ URTRAC sheath and the RD 180 endoscopic suturing device. Two sutures are placed on either side of the urethrotomy incision site, allowing the proximal and distal ends of the mucosa to be pulled perpendicular to the urethrotomy. After reapproximation, a titanium knot is introduced endoscopically to anchor each suture into place. An indwelling catheter is then left in place. Patients are then seen at four months postoperatively. Results: Out of four total patients, there is a 100% success rate cystoscopically at 4 months postoperatively. There have been no recorded intraoperative or postoperative complications. The average operating room time was 54 minutes, and the average estimated blood loss was 9 mL. Conclusions: Transmeatal urethral surgery for short strictures via incision and urethral reapproximation appears to be a safe and effective repair option for the management of short urethral strictures. All research procedures were carried out in accordance with ethical guidelines and institutional policies, reviewed by the IRB. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. The authors declare that there are no commercial associations or financial interests in any product or service discussed in this article that might create a conflict of interest. The authors have not engaged in any activities or relationships with commercial entities that would bias or influence the content of this study. Runtime of video: 5 mins 40 secs.

Objective: To characterize our single institutional experience with robotic and open uretero-enteric stricture (UES) repair. Materials and Methods: We queried our ureteral reconstructive database for UES repair between 01/2017 and 10/2023. Patients with <3 months follow-up were excluded. Prior to surgery, patients underwent ureteral rest (4 weeks) with conversion to nephrostomy tube. Clinical characteristics, complications, reconstructive success (uretero-enteric patency), need for repeat intervention, and renal function were assessed in patients undergoing open and robotic UES reconstruction. Results: Of 50 patients undergoing UES repair during the study period, 45 were included for analysis due to complete follow-up (34 [76%] robotic and 11 [24%] open repair). UES repair was performed in 50 renal units a median of 13 months (interquartile range 7–30) from index surgery, and most often involved the left renal unit (34/50; 68%). Compared with robotic, open cases were significantly more likely to have undergone open cystectomy (100% vs 68%, p = 0.04), have longer strictures (median 4 vs 1 cm, p < 0.001), require tissue substitution (27% vs 3%, p = 0.04), and have lengthier postoperative hospitalization (5 vs 2 days, p < 0.001). There was no significant difference in total operative time (410 vs 322 minutes) or 30d major complications (18% vs 21%). At a follow-up of 13 months, per patient reconstructive success was 100% (11/11) for open and 97% (33/34) for robotic, respectively. Conclusion: In select patients with short UES unlikely to require advanced reconstructive techniques, a robotic-assisted approach can be considered. Careful patient selection is associated with limited morbidity and high reconstructive success.

Objectives To characterise the prevalence of impostor phenomenon (IP; tendency for high‐achieving individuals to perceive themselves as fraudulent in their successes) amongst attending staff in urology, to identify variables that predict more severe impostorism, and to study the association of IP with burnout. Subjects and Methods A survey composed of the Clance Impostor Phenomenon Scale (CIPS), demographic information, practice details, and burnout levels was e‐mailed to urologists via urological subspecialty societies. Survey results were analysed to identify associations between IP severity, survey respondent characteristics, and symptoms of professional burnout. This study was conducted in the United States of America. Results A total of 614 survey responses were received (response rate 11.0%). In all, 40% ( n = 213) of responders reported CIPS scores qualifying as either ‘frequent’ or ‘intense’ impostorism (i.e., scores of 61–100). On multivariable analysis, female gender, fewer years in practice (i.e., 0–2 years), and lower academic rank were all independently associated with higher CIPS scores (adjusted P < 0.05). Regarding burnout, 46% of responders reported burnout symptoms. On multivariable analysis, increase in CIPS score was independently associated with higher odds of burnout (odds ratio 1.06, 95% confidence interval 1.04–1.07; P < 0.001). Conclusion Impostor phenomenon is prevalent in the urological community and is experienced more severely in younger and female urologists. IP is also independently associated with burnout. Increased female representation may improve IP amongst our female colleagues. More work is needed to determine strategies that are effective in mitigating feelings of IP and professional burnout amongst urologists, particularly those earlier in their careers.

Clinical History: The case is a 17-year-old boy with a history of bilateral grade 4 vesicoureteral reflux and end-stage renal disease who underwent a living-unrelated donor renal transplantation in November 2021. He presented in June 2022 with vague abdominal pain and creatinine 4.3 mg/dL. Physical Examination: Transplant biopsy showed no evidence of acute rejection. Antegrade nephrostogram at the time of nephrostomy tube placement demonstrated hydronephrosis and a focal stricture of the proximal transplant ureter. His anatomy was further complicated because of prior ligation of his native distal right ureter at the time of transplant and intraperitoneal location of his transplant kidney through a peritoneal window. Diagnosis: Focal proximal stricture of transplant ureter. Intervention: Given the complex anatomy, a 3D-printed anatomical model was created to facilitate surgical planning. The 3D model highlighted a complex trajectory of the proximal ureter and strictured segment directly posterior to the transplant hilar vessels. In addition, the transplant kidney was directly overlying the dome of the bladder because of its intraperitoneal location. Given these anatomic considerations, the patient underwent an uncomplicated robot-assisted ureteropelvicostomy between his native left ureter and transplant renal pelvis. Follow-Up/Outcomes: Total robotic operative time was 2 hours 17 minutes. He was dismissed on postoperative day 1 with a creatinine nadir equivalent to his post-transplant baseline at 10-week follow-up. 3D-printed models have utility in select cases with complex anatomy. These models facilitate accurate regional and spatial anatomy of critical structures to enable effective operative planning. No competing financial interests exist. Patient consent statement: Patient consented to the use of nonidentifiable intraoperative photography and video recording for the purpose of medical education and publication in professional journals. Source of 3D model: Mayo clinic 3D Anatomic Modeling Laboratory. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No funding was received for this article. Music: All music was from Pixabay.com, royalty free. Runtime of video: 04 mins 58 secs