Premo, Hayley

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: Urethral strictures affect about 1% of men over 65 in the United States and significantly impact quality of life. 1 Most strictures (92.2%) occur anteriorly. 2 Urethroplasty, the gold standard treatment, is traditionally open but can be performed endoscopically with comparable results. This prospective study describes a technique for transmeatal urethral surgery with buccal graft urethroplasty for anterior urethral strictures. Methods: A 21 French direct vision internal urethrotomy (DVIU) cystoscope is used to inspect the stricture and make an incision along its ventral aspect. After the stricture is measured, a graft of buccal mucosa is harvested. For graft deployment, we utilize a 26 French Wolf Offset Nephroscope™ and a rigid injeTAK® cystoscopy needle. At the distal aspect of the urethrotomy, the needle is passed through the urethra and out the perineum. A pair of the sutures is placed on either side of the urethrotomy and held externally at the meatus. The graft is oriented with the lamina propria facing the spongiosum. The previously placed sutures are then passed from lamina propria to mucosa at the distal aspect of the graft. The sutures are tied, creating a knot on the mucosal side. The external sutures are then pulled, and the graft retracts into the urethra. The JNW Urtract™ and Securestrap® are then used for graft fixation. Graft Deployment: At the distal aspect of the urethrotomy, the injeTAK® needle is passed through the urethra and out of the perineum. A pair of the sutures is then placed on either side of the urethrotomy. These are held in place at the meatus to maintain proper laterality and avoid twisting. The graft is oriented into position, with the anti-mucosa facing the exposed spongiosum and the mucosa facing the lumen. The previously placed sutures are then passed from anti-mucosa to mucosa using a free Mayo needle at the distal aspect of the graft. The suture pairs are tied, creating a knot on the mucosal side. The external sutures are then pulled, and the graft retracts into the urethra. Cystoscopy is performed to ensure the graft is covering the urethrotomy. Graft Fixation: The JNW Urtract was then introduced with the Securestrap® (a Vicryl tacking suture). While a finger externally compresses the perineum toward the tip of the Securestrap®, the ventral midline portion of the graft is secured. A 22 French Foley catheter is then placed over a wire. Results: Out of 20 total patients, 13 are eligible for their 4-month follow-up. Of those who have completed follow-up, 86% had urethral patency on cystoscopy. The average duration of foley catheterization was 2.4 weeks. The average operative time was 100.8 minutes, and the average estimated blood loss was 37.5 cc. Conclusion: Transmeatal urethral surgery is a safe and effective repair option for management of anterior urethral stricture disease. The authors have no disclosures or commercial associations that might create a conflict of interest. Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. Data and video obtained during the treatment of patients at Mayo Clinic in Rochester, Minnesota. Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. No conflicts of interest or obligations resulted from data collection. Runtime of video: 8 mins 52 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 describe a step-by-step guide for successful implementation of transmeatal urethral surgery for obliterated membranous urethral strictures. Patient and Methods: The patient is placed in the dorsal lithotomy position. Cystoscopy will be performed through both the suprapubic tube above and transmeatally from below. A Libri rigid endoscopic needle will be passed under guidance, with placement of a 0.38 wire through the inner lumen. Subsequently, over the wire, a tiger tail catheter will be placed and the wire exchanged for a rigid sensor wire, over which a charger balloon will be passed and used for dilation. The Olympus resectoscope will be used to resect the area of the stricture. The RD180 from LSI solutions will be used to situate the graft over the area of the stricture. Results: Our number of cases is five, of which 4 have had no recurrence. The median follow-up is 6 months. We have three from radiation and two from pelvic fractures. In the radiation population, one patient did recur. However, he was not obliterated and has been voiding even though he has a 14 French urethra. Conclusion: This technique appears to be a safe and effective repair option for management of obliterated membranous urethra strictures. Author disclosure statement: J.N.W. is a consultant for Olympus. The other authors have no conflicts of interest to disclose. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure . Runtime of video: 7 min 38 sec.

Abstract Introduction Penile plication is an excellent approach for patients with congenital penile curvature and Peyronie’s disease. Beginning in March of 2023, patients who were candidates for penile plication were offered the procedure in the operating room under general anesthesia or in the office setting with no sedation. Fourteen patients opted for the procedure in the clinic. Objective We therefore sought to assess patient responses and experience after undergoing surgery in the clinic setting. Methods Fifteen patients, ages ranging from 21 to 74 were seen in clinic for penile plication surgery. Exclusion criteria included patients younger than 18 years and preoperative systolic blood pressure greater than 160. One patient was noted to have a systolic blood pressure over 200 and thus was unable to have the procedure. Five patients had a penile plication for congenital curvature, eight patients for Peyronie’s disease, and 1 patient had a release of a previously placed palpable plication suture. Degree of curvature, direction of curvature, presence of secondary curvature, presence of hinge defect, and indentation were not considerations in patient selection. Three patients were on anticoagulation, which was held prior to surgery. Twelve patients underwent a ventral approach and two a degloving approach. Results Patients are allowed and encouraged to eat and drink prior to the procedure. All patients were given a preoperative antibiotic, normally either Bactrim or ciprofloxacin prior to the procedure and 20 mg of oral versed. They were then taken to the in-office procedure room after consent was obtained. The procedure room contains a television for patients to watch. At the end of the procedure, an Exparel block was performed. Patients are then prepped and draped in standard sterile fashion. A dorsal penile nerve block and circumferential block were utilized at the beginning of the case. A catheter is not placed to help reduce patient discomfort. Alprostadil is injected to help identify curvature. Ten patients were noted to have dorsal, 2 patients’ ventral, and 2 patients’ lateral curvature with degree of curvature ranging from 30 to 60 degrees. Eight patients had a secondary curvature identified. Total number of plication sutures utilized ranged from 2 to 8. All procedures were successfully conducted, and patients discharged home. Patients were then contacted to determine their experiences with the procedure. Only seven patients were able to be reached. One patient did have a vasovagal response in the procedure room, but this resolved with a small snack. Average intraoperative discomfort was rated as a 2/10 and was mainly present during the initial block. All patients stated that they would choose this surgical approach again and have noted clinically significant improvement to their curvature. Conclusions Penile plication in the clinic setting reduces anesthetic risks as well as costs associated with the operating room. This study shows the safety and feasibility of this approach. Disclosure No.