Warner, J Nicholas

ABSTRACT Distal urethral strictures involving the meatus and fossa navicularis present unique challenges for reconstructive urologists due to the short segment’s proximity to the glans and high stakes for cosmetic and functional outcomes. Traditional approaches such as ventral meatotomy, skin-flap urethroplasty, and 2-stage techniques are known to compromise cosmesis, increase the risk of urethrocutaneous fistula, and have high recurrence rates, particularly in patients with lichen sclerosis (LS). The evolution of one-sided dorsal onlay urethroplasty with buccal mucosa graft has increased the success rates of single-stage urethroplasties by emphasizing preservation of tissue vascularity, leading to robust graft support. Traditionally, literature described the one-sided dorsal onlay urethroplasty through a perineal incision. This review seeks to describe the refinement of this technique, adapting the one-sided dorsal onlay concept to distal strictures by accessing the urethra through a subcoronal, ventral, or penoscrotal incision. Ventral penile incisions may limit unnecessary dissection, preserve glans architecture, and allow for supine positioning, thereby mitigating risks associated with high dorsal lithotomy. All while retaining the advantages of a well-vascularized dorsal graft bed. Limited reports describe high rates of anatomic and functional success and low complication rates across etiologies, including LS, iatrogenic, and hypospadias repair. Failures tend to be focal and amenable to minor interventions.

Abstract Background 0.05% Chlorhexidine gluconate (CHG) is now commonly used as an antiseptic irrigation for inflatable penile prosthesis (IPP) surgery. Limited in vitro data suggest compatibility of 0.05% CHG with antibiotic impregnated IPP devices; however, very little clinical research exists to guide use of 0.05% CHG in this population. Aim Assess the relationship of 0.05% CHG and antibiotic impregnated IPP infection in a large multi-institutional cohort. Methods We retrospectively reviewed a multi-institutional cohort of patients who underwent antibiotic impregnated IPP implantation. We identified cases using intraoperative 0.05% CHG and an equal number of consecutive control cases without 0.05% CHG use from each center for comparison. The primary outcome was IPP infection requiring explantation. Patient demographics and surgical variables were analyzed using chi-square tests and multivariable logistic regression to identify variables associated with infection. Outcomes The primary outcome was IPP infection requiring device explanation. Results Among 14 participating institutions, 761 cases using an antibiotic impregnated IPP were analyzed. Of these, 348 (45.7%) had 0.05% CHG used during the case. Median follow-up was 4 months (interquartile range 1-12) for the 0.05% CHG group and 8 months (interquartile range 2-21) for the control group. Intraoperative 0.05% CHG utilization was not associated with antibiotic impregnated IPP infection rate (1.9% vs. 2.0%, P = .9). On multivariable analysis, prior IPP infection (OR 6.32, 95% CI 1.32-30.2, P = .021) and prior priapism (OR 10.01, 95% CI 1.18-89.7, P = .039) were associated with increased infection risk. Clinical implications The use of 0.05% CHG irrigation with antibiotic impregnated IPPs was associated with similar infection rates compared to antibiotic irrigation. Strengths and limitations Limitations include the use of a historical comparator cohort which may introduce unknown confounders, practice variation between multiple sites, shorter follow-up in the 0.05% CHG cohort, and the low incidence of IPP infection which may limit statistical power despite a large sample. The major strengths include the large, multi-institutional cohort, and the use of consecutive patients to minimize selection bias. Conclusion 0.05% CHG utilization was not associated with infection rates in antibiotic impregnated IPPs.