Citations

Abstract Background Concerns exist regarding inflatable penile prosthesis (IPP) placement after transcorporal artificial urinary sphincter (TC-AUS) surgery due to potential risk of damaging the AUS cuff during corporal dilation and device placement. Aim To evaluate perioperative complications, infections, revision rates, and device longevity in patients undergoing IPP placement following prior TC-AUS surgery. Methods We present a case series of men who underwent IPP surgery with an existing TC-AUS in place. A retrospective review was conducted of all patients who underwent TC-AUS placement at a single tertiary institution between 2015 and 2025. Patients who subsequently received IPP surgery were identified. Standard IPP techniques were used with additional precautions to protect the AUS, including use of electrocautery instead of sharp dissection and contralateral reservoir placement. Demographics, operative details, complications, infections, revision events, and device survival were collected through review of operative notes and patient records. Outcomes Primary outcomes included intra-operative difficulties, perioperative complications, infection and erosion rates, and revision or failure rates for both the TC-AUS and IPP devices. Results Among 757 TC-AUS placements, 17 patients subsequently underwent IPP surgery. Seven patients (41%) had a history of pelvic irradiation. The median operative time for IPP placement was 83 minutes (interquartile range [IQR] 68-87), and median follow-up was 31.5 months (IQR 11.2-40.6). All reservoirs were positioned contralateral to the AUS reservoir. A 12 Fr catheter was left postoperatively in 10 patients (59%) for <24 hours. Proximal corporal dilation was noted to be challenging in 3 patients (18%) but dilation was completed without cuff injury or corporal perforation. One patient (6%) had TC-AUS cuff erosion 9.5 months after IPP surgery; one patient (6%) experienced TC-AUS device infection 11.5 months after IPP surgery when his AUD pump eroded through the scrotum. Four patients (24%) developed AUS mechanical failure due to cuff leak at a median of 31.9 months after IPP placement (39.9 months post-AUS). Clinical implications IPP implantation following TC-AUS can be performed safely using careful surgical technique, though vigilance for later AUS mechanical failure is warranted. Strengths and limitations This study represents one of the largest single-institution series evaluating IPP after TC-AUS and includes detailed operative and follow-up data. However, its retrospective design, small cohort size, and limited follow-up duration restrict generalizability. Conclusion IPP placement after TC-AUS appears safe, with low infection and erosion rates, though AUS cuff leaks may occur more frequently than when either device is implanted alone.

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 Concerns exist when inflatable penile prosthesis (IPP) surgery is performed following transcorporal artificial urinary sphincter (TC-AUS) due to risk of damaging the AUS cuff during proximal corporal dilation and device placement. Aside from rare case reports, no data exists on outcomes and complications in patients who undergo IPP surgery with existing TC-AUS in place. Objective We aim to describe perioperative complications, infections, revision rates, and device longevity when IPP surgery is performed with existing TC-AUS in place. Methods A retrospective search was conducted to identify all patients who had undergone TC-AUS placement at a single institution from 2015-2023. Patients who had undergone IPP placement following TC-AUS at the same institution were identified. Operative technique for IPP placement was similar to standard IPP surgery with additional care taken to avoid the AUS device and preferential use of electrocautery over sharp dissection. Operatives notes and all patient encounters were reviewed, and data on demographics, operative details, perioperative complications, infections, revision rates, and device longevity were recorded. Results 727 patients underwent TC-AUS placement from 2015-2023. Of these, 13 patients underwent subsequent IPP placement (fig. 1). All patients had history of prostatectomy, and 6 (46%) patients had prior radiation. The median follow-up after IPP was 31.7 months and the time gap between AUS and IPP averaged 18.3 months (range 2.3 to 56.7 months). Average operative time for IPP was 85 minutes (range 53 to 202 minutes). Reservoirs were all placed contralateral to the AUS reservoir to minimize risk of injury to the AUS device. 8 patients had a 12 Fr catheter left post-operatively for less than 24 hours. Proximal dilation was noted to be difficult in 2 patients (15%), both of which were successfully dilated without perforation or damage to the AUS cuff. No infections or erosions occurred. 3 patients (23%) developed mechanical failure at a mean time of 28.7 months following IPP placement (36.5 months after AUS). Cuff leak was identified in 2 patients and the third has yet to undergo revision surgery to determine etiology. Conclusions IPP placement appears safe and effective in men who have previously undergone TC-AUS without increased risk of infection or device erosion. Care should be taken when dilating proximally, though proximal dilation was uneventful in most patients. Mechanical failure rates may be slightly higher compared to patients who have either device alone, and patients should be counseled accordingly. Disclosure No.

Abstract Introduction We report outcomes for patients in which the IPP became unusable by the patient because of pump difficulties or inadequate fluid volume in the IPP system. Objective We sought to assess outcomes of penile implant single component exchange or fluid instillation in a cohort of patients, challenging the entire device replacement dogma. Methods 17 patients underwent single component exchange by a single surgeon. CT scan was obtained to ensure device integrity, assess for air in the system, and to delineate device details. In cases of pump difficulties, the old pump was removed and replaced with a “classic” Genesis Coloplast pump regardless of initial device brand (“Frankenstein” if brands are mixed). Patients are taught pump rocking techniques and have > 6 months of difficulty before exchange. Patients are warned of auto-inflation as there is no lock out valve in the Genesis pump. For fluid addition to the system, the two old connector collars are separated and sometimes re-used after saline is added to only the cylinders. We never add fluid to the reservoir using a piston syringe for fear of reservoir capsule rupture into adjacent structures. Revisions were copiously irrigated, as of 2022, with Irrisept. Results Pump exchange: 14 patients underwent single component pump exchange secondary to inability for the patient to be able to adequately cycle the device (11 AMS MS, 1 Coloplast Touch). Remarkable differences were noted in pump cycling between office exam (difficult), exam under anesthesia prior to incision (sometimes difficult), and once the pump is removed from its capsule (universally easy). Complications of these 14 patients include 1 fungal infection requiring replacement with a malleable device and one repeat pump exchange (AMS MS - AMS MS - Genesis). Two patients noted non-bothersome minor auto-inflation. The single Coloplast case had a remarkably thickened capsule after a likely low grade infection. All patients can successfully use their devices now. Fluid Addition: Three patients underwent fluid addition to the system. One had a significant proximal aneurysm for which we added 35 ml. A different case had both a pump exchange and 30 ml added to the system as the initial reservoir appeared to have folded cordoning off fluid. The final fluid addition occurred 18 months after initial Coloplast 22+2 cm placement in which the patient very aggressively cycled the device and could not obtain 10/10 erection. 30 ml was added to the system totaling 140 cc. All patients have done well with fluid addition with mean time since surgery of 1 year. Conclusions Pump exchange with genesis pump or simple fluid addition to the system are safe and feasible and successfully restores IPP functionality. The Frankenstein strategy is a viable alternative, although patients must be counseled that auto-inflation may occur. With modern day irrigation techniques and CT confirmation of fluid system integrity, the dogma to replace the entire device may actually carry higher morbidity in some patients. Disclosure No