Reconstructive Surgery Archives - Grand Rounds in Urology

Pitfalls in Perineal Surgery

by Ryan P. Terlecki, MD, FACS | May 2022

Ryan P. Terlecki, MD, FACS, Vice Chair and Associate Professor of Urology, Director of the Men’s Health Clinic, Director of Medical Student Education, and Fellowship Director for Reconstructive Urology at Wake Forest University School of Medicine in Winston-Salem, North Carolina, discusses perineal surgery and key elements of preoperative planning to optimize the surgeon and patient experience while highlighting some intraoperative technical considerations to facilitate efficiency. He advises practitioners to choose patients commensurate with their own experience, to prioritize risk reduction, to under-promise and over-deliver, and to maintain technical poise. Dr. Terlecki addresses helping patients set expectations, which is dependent upon the patient’s preoperative level of suffering and upon the definition of success. He discusses patient preparation and the importance of doctors investing time to understand their patients as well as his own requirements, such as patients undergoing urine testing and suspending blood thinners preoperatively. He underlines the importance of clearly laying out the process—from start to finish—for the patient. He also warns of the “CURSED” patient—one who is compulsive-obsessive, unrealistic, revision-seeking, surgeon-shopping, entitled, and in denial. Dr. Terlecki then turns to optimizing the operating room through organization and aiming for what he calls “SWEET”; doing things the same way each and every time. He suggests video primers for support staff and an instrument and equipment checklist as well as pre-gaming with anesthesiologists and paying special attention to patient preparation. He addresses antibiotic stewardship before shifting to some technical items, highlighting the challenge of working in tight spaces during perineal surgery and the importance of surgeons freeing their hands and not struggling. Dr. Terlecki discusses the importance of illumination and magnification but advises surgeons to be mindful of ergonomics and equipment weight. Dr. Terlecki discusses considerations when doing artificial urinary sphincter (AUS) surgery, such as challenges when a patient has had a prior sling, before turning to combination cases (sling or AUS with inflatable penile prosthesis [IPP]). Here, he advises surgeons to accomplish the sling part of the operation first, noting that single-incision approaches are problematic and there are implications for the patient, the surgeon, and the hospital. Dr. Terlecki offers several items that allow for more efficient use of the surgeon’s time during urethroplasty. For example, surgeons should know whether the repair is an anastomotic repair or a substitution repair. He prefers scoping before and during the procedure to avoid a suboptimal incision site and addresses instruments that can be helpful throughout surgery. Dr. Terlecki then turns to the principles for urethral surgery, and poses a question for practitioners’ consideration: “If this was going perfectly, what would it look like?” He closes by citing Sir William Osler who advocated for equanimity, meaning the ability to calmly assess a situation, determine the best course of action and correction, and then to move forward. Dr. Terlecki discusses the importance of asking for help when needed, emphasizing that reaching out also helps build relationships and is a sign of excellence, not weakness.

The History of Penile Enlargement and the Advent of Penuma

by James J. Elist, MD | Feb 2022

James J. Elist, MD, FACS, a urologist and surgeon in private practice in Beverly Hills, California, explains why a patient may request penile enlargement, lists available treatment options for these patients, and discusses how to screen and select patients for a penile implant. He highlights the importance of the selection and screening process, observing that patients may have unrealistic expectations about how penile enlargement will affect their penis, may need psychological counseling or psychotherapy to address certain feelings about their penis, and may have undergone plastic surgery that affects their options for penile enlargement. Dr. Elist then looks at Penuma®, the first FDA-cleared, patented, and manufactured subcutaneous silicone implant for penile cosmetic corrective surgery. He explains how to perform the quick outpatient surgical procedure, goes over recovery and follow-up details, and considers the benefits of the implant compared to other options. Dr. Elist notes that the Penuma® implant is permanent yet reversible, customizable to patient anatomy, has no effect on erectile function and does not interfere with the urethra, remains accessible across the country, and boasts a strong and long term track record of patient satisfaction and low adverse events.

Genital Reconstruction After Massive Tissue Loss

by Maxx A. Gallegos, MD | Feb 2021

Maxx A. Gallegos, MD, Director of Reconstructive Urology at the University of New Mexico Health Sciences Center in Albuquerque, New Mexico, presents on genital reconstruction after patients have suffered massive tissue destruction. He addresses the epidemiology and etiology of genital tissue destruction, as well as the physiology of healing. Though rare, there are many possible ways a person can experience loss of genital skin, including burns, necrotizing fasciitis, lymphedema, self-mutilation, and sclerotic conditions. The incidence of necrotizing fasciitis is also rising, likely due to increased incidence of diabetes in the United States population. As primary intention healing is not a viable option in these severe cases, Dr. Gallegos recommends secondary intention techniques, such as grafts and fasciocutaneous flaps. Dr. Gallegos then presents several case studies, including four patients with Fournier’s gangrene, a patient with stab wounds, and a patient with lymphedema. He concludes by describing his postoperative process and how frequently patients should return for wound checks.

Dilating Scarred Corporal Bodies for Penile Implant Cylinder Placement

by John J. Mulcahy, MD | Sep 2020

John J. Mulcahy, MD, Clinical Professor of Urology at the University of Alabama and the University of Arizona, discusses how urologic surgeons should place penile implant cylinders into scarred corpora cavernosa. He explains that the approach taken (either penoscrotal or infrapubic) should be the one with the fewest prior procedures, but notes that many urologists tend to favor one approach over the other. Dr. Mulcahy then discusses the surgical process he follows, from obtaining adequate exposure with a broad incision to selecting an appropriate corporotomy site. He also discusses the tools he finds most useful, including the Otis urethrotome for cutting corporal scar tissue.

Following the presentation, E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, conducts a Q&A session with Dr. Mulcahy. They discuss salvage protocols for prosthetic infections, as well as the role of new evaluation tools, such as next-generation sequencing, for identifying microbes and fungi.

Path to the First Penoscrotal Transplant: Pre-Clinical Studies that Led to Penile Allotransplantation

by Trinity J. Bivalacqua, MD, PhD | May 2020

Trinity J. Bivalacqua, MD, PhD, Director of Urologic Oncology at the James Buchanan Brady Urological Institute of Johns Hopkins Medicine, discusses the groundbreaking penoscrotal implant surgery performed by a multidisciplinary team at Johns Hopkins Medicine in 2018. He explains their rationale for performing a procedure that many consider dangerous and unnecessary, saying that patients have a right to be normal and to decide on their own fate, and noting that they discussed the surgery with their patient, a military vet who lost his phallus from a blast injury, for years before operating. Dr. Bivalacqua goes on to summarize the pre-clinical cadaveric and ex vivo studies conducted before the procedure, emphasizing the important developments in increasing transplant tolerance and improvements in vascularizing penile allografts. He concludes by saying that the surgery was successful and thus far the graft has not shown rejection, but he notes that the procedure’s utility in clinical practice remains unknown.

Penile Allotransplantation: An Advance in Genitourinary Reconstruction

by Arthur L. Burnett II, MD, MBA, FACS | Sep 2019

Arthur L. Burnett II, MD, MBA, presents penile allotransplantation as an emerging alternative to autogenous reconstruction. He discusses the benefits for military trauma patients in particular, and the importance of considering potential complications as well as improved quality of life.

Robotic Assisted Laparoscopic Buccal Mucosa Graft Ureteroplasty

by Brian J. Flynn, MD | Jul 2019

Brian J. Flynn, MD, discusses the management of mid/upper ureteral strictures, from evaluation and medical decision making to available treatment options for ureteral reconstruction. He then illustrates surgical techniques and considerations for robotic ureteral reconstruction using buccal mucosa grafts.

Management of High Grade Renal Trauma

by Michael Coburn, MD, FACS | Dec 2018

Michael Coburn, MD, FACS, discusses decision-making for urologists consulted in kidney trauma cases. He defines indications for active observation, nephrectomy, and non-operative interventions, as well as practical techniques for gaining vascular control and reconstruction.

Novel Application of Autologous Fascia for Pelvic Floor Reconstruction in the Mesh Era

by Ja-Hong H. Kim, MD | Nov 2018

Ja-Hong Kim, MD, discusses the increased demand for pelvic floor reconstructive surgery, historical surgical methods, and complications associated with these methods. She then reviews two novel applications of fascia lata graft with video demonstrations of surgical techniques.

Pitfalls and Pearls of Penile Prosthesis Surgery

by Brian S. Christine, MD | Nov 2018

Brian S. Christine, MD, reviews the history of penile implant surgery. He then demonstrates critical steps, correct technique, and precautions to avoid intraoperative complications in scrotal and infrapubic placement of inflatable penile prosthesis (IPP).

Urethral Stricture Management in the 21st Century: Treatments for Even the Worst Urethras

by Maxx A. Gallegos, MD | Nov 2018

Maxx Gallegos, MD, reviews traditional urethral stricture management techniques, specifically direct visualization internal urethrotomy (DVIU) and dilation. He then discusses new and emerging techniques, especially urethroplasty, that may better benefit these patients.

Surgical Management of Refractory Bladder Neck Contracture after BPH Surgery

by Brian J. Flynn, MD | Jun 2018

Brain J. Flynn, MD, identifies the frequency of bladder neck contracture (BNC) following benign prostatic hyperplasia (BPH) surgery, prevention strategies, and endoscopic and surgical management. Furthermore, he explains his BNC management algorithm and the currently available lower urinary tract reconstructive procedure options.

Topic: Reconstructive Surgery