Barriers in transitioning urologic patients from pediatric to adult care

As the advances in medicine continue to emerge, more children with congenital or pediatric-onset chronic urologic conditions are surviving well into adulthood. This imposes an ever rising there is a need for adequate transition of these patients from pediatric to adult care. Despite position statements from multiple heath care organizations and several models proposed in literature, different issues and gaps in urologic transition continue to exist. Major barriers in this transition are adolescence, a challenging time that is characterized by impulsive behavior and risk taking, and the longstanding relation between both patients and paediatric providers. Both pediatric and adult care providers need to be aware of the special needs of maturing youth with chronic care problems related to education, self-management, legal issues and psychological support during care transition. Furthermore, they need to understand and address the currently existing obstacles for adequate transition. There is need for active communication with each other and the patient to develop sustainable relationships that can support the transitioning process. It is therefore in the greatest interest of the care provider to make this transition as smooth as possible. This paper aims to point out the currently perceived barriers in care transition within the urological context, reflect on previous implemented models for care transition and present proposals for improvement

The SAGASF-M Questionnaire, at home or in the office? A validation study

Introduction To date, information on self-perceived genital anatomy and sensitivity are not a part of long-term follow-up urogenital reconstructive procedures. This could be useful to specialists and patients involved in genital reconstructive surgery. This is especially the case for transgender patients in whom the invasive genital gender reaffirming surgery has a high risk of complications and is susceptible for redo procedures. Until shortly, no normative large sample of data on this subject existed in cisgender men. Nor is there a validated instrument available that can be used in a Dutch speaking population. Aims This study aimed to validate the "Self-Assessment of Genital Anatomy and Sexual Functioning" (SAGASF-M) questionnaire within a Dutch speaking cisgender male population. We evaluated its’ psychometric properties in this different population, environment and healthcare system. Methods 808 cisgender men with no prior history of genital surgery other than circumcision completed an internet-based survey of whom 24 were invited two weeks later to fill in the questionnaire again together with a urological examination to correlate the answers to clinical practice. Psychometric criteria included are content validity, internal consistency and reproducibility. Given this population has not undergone any surgical procedures other than circumcision, floor and ceiling effects and responsiveness could not be evaluated. Main outcome measures The SAGASF-M enables men to rate the sexual pleasure, discomfort, intensity of orgasm and effort required for achieving orgasm in eleven different detailed areas of the male genitalia using a 5-point Likert scale. Furthermore, the questionnaire assesses differences in genital anatomy. For the purpose of this study, biological men were asked to rate the sensory function in these same different areas when pointed out by the urologist. Results Median age of the participants was 39 and around 20% of them was circumcised. The vast majority of patients described an anatomic location of the meatus and average penile, scrotal and testicular size. When these anatomical variations were compared with the urological examination, we discovered an overall 97.2% match. Significant discrimination between different locations of the genital area was possible for each of the evaluated domains (sexual pleasure, orgasm intensity, orgasm effort, discomfort/pain). When these evaluations were compared with the urologist’s’ examination in the comparator group, nearly no significant differences could be noted. Except for the back of the scrotum and the perineum. This indicates that the patients are well capable of performing a correct self-examination without need of a urological examination. Conclusion The SAGASF-M questionnaire discriminates well between the different genital areas concerning erotic sensation. The ventral and lateral sides of the glans penis showed the most sensitive, which corresponds to the highest nerve density in this area. The Dutch version of the SAGASF-M questionnaire has adequate psychometric properties and is a valid instrument to assess genital anatomy and genital sensitivity as self-reported measures in cisgender men. This could be a first step in assessing the postoperative changes in genital sensitivity and sexual function transgender patients undergoing genital gender reaffirming surgery

Metoidioplasty without urethral lengthening in a transgender male patient

Introduction and objectives Metoidioplasty is a type of gender affirming surgery performed in female-to-male transgender men. Genital gender reaffirming surgery with urethral lengthening is associated with a high risk of urethral complications, such as urethral stricture and fistula. In order to decrease the risk of complications, some patients prefer not to have urethral lengthening performed. If the patient has no particular wish for voiding in a standing position, it could be a good solution to construct a primary perineostomy. The aim of our study was to report our approach of a modified metoidioplasty without urethral lengthening. This video demonstrates the different steps of our technique. Materials and Methods A 23-year-old female-to-male transgender patient underwent metoidioplasty and scrotoplasty without urethral lengthening. His past surgical history included trans-areolar mastectomy and hysterectomy with oophorectomy one year earlier. The patient had no wish to be able to void while standing and therefore, a urethral lengthening was not performed. Instead, the urethral meatus was repositioned by means of a perineostomy. As the patient wished metoidioplasty as a final surgery, maximal penile lengthening was pursued. The patient was placed in lithotomy position. Vaginectomy is performed in the standard fashion after hydro-dissection of the anterior vesico-vaginal wall. The urethral meatus is dissected away from the vestibular part of the clitoris. All other mucosal tissue underneath the clitoral corona, including the labia minora is excised. The neo-penoscrotal angle is constructed at the original lowest point of the clitoris. Scrotoplasty is performed by posterior release of the labia majora up to the point of the penoscrotal angle. The posterior edges are brought anteriorly and fixed to the midpoint of the penoscrotal angle according to the Ghent scrotoplasty technique. The urethral meatus is anchored underneath the scrotum and sutured to the skin after ventral spatulation, creating a perineostomy. The perineal defect is closed up to the point of the perineal urethrostomy. We plan second stage scrotoplasty with ventral release of the labia majora to further increase the size of the neo-scrotum and create a more anatomical position of the penis and the scrotum. Results We present our modified metoidioplasty technique in a step-by-step-video guide. The technique results in the construction of a perineostomy just below the perineal scrotal transition, an advanced neo-scrotum and a maximally lengthened neo-phallus. Conclusion Metoidioplasty as gender affirming surgery for female to male transgender patients remains a complex procedure with high risk of urethral complications. In patients who are not keen on being able to void while standing, the construction of a perineostomy be a good solution to avoid these urethral complications

The Self‐Assessment of genital anatomy, sexual function and genital sensation (SAGASF‐M) questionnaire in a Belgian Dutch‐speaking male population: A validating study

Introduction: Penile and genital surgery for congenital or acquired conditions is daily practice in reconstructive urology. These procedures, which carry the risk of disrupting nerves and blood vessels, may impair the genital sensation, and affect the capacity for sexual pleasure. Self-reported tools are needed to systematically assess the male genitalia before and after reconstructive surgeries in terms of genital sensation and sexual experience. Aim: This study validated the Dutch translation of the self-assessment of genital anatomy and sexual functioning (SAGASF-M) questionnaire and investigated the perceptions of healthy men regarding their genital anatomy and sensory function. Methods: Eight-hundred and eight sexually active men with a median age of 39 years (18-79 years) and no history of genital procedures other than circumcision filled out an online version of the questionnaire. Twenty-four participants were randomly recruited to confirm the responses of the SAGASF-M questionnaire by a clinical evaluation. Main outcome measures: The SAGASF-M questionnaire comprises of multiple-choice questions and clarifying illustrations asking men to rate their genital appearance, overall sexual sensitivity, and pain perception as well as the intensity and the effort to reach orgasm. Prespecified regions of the glans, penile shaft, scrotum, perineum, and anus are evaluated through this questionnaire. Results: Only slight variability in anatomical ratings was observed. Overall discrimination between different genital areas in terms of genital sensation was significant. The bottom of the glans or frenular area was rated the highest contributor to "Sexual pleasure", followed by the other regions of the glans and shaft. The same distribution was found for "Orgasm intensity" and "Orgasm effort". The anal region was generally rated the lowest. "Discomfort/Pain" was rated lower than any of the other sensory function indicators and the top of the glans and anal region were rated most likely to perceive this unpleasant sensation. Participants reported significantly more sexual pleasure and intense orgasms when stimulated by a sexual partner compared to self-stimulation. Homosexual and bisexual men reported a higher contribution of the perineal and anal regions in sexual pleasure and orgasm. No significant difference between circumcised and uncircumcised individuals regarding overall genital sensation could be found. Conclusion: The Dutch translation of the SAGASF-M questionnaire is a valuable and reliable tool for self-assessment of genital anatomy and sensation, providing a site-specific attribution of a patient's perceived sexual function. Further prospective research with this questionnaire could aid in the patient-centered improvement of genital surgery

Treatment of meatal strictures by dorsal inlay oral mucosa graft urethroplasty : a single-center experience

Background: To report on the use of oral mucosa graft urethroplasty for meatal strictures using the dorsal inlay technique. Material and methods: Patients who underwent single-stage dorsal inlay oral mucosal graft urethroplasty between January 2000 and May 2021 were included in this study. A follow-up of minimum 12 months was necessary for inclusion. Exclusion criteria were stricture extension into the penile urethra, concomitant stricture at another location, flap urethro- plasty for a meatal stricture, dorsal inlay urethroplasty with another type of graft, ventral onlay graft urethroplasty or staged urethroplasty. Recurrence was defined by the inability to pass a 14F metal sound through the reconstructed meatus irrespective of patients complaints. Results: Our study cohort included 40 patients. Buccal mucosal graft (BMG) urethroplasty was used in 25 patients and 15 patients were treated with the aid of lingual mucosal graft (LMG). The median follow-up was 85 (IQR: 69-110) months. Seven (17,5%) patients suffered a stricture recurrence of which 4 (10%) needed re-intervention. Median 5-y recurrent free survival (RFS) for the entire cohort was 85 (±6)%. Median 5-y RFS was 96 (±4)% versus 65 (±13)% for respectively BMG and LMG (p=0.03). Post-oper- ative complications were identified in 11 (27,5%) patients with only 1 (2.5%) patient who had a grade 3a complication. Conclusion: Dorsal inlay oral mucosa graft urethroplasty is a safe and feasible tech- nique for selected patients with meatal stenosis

Penis and glans reconstruction with buccal mucosa graft in a multi-operated, failed hypospadias repair

Introduction & Objectives: Hypospadias surgery represents a complex field within the domain of the reconstructive urologist. 1 Today, it is known 2 failed hypospadias repair comprises an even more challenging problem that requires the mastering of multiple different techniques in order to that more severe grades of hypospadias are associated with a higher failure rate after primary intervention. Therefore, restoration of a penis after 3 using buccal mucosa grafts in patients with failed hypospadias repair. This video demonstrates the different steps of our technique. Materials & Methods: A 21-year-old male patient who has previously undergone over 40 failed surgeries to correct for penoscrotal hypospadias was referred to our department for penis and glans restoration. His past surgical history included 41 failed hypospadias surgeries elsewhere. As the patient is able to have sexual intercourse with residual sensate glans tissue, a complete phallic reconstruction was not considered. Furthermore, we created a retrospective database of all patients who underwent penis and glans reconstruction after multiple failed attempts of hypospadias repair. Results: A prepubic Z-plasty is performed to allow dorsal lengthening of the penile shaft. The remaining glans tissue is circumcised to retain maximal genital sensitivity. Scar tissue surrounding the penile shaft is removed, the suspensory ligament is incised and the cavernosal bodies are dissected to further gain penile length. All prepubic and penoscrotal subcutaneous fibrosis in the is resected to gain skin elasticity. The proximal penile shaft is covered with skin while the most distal aspect is covered with two buccal mucosa grafts of each 6 x 2.5cm to reconstruct an aesthetic glans. Between November 2014 and June 2020, 6 adult patients underwent reconstruction with buccal graft mucosa. All patients had undergone multiple (>15) surgeries before being referred to our centre. The initial condition was hypospadias in 1 patient, partial penile amputation for carcinoma in 3 patients, and glans amputation after circumcision accident in 2 patients. More information about previous surgeries could not be retrieved. All patients were pleased with the aesthetic result and reported satisfying sexual functioning at six months after surgery. Conclusions: Penile and glans restoration after failed hypospadias surgery remains a great challenge to the reconstructive surgeon. Buccal mucosa grafts have an established function in urethral repair. They also form a valid option for glans reconstruction in failed hypospadias patients

Complete bladder duplication presenting in adulthood : a case report on reconstructive technique and reflections on translational urology in refugees

Introduction and aim of study: The bladder-Exstrophy-Epispadias (BEEC) complex is a spectrum of congenital malformations with many variations. A never operated political refugee with BEEC was referred to our center for management upon arrival in Europe. Our aim is to report the technique and outcomes on a never operated on BEEC adult, highlighting the importance of transitional urologic care for congenital malformations in adult patients. Materials and methods: A 27-year old female patient was referred to our center for complete incontinence since birth by the General practitioner from the refugee center who suspected BEEC. Upon further investigation, an exstrophic bladder with blind ending ureteral orifices and a urethral meatus caudal to the exstrophic bladder plate were highlighted. A second non-exstrophic bladder with two orthotopic ureters was demonstrated, thereby a bladder duplication in the sagittal plane was diagnosed, presenting a wide-open bladder neck and a 7 cm pubic diastasis, causing the incontinence she was initially referred for. With the patient in a supine position, laparotomy incision was done with excision of the umbilical scar. The exstrophic bladder plate is dissected caudally. As it presents good detrusor quality, decision is taken to use it as a ventral inlay to augment the non-exstrophic bladder. A Mitchell-type bladder neck reconstruction is performed with a classical fascia sling wrapped around the bladder neck to increase the continence mechanism given the very wide pubic diastasis. Given the risk for hyper-continence, interposition of a continent Mitrofanoff-type vesicostomy is additionally realized. Genital reconstruction is achieved. Results: Over 1 year post operatively, the patient is completely dry, can holp up to 250ml between catheterization she performs five times per day and once at night. No post-operative complications were observed. Conclusion: The case of one adult patient with a rare urological condition like bladder exstrophy with duplication is presented, illustrating challenges political refugees referred to Europe implicates in terms of surgery regarding congenital malformations in adult patients. A multidisciplinary approach is highly important, demonstrating the importance of transitional care

Female urethroplasty : outcomes of different techniques in a single center

Introduction: Female urethral strictures and injuries are relatively uncommon compared to males. A wide range of possible causes and treatment modalities have been described. Lately female urethral reconstruction is gaining attention and is fortunately no longer a neglected topic within the reconstructive urology. As such, we aimed to describe our surgical techniques and outcomes for female urethroplasty from a tertiary center. Materials and Methods: Records of female patients who underwent a urethroplasty between July 2018 and May 2021 in our tertiary referral center were reviewed. Patients were subdivided in two groups: patients who suffered from a urethral injury and received an early repair urethroplasty, and patients with a true urethral stricture who received a delayed urethroplasty. Preprocedural, surgical and postoperative data were collected and analyzed with descriptive statistics. Results: A total of five patients in group 1 and nine patients in group 2 were included. Etiology of the urethral injury in group 1 was iatrogenic in 80% and transitional cell carcinoma of the urethra in 20% of cases. A patency rate of 100% at a follow‐up of 30 months was achieved with the different techniques. In group 2 etiology was idiopathic (44%), iatrogenic (44%) and due to external trauma in 12% of cases. Urethroplasty technique consisted of primary repair or dorsal onlay of a buccal mucosal graft. Patency rate was 100% at a median follow‐up of 13 months. Three patients suffered from postoperative urinary incontinence, one in group 1 and two in group 2. Conclusion: Female urethroplasty is a relatively rare entity within reconstructive urethral surgery. This case series of 14 patients demonstrates that with appropriate surgical techniques, a high patency rate with a low complication rate can be achieved. Further prospective studies with standardized diagnostic workup and follow‐up should be performed in order to optimize management strategy

Treatment of urethral strictures in transmasculine patients

Background. Urethral strictures are a common complication after genital gender-affirming surgery (GGAS) in transmasculine patients. Studies that specifically focus on the management of urethral strictures are scarce. The aim of this systematic review is to collect all available evidence on the management of urethral strictures in transmasculine patients who underwent urethral length- ening. Methods. We performed a systematic review of the management of urethral strictures in transmasculine patients after phalloplasty or metoidioplasty (PROSPERO, CRD42021215811) with literature from PubMed, Embase, Web of Science and Cochrane. Preferred Reporting Items for Sys- tematic reviews and Meta-Analysis-(PRISMA) guidelines were followed, and risk of bias was as- sessed for every individual study using the 5-criterion quality appraisal checklist. Results. Eight case series were included with a total of 179 transmasculine patients. Only one study discussed the management of urethral strictures after metoidioplasty. Urethral strictures were most often seen at the anastomosis between the fixed and pendulous urethra. For each stricture location, different tech- niques have been reported. All studies were at a high risk of bias. The current evidence is insuffi- cient to favor one technique over another. Conclusions. Different techniques have been described for the different clinical scenarios of urethral stricture disease after GGAS. In the absence of com- parative studies, however, it is impossible to advocate for one technique over another. This calls for additional research, ideally well-designed prospective randomized controlled trials (RCTs), focus- ing on both surgical and functional outcome parameters