- Email: [email protected]
101 AUTOTRANSPLANTATION - AN EXCELLENT CHOICE FOR EXCELLENT RESULTS
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THE JOURNAL OF UROLOGY姞
Vol. 189, No. 4S, Supplement, Saturday, May 4, 2013
RESULTS: All patients achieved good cosmetic results. Operative variables such as disease severity, blood loss, and length of hospital stay was dependent on severity of disease and patient comorbidities. No wound complications occurred at the STSG donor site. STSG take on the scrotum and penis ranged from 60-100%. Wound complications from local flap closure were clinically insignificant and includes small (2cm or less) areas of wound breakdown with no evidence of infection. CONCLUSIONS: Genital and perineal hidradenitis suppurativa is a debilitating and disfiguring disease. The use of radical resection and reconstruction with skin flaps and grafts provides a viable treatment option for these patients. Source of Funding: None
99 SURGICAL OUTCOMES FOLLOWING SURGICAL REPAIR OF ADULT GENITAL SKIN DEFICIENCY USING LIMITED PANNICULECTOMY AND SPLIT THICKNESS SKIN GRAFT Bryan Voelzke*, Seattle, WA; Alex Vanni, Burlington, MA; Brad Figler, Hunter Wessells, Jeffrey Friedrich, Seattle, WA INTRODUCTION AND OBJECTIVES: Genital skin deficiency (GSD), or adult buried penis, is a disorder that is highly correlated to abdominal obesity and/or circumcision. Common manifestations of GSD include phimosis, lower urinary tract symptoms, and sexual dysfunction. Secondary manifestations include balanitis and lichen sclerosis. Our primary aim was to report surgical outcomes following GSD intervention. Patient reported outcome measures among a subset of our patients are presented. METHODS: Outcomes following GSD surgery were assessed from 2005 to present. Surgical reconstruction consisted of limited panniculectomy, radical excision of penile shaft skin, scrotoplasty, and split thickness skin graft (STSG). To prevent GSD recurrence, the inferior border of the panniculectomy site was sutured to the rectus fascia or pubic symphysis periostium and a scrotoplasty was performed. The surgical team included plastic surgery and urology. Patients were evaluated for complications of panniculectomy, donor, and graft sites. Beginning in 2010, patient reported outcome data was collected. RESULTS: A total of 24 men underwent GSD surgery. Mean follow up was 12 months. Demographics are presented in the table. Predominately, the STSG donor site was the leg, while skin from the excised pannus was used in the remainder (2/24). Reconstruction was most commonly performed in one stage; however, a staged approach using a temporary allograft was done in three patients. All patients had 90-100% take of their STSG; however, one patient experienced poor cosmetic outcome due to lichen sclerosis recurrence. There were no donor site complications. Three patients had panniculectomy complications (cellulitis, lymphedema, poor wound healing). An improved/ stable response was noted among all patients (n⫽7) answering a pre/post general quality of life question. Compared to preoperative scores, all seven patients experienced improved voiding per the AUA-SS instrument, while 4/7 experienced improved IIEF-5 instrument scores. CONCLUSIONS: Surgical correction of GSD with a penile STSG and limited panniculectomy is well tolerated. Preliminary data suggests improved patient related outcomes among a subset of our patients.
Demographics of GSD cohort (n⫽24). Mean BMI
22/24 (91.7%)
Repeated Circumcision
6/24 (25%)
Hypertension
14/24 (58.3%)
Diabetes
10/24 (41.7%)
Tobacco Use
7/24 (29%)
100 PYELOPLASTY: ANALYSIS OF SYMPTOMATIC PATIENTS WITH EQUIVOCAL RENAL SCANS Bradley Wilson*, Andrew Arther, David Duchene, Kansas City, KS INTRODUCTION AND OBJECTIVES: Ureteropelvic junction obstruction (UPJO) has become one of the most successful surgically treated diseases in Urology. Multiple studies have established success rates over 95% for open, laparoscopic, and robotic pyeloplasty. However, these studies include clearly obstructed patients, with diuretic T1⁄2 greater than 20 minutes on renal scan. Nonetheless, clinical practice often presents symptomatic patients with radiographic findings, but equivocal renal scans (T1⁄2 ⬍ 20). The purpose of our study is to review the success of pyeloplasty in this population. METHODS: We retrospectively reviewed 65 patients with symptomatic UPJO, who underwent Robotic Assisted Laparoscopic Pyeloplasty (RAP), between 2006 and 2010. Subjects were grouped by renal scan findings. The first group had a diuretic T1⁄2 of ⬎ 20. The remaining patients had a T1⁄2 ⬍ 20, but had clinical symptoms of UPJO and radiographic findings of hydronephrosis. Subjects were followed 1,3, and 9 months postoperatively. Data was collected on age, sex, symptoms, BMI, previous UPJ surgery, presence of crossing vessels, pre/postoperative hemoglobin, length of hospitalization, pre/postoperative renal scan, pre/postoperative creatinine levels, and complications. RESULTS: The mean patient age was 41.3 yrs (median 34) – 62% were female. UPJO occurred 44% on left and 56% on right, with 86% presenting with flank pain. Seven patients underwent previous pyeloplasty and 14 patients previous endopylotomy. Crossing vessels were present in 41% and preserved in all cases. There were no intraoperative complications. Of the 65 patients, 43 had obstructive findings with a diuretic T1⁄2 ⬎20 min. All but two (95%) had resolution of obstruction measured by renal scan. All but three (93%) had resolution of their pain. All patients reported improvement of pain. The remaining 22 patients had a mean diuretic T1⁄2 of 12.7 (median 14.3). All but two (90%) had improvement in renal scan findings, with a mean decrease in T1⁄2 of 4.4 min. Despite this, only nine (41%) had improvement of pain. Closer analysis of this group revealed a significant number (12/13) with persistent pain were female (p⫽ 0.0231). Additionally, those with continued pain more likely had crossing vessels (69%), compared to those with pain resolution (33%). CONCLUSIONS: The success of Pyeloplasty in patients with a diuretic T1⁄2 ⬎20 minutes has been well established. Our study examines outcomes in patients with clinically symptomatic UPJO and equivocal diuretic renography. We found these patients had significantly less resolution of symptoms (41%), compared to those with obstructive renal scans (93%) (p⬍.0001). Source of Funding: None
101 AUTOTRANSPLANTATION - AN EXCELLENT CHOICE FOR EXCELLENT RESULTS
Source of Funding: None Mean Age
Previous Circumcision
54.9 years 45.6
Obese (BMI 30-34)
2/24 (8.3%)
Morbidly Obese (BMI 35-44)
9/24 (37.5%)
Super Obese (BMI ⱖ 45)
12/24 (50%)
Lichen Sclerosis
9/24 (37.5%)
Richard Johnston, Natalya Lopushnyan*, Paul Kozlowski, Thomas Hefty, Seattle, WA INTRODUCTION AND OBJECTIVES: Renal autotransplantation has been described in the past as a management option for complex ureteral and renal vascular pathology. We report a single center’s long-term outcomes and late complications after nephrectomy with autotransplantation for a variety of pre-operative indications.
Vol. 189, No. 4S, Supplement, Saturday, May 4, 2013
METHODS: We retrospectively reviewed clinical data on all patients who underwent nephrectomy with auto transplantation between July 2007 and August 2012. Indications, intra- and perioperative complications as well as late complications were analyzed. RESULTS: A total of 22 patients were identified. Autotransplantation of a solitary kidney was performed in 3 out of 22 patients. Indications for autotransplantation included complex ureteral stricture disease in 8 patients, 3 failed UPJ repairs, 3 renal artery aneurysms, 3 iatrogenic injuries resulting in long strictures, 2 patients with recurrent stone disease and pain, 1 retroperitoneal fibrosis, 1 desmoid tumor and a heminephrectomy of a large diverticulum with re-implantation. Median age at surgery was 49 years (range 25 to 74). Median follow up was 24 months. One patient (4.5%) required immediate re-operation due to renal artery thrombus, this patient’s graft was saved with no long term impact on renal function. No patient required repeat surgery following initial discharge. All other grafts performed well with no discernible reduction in renal function over the follow up period. Mean Cr decreased overall from 1.19 to 0.96 mg/dL. CONCLUSIONS: Complex ureteric or renal vascular abnormalities are difficult to manage. In selected patients autotransplantation provides safe and effective approach to prevent renal loss and preserve existing renal function. Urologists should continue to have some presence in the world of non autologus transplant to maintain the transplantation skills necessary to manage these complex cases. Difficult reconstructive cases should be referred to centres of excellence where these difficult cases are best managed. Source of Funding: None
102 EXTRACELLULAR MATRIX VERSUS BUCCAL MUCOSA GRAFT IN URETHRAL STRICTURE REPAIR David Koslov, Winston Salem, NC; Kyle Wood, Ilya Gorbachinksy, Christopher King, Ryan Terlecki, Brandy Hood*, Winston-Salem, NC INTRODUCTION AND OBJECTIVES: Urethral strictures can be a challenge to repair. Many are amenable to single stage repair, however longer and/or more complex strictures require multiple stage repairs. Buccal mucosa is a well established modality in bridging these distances and has become the standard of care in multiple stage repairs. Yet harvesting buccal mucosa, a limited resource, adds time and potential morbidity to this procedure. An alternative matrix that is commercially available and performs well clinically would be ideal. We report our experience with urethral repair comparing buccal mucosa graft and Acell®, an extracellular matrix (ECM), for urethroplasty. The objective of this study was to compare ECM and buccal mucosa rate of contraction and take in urethral stricture repair. METHODS: This is a retrospective chart review of a single surgeon’s experience with 3 patients undergoing the first stage of a multistage urethral repair using extracellular matrix only in one patient and both buccal mucosa and extracellular matrix in the remaining two. Comparison of buccal mucosa and ECM contraction rates towards midline and take were demonstrated by time lapse photography. RESULTS: Strictures were primarily bulbar, with one extending to the pendulous urethra. Average age was 68.6 (low of 66 high of 73). In all patients, both extracellular matrix and buccal mucosa showed good take, with appropriate granulation. Over 3 months, the patient receiving ECM only showed equal contraction towards midline, with good granulation. Patient reports satisfaction with treatment. Over 5 months, patients receiving both ECM and buccal showed slightly more contraction in ECM versus buccal mucosa. Photo at original procedure demonstrated buccal graft occupying 34.6% of urethral plate, and 54.3% at 5 months. Contraction was decided through photograph analysis using the urethral midline as a marker. Percentage of total wound occupied by the respective tissue was calculated. CONCLUSIONS: Here we demonstrate a novel use of Acell®, a commercially available extracellular matrix. Compared to the current standard of care for urethral reconstruction, Acell® shows similar take
THE JOURNAL OF UROLOGY姞
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and rates of contraction. All patients demonstrated urethral patency at follow up. This use of ECM is promising when compared to the standard of care, and merits further investigation. Source of Funding: Departmental.
103 TRANSSEXUAL GENITAL SURGERY: COMPLICATIONS AND FUNCTIONAL RESULTS AFTER 13 YEARS OF EXPERIENCE Maria Helena Sircili*, Francisco Tibor De´nes, Alessandro Tavares, Elaine Maria Frade Costa, Sorahia Domenice, Fla´via Siqueira Cunha, Miguel Srougi, Berenice Mendonça, Sa˜o Paulo, Brazil INTRODUCTION AND OBJECTIVES: Due to continuous increase in the number of transsexual patients requiring genital reconstruction, the surgeons involved in sex reassignment should be prepared to perform the best technique and to deal with the complications of the procedures. Our aim is to present our results after 13 years of experience. METHODS: From 1999 to 2012, 70 patients were submitted to sex reassignment [50 male (MT) and 20 female transsexuals (FT)], with average age of 35ys (23-68ys). All patients had confirmed psychiatric diagnosis and underwent psychological therapy for at least 2 years. All had hormonal replacement under endocrinological supervision. The techniques used were penile inversion to create the neovagina for MT and panhysterectomy with colpectomy followed by metoidioplasty in two staged procedure for FT. The mean follow-up was 6.5ys (1-12ys). RESULTS: After male-to-female procedure, physical examination showed normal female appearance in all patients. The mean penile length before surgery was10.6 (9-15) and the neovaginal length was 8.8cm (5-12cm). Four patients had loss of the neovagina, due to hematoma in one and total vaginal prolapse with recto-vaginal fistula in 3. Six patients had urethral meatus stenosis. Five patients had partial vaginal prolapse, corrected by laparoscopy in one and by suprapubic suspension in 3. One patient had the glans removed because of prolapse to the labia majora. One patient had a compartmental syndrome in the left leg, treated with fasciotomy. The overall complication rate was 40% and reoperation was necessary in 20 patients, being more frequent in the first 20 patients (45% x 30%). After all procedures, 40 patients had normal sexual intercourse, 3 reported no desire for relationship, 4 had recent surgery and 3 are schedule for reoperation. The average number of procedures in the FT group was 3 (1-4). Twelve patients completed masculinization, and the length of the phallus was 5cm (4.8 to 5.5cm). Despite limited penile size, sexual satisfaction is achieved in all patients. Urethral stenosis occurred in 2 patients, and was treated by dilatation. CONCLUSIONS: The surgery in MT is a single stage procedure with high rate of complications, but most patients have sexual intercourse with sensibility and orgasm. Surgery in FT is a staged procedure with a low rate of complications. Despite sexual satisfaction, penetration is limited by phallic length. Source of Funding: None
104 PENILE ENTRAPMENT BY CONSTRICTION DEVICE: A NOVEL TECHNIQUE FOR REMOVAL OF STUBBORN RINGS Daniel T. Oberlin*, Puneet Masson, Robert E. Brannigan, Chicago, IL INTRODUCTION AND OBJECTIVES: Penile entrapment via penile ring is an increasingly encountered clinical entity requiring urgent and effective treatment. Management poses unique challenges to the treating physician through variable presentation as well as the lack of a standardized approach to ring removal. Power-drive cutting tools, which include Dremel saws and oscillating orthopedic saws, have been utilized but have variable success and increased potential for morbidity. We present a novel technique to facilitate penile ring removal in patients presenting with this devastating condition.
THE JOURNAL OF UROLOGY姞
Vol. 189, No. 4S, Supplement, Saturday, May 4, 2013
RESULTS: All patients achieved good cosmetic results. Operative variables such as disease severity, blood loss, and length of hospital stay was dependent on severity of disease and patient comorbidities. No wound complications occurred at the STSG donor site. STSG take on the scrotum and penis ranged from 60-100%. Wound complications from local flap closure were clinically insignificant and includes small (2cm or less) areas of wound breakdown with no evidence of infection. CONCLUSIONS: Genital and perineal hidradenitis suppurativa is a debilitating and disfiguring disease. The use of radical resection and reconstruction with skin flaps and grafts provides a viable treatment option for these patients. Source of Funding: None
99 SURGICAL OUTCOMES FOLLOWING SURGICAL REPAIR OF ADULT GENITAL SKIN DEFICIENCY USING LIMITED PANNICULECTOMY AND SPLIT THICKNESS SKIN GRAFT Bryan Voelzke*, Seattle, WA; Alex Vanni, Burlington, MA; Brad Figler, Hunter Wessells, Jeffrey Friedrich, Seattle, WA INTRODUCTION AND OBJECTIVES: Genital skin deficiency (GSD), or adult buried penis, is a disorder that is highly correlated to abdominal obesity and/or circumcision. Common manifestations of GSD include phimosis, lower urinary tract symptoms, and sexual dysfunction. Secondary manifestations include balanitis and lichen sclerosis. Our primary aim was to report surgical outcomes following GSD intervention. Patient reported outcome measures among a subset of our patients are presented. METHODS: Outcomes following GSD surgery were assessed from 2005 to present. Surgical reconstruction consisted of limited panniculectomy, radical excision of penile shaft skin, scrotoplasty, and split thickness skin graft (STSG). To prevent GSD recurrence, the inferior border of the panniculectomy site was sutured to the rectus fascia or pubic symphysis periostium and a scrotoplasty was performed. The surgical team included plastic surgery and urology. Patients were evaluated for complications of panniculectomy, donor, and graft sites. Beginning in 2010, patient reported outcome data was collected. RESULTS: A total of 24 men underwent GSD surgery. Mean follow up was 12 months. Demographics are presented in the table. Predominately, the STSG donor site was the leg, while skin from the excised pannus was used in the remainder (2/24). Reconstruction was most commonly performed in one stage; however, a staged approach using a temporary allograft was done in three patients. All patients had 90-100% take of their STSG; however, one patient experienced poor cosmetic outcome due to lichen sclerosis recurrence. There were no donor site complications. Three patients had panniculectomy complications (cellulitis, lymphedema, poor wound healing). An improved/ stable response was noted among all patients (n⫽7) answering a pre/post general quality of life question. Compared to preoperative scores, all seven patients experienced improved voiding per the AUA-SS instrument, while 4/7 experienced improved IIEF-5 instrument scores. CONCLUSIONS: Surgical correction of GSD with a penile STSG and limited panniculectomy is well tolerated. Preliminary data suggests improved patient related outcomes among a subset of our patients.
Demographics of GSD cohort (n⫽24). Mean BMI
22/24 (91.7%)
Repeated Circumcision
6/24 (25%)
Hypertension
14/24 (58.3%)
Diabetes
10/24 (41.7%)
Tobacco Use
7/24 (29%)
100 PYELOPLASTY: ANALYSIS OF SYMPTOMATIC PATIENTS WITH EQUIVOCAL RENAL SCANS Bradley Wilson*, Andrew Arther, David Duchene, Kansas City, KS INTRODUCTION AND OBJECTIVES: Ureteropelvic junction obstruction (UPJO) has become one of the most successful surgically treated diseases in Urology. Multiple studies have established success rates over 95% for open, laparoscopic, and robotic pyeloplasty. However, these studies include clearly obstructed patients, with diuretic T1⁄2 greater than 20 minutes on renal scan. Nonetheless, clinical practice often presents symptomatic patients with radiographic findings, but equivocal renal scans (T1⁄2 ⬍ 20). The purpose of our study is to review the success of pyeloplasty in this population. METHODS: We retrospectively reviewed 65 patients with symptomatic UPJO, who underwent Robotic Assisted Laparoscopic Pyeloplasty (RAP), between 2006 and 2010. Subjects were grouped by renal scan findings. The first group had a diuretic T1⁄2 of ⬎ 20. The remaining patients had a T1⁄2 ⬍ 20, but had clinical symptoms of UPJO and radiographic findings of hydronephrosis. Subjects were followed 1,3, and 9 months postoperatively. Data was collected on age, sex, symptoms, BMI, previous UPJ surgery, presence of crossing vessels, pre/postoperative hemoglobin, length of hospitalization, pre/postoperative renal scan, pre/postoperative creatinine levels, and complications. RESULTS: The mean patient age was 41.3 yrs (median 34) – 62% were female. UPJO occurred 44% on left and 56% on right, with 86% presenting with flank pain. Seven patients underwent previous pyeloplasty and 14 patients previous endopylotomy. Crossing vessels were present in 41% and preserved in all cases. There were no intraoperative complications. Of the 65 patients, 43 had obstructive findings with a diuretic T1⁄2 ⬎20 min. All but two (95%) had resolution of obstruction measured by renal scan. All but three (93%) had resolution of their pain. All patients reported improvement of pain. The remaining 22 patients had a mean diuretic T1⁄2 of 12.7 (median 14.3). All but two (90%) had improvement in renal scan findings, with a mean decrease in T1⁄2 of 4.4 min. Despite this, only nine (41%) had improvement of pain. Closer analysis of this group revealed a significant number (12/13) with persistent pain were female (p⫽ 0.0231). Additionally, those with continued pain more likely had crossing vessels (69%), compared to those with pain resolution (33%). CONCLUSIONS: The success of Pyeloplasty in patients with a diuretic T1⁄2 ⬎20 minutes has been well established. Our study examines outcomes in patients with clinically symptomatic UPJO and equivocal diuretic renography. We found these patients had significantly less resolution of symptoms (41%), compared to those with obstructive renal scans (93%) (p⬍.0001). Source of Funding: None
101 AUTOTRANSPLANTATION - AN EXCELLENT CHOICE FOR EXCELLENT RESULTS
Source of Funding: None Mean Age
Previous Circumcision
54.9 years 45.6
Obese (BMI 30-34)
2/24 (8.3%)
Morbidly Obese (BMI 35-44)
9/24 (37.5%)
Super Obese (BMI ⱖ 45)
12/24 (50%)
Lichen Sclerosis
9/24 (37.5%)
Richard Johnston, Natalya Lopushnyan*, Paul Kozlowski, Thomas Hefty, Seattle, WA INTRODUCTION AND OBJECTIVES: Renal autotransplantation has been described in the past as a management option for complex ureteral and renal vascular pathology. We report a single center’s long-term outcomes and late complications after nephrectomy with autotransplantation for a variety of pre-operative indications.
Vol. 189, No. 4S, Supplement, Saturday, May 4, 2013
METHODS: We retrospectively reviewed clinical data on all patients who underwent nephrectomy with auto transplantation between July 2007 and August 2012. Indications, intra- and perioperative complications as well as late complications were analyzed. RESULTS: A total of 22 patients were identified. Autotransplantation of a solitary kidney was performed in 3 out of 22 patients. Indications for autotransplantation included complex ureteral stricture disease in 8 patients, 3 failed UPJ repairs, 3 renal artery aneurysms, 3 iatrogenic injuries resulting in long strictures, 2 patients with recurrent stone disease and pain, 1 retroperitoneal fibrosis, 1 desmoid tumor and a heminephrectomy of a large diverticulum with re-implantation. Median age at surgery was 49 years (range 25 to 74). Median follow up was 24 months. One patient (4.5%) required immediate re-operation due to renal artery thrombus, this patient’s graft was saved with no long term impact on renal function. No patient required repeat surgery following initial discharge. All other grafts performed well with no discernible reduction in renal function over the follow up period. Mean Cr decreased overall from 1.19 to 0.96 mg/dL. CONCLUSIONS: Complex ureteric or renal vascular abnormalities are difficult to manage. In selected patients autotransplantation provides safe and effective approach to prevent renal loss and preserve existing renal function. Urologists should continue to have some presence in the world of non autologus transplant to maintain the transplantation skills necessary to manage these complex cases. Difficult reconstructive cases should be referred to centres of excellence where these difficult cases are best managed. Source of Funding: None
102 EXTRACELLULAR MATRIX VERSUS BUCCAL MUCOSA GRAFT IN URETHRAL STRICTURE REPAIR David Koslov, Winston Salem, NC; Kyle Wood, Ilya Gorbachinksy, Christopher King, Ryan Terlecki, Brandy Hood*, Winston-Salem, NC INTRODUCTION AND OBJECTIVES: Urethral strictures can be a challenge to repair. Many are amenable to single stage repair, however longer and/or more complex strictures require multiple stage repairs. Buccal mucosa is a well established modality in bridging these distances and has become the standard of care in multiple stage repairs. Yet harvesting buccal mucosa, a limited resource, adds time and potential morbidity to this procedure. An alternative matrix that is commercially available and performs well clinically would be ideal. We report our experience with urethral repair comparing buccal mucosa graft and Acell®, an extracellular matrix (ECM), for urethroplasty. The objective of this study was to compare ECM and buccal mucosa rate of contraction and take in urethral stricture repair. METHODS: This is a retrospective chart review of a single surgeon’s experience with 3 patients undergoing the first stage of a multistage urethral repair using extracellular matrix only in one patient and both buccal mucosa and extracellular matrix in the remaining two. Comparison of buccal mucosa and ECM contraction rates towards midline and take were demonstrated by time lapse photography. RESULTS: Strictures were primarily bulbar, with one extending to the pendulous urethra. Average age was 68.6 (low of 66 high of 73). In all patients, both extracellular matrix and buccal mucosa showed good take, with appropriate granulation. Over 3 months, the patient receiving ECM only showed equal contraction towards midline, with good granulation. Patient reports satisfaction with treatment. Over 5 months, patients receiving both ECM and buccal showed slightly more contraction in ECM versus buccal mucosa. Photo at original procedure demonstrated buccal graft occupying 34.6% of urethral plate, and 54.3% at 5 months. Contraction was decided through photograph analysis using the urethral midline as a marker. Percentage of total wound occupied by the respective tissue was calculated. CONCLUSIONS: Here we demonstrate a novel use of Acell®, a commercially available extracellular matrix. Compared to the current standard of care for urethral reconstruction, Acell® shows similar take
THE JOURNAL OF UROLOGY姞
e41
and rates of contraction. All patients demonstrated urethral patency at follow up. This use of ECM is promising when compared to the standard of care, and merits further investigation. Source of Funding: Departmental.
103 TRANSSEXUAL GENITAL SURGERY: COMPLICATIONS AND FUNCTIONAL RESULTS AFTER 13 YEARS OF EXPERIENCE Maria Helena Sircili*, Francisco Tibor De´nes, Alessandro Tavares, Elaine Maria Frade Costa, Sorahia Domenice, Fla´via Siqueira Cunha, Miguel Srougi, Berenice Mendonça, Sa˜o Paulo, Brazil INTRODUCTION AND OBJECTIVES: Due to continuous increase in the number of transsexual patients requiring genital reconstruction, the surgeons involved in sex reassignment should be prepared to perform the best technique and to deal with the complications of the procedures. Our aim is to present our results after 13 years of experience. METHODS: From 1999 to 2012, 70 patients were submitted to sex reassignment [50 male (MT) and 20 female transsexuals (FT)], with average age of 35ys (23-68ys). All patients had confirmed psychiatric diagnosis and underwent psychological therapy for at least 2 years. All had hormonal replacement under endocrinological supervision. The techniques used were penile inversion to create the neovagina for MT and panhysterectomy with colpectomy followed by metoidioplasty in two staged procedure for FT. The mean follow-up was 6.5ys (1-12ys). RESULTS: After male-to-female procedure, physical examination showed normal female appearance in all patients. The mean penile length before surgery was10.6 (9-15) and the neovaginal length was 8.8cm (5-12cm). Four patients had loss of the neovagina, due to hematoma in one and total vaginal prolapse with recto-vaginal fistula in 3. Six patients had urethral meatus stenosis. Five patients had partial vaginal prolapse, corrected by laparoscopy in one and by suprapubic suspension in 3. One patient had the glans removed because of prolapse to the labia majora. One patient had a compartmental syndrome in the left leg, treated with fasciotomy. The overall complication rate was 40% and reoperation was necessary in 20 patients, being more frequent in the first 20 patients (45% x 30%). After all procedures, 40 patients had normal sexual intercourse, 3 reported no desire for relationship, 4 had recent surgery and 3 are schedule for reoperation. The average number of procedures in the FT group was 3 (1-4). Twelve patients completed masculinization, and the length of the phallus was 5cm (4.8 to 5.5cm). Despite limited penile size, sexual satisfaction is achieved in all patients. Urethral stenosis occurred in 2 patients, and was treated by dilatation. CONCLUSIONS: The surgery in MT is a single stage procedure with high rate of complications, but most patients have sexual intercourse with sensibility and orgasm. Surgery in FT is a staged procedure with a low rate of complications. Despite sexual satisfaction, penetration is limited by phallic length. Source of Funding: None
104 PENILE ENTRAPMENT BY CONSTRICTION DEVICE: A NOVEL TECHNIQUE FOR REMOVAL OF STUBBORN RINGS Daniel T. Oberlin*, Puneet Masson, Robert E. Brannigan, Chicago, IL INTRODUCTION AND OBJECTIVES: Penile entrapment via penile ring is an increasingly encountered clinical entity requiring urgent and effective treatment. Management poses unique challenges to the treating physician through variable presentation as well as the lack of a standardized approach to ring removal. Power-drive cutting tools, which include Dremel saws and oscillating orthopedic saws, have been utilized but have variable success and increased potential for morbidity. We present a novel technique to facilitate penile ring removal in patients presenting with this devastating condition.