Topic: Reconstructive Surgery

Genital Reconstruction After Massive Tissue Loss

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.

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Dilating Scarred Corporal Bodies for Penile Implant Cylinder Placement

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.

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

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.

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Management of High Grade Renal Trauma

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.

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AUA Urethral Stricture Guidelines

Chris Gonzalez MD, MBA, FACS, who served on the 2016 American Urological Association (AUA) Male Urethral Stricture Panel, summarizes the guidelines his panel drafted and provides commentary. He analyzes the indications for evaluation, diagnosis, treatment, and follow up in bulbar, penile, and prostatic urethral strictures, as well as in pelvic fracture urethral injury (PFUI). Furthermore, he discusses the future research needed to perfect urethral stricture management practices.

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Principles of Tissue Transfer in Reconstructive Urology

Joel Gelman, MD, discusses the basic plastic surgery principles of tissue transfer in reconstructive urology. Specifically, he describes plastic surgery applications for urethral strictures, pelvic fractures, and hypospadias. Furthermore, he explains how these principles can improve surgery best practices and patient outcomes.

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