Łukasz Białek

Background/Objectives: Routine local gentamicin irrigation has been used during artificial urinary sphincter (AUS) implantation despite limited procedure-specific evidence. We evaluated early outcomes after its calendar-defined discontinuation. Methods: This single-centre retrospective before–after cohort included 173 uncoated AMS 800 procedures in 164 men: 59 under a gentamicin-containing local protocol and 114 after gentamicin withdrawal. Saline device immersion and Betadine-containing intraoperative irrigation of the operative field and both wounds continued in both periods. Clinician-recorded surgical-site infection (SSI) within 90 days was the antimicrobial outcome of greatest direct relevance. Complete explantation within 90 days for SSI and/or urethral erosion was an exploratory device-related endpoint; all-cause complications at 30 and 90 days were secondary safety outcomes. Results: SSI occurred after 1/59 (1.7%) gentamicin-protocol and 2/114 (1.8%) gentamicin-free procedures (risk difference +0.1 percentage points, 95% confidence interval −7.4 to +4.7; p = 1.000). Erosion occurred after 0/59 and 4/114 (3.5%) procedures; all four led to complete explantation. The explantation endpoint occurred after 1/59 versus 4/114 procedures (risk difference +1.8 percentage points, 95% confidence interval −5.8 to +7.2; p = 0.662). Thirty-day all-cause complications occurred after 14/59 versus 16/114 procedures and 90-day complications after 15/59 versus 26/114. Conclusions: No statistically significant between-period difference was detected in SSI, exploratory device-related explantation, or broad all-cause complications. Sparse events, wide confidence intervals and calendar-defined exposure amid concurrent era changes preclude conclusions regarding equivalence or absence of clinically relevant benefit or harm.

Objective: To establish international expert consensus on indications, contraindications, risk factors, and complication management in masculinising genital surgery (MGS) for assigned female at birth individuals, addressing the current lack of evidence‐based selection criteria. Methods: A two‐round Delphi study was conducted between May and July 2025 using an on‐line platform, followed by a final consensus meeting in September 2025. A total of 27 internationally recognised urologists with ≥5 years of independent experience in gender‐affirming genital surgery were invited; response rates were 96% and 89% in rounds one and two, respectively. In all, 83 statements related to metoidioplasty and phalloplasty were evaluated using a Likert scale. Consensus was pre‐defined as ≥75% agreement or disagreement. Results: Consensus was achieved on 75 of 83 statements. No strict upper age limit was recommended for metoidioplasty or phalloplasty; however, advanced age and comorbidities were recognised as risk factors for prolonged healing and severe complications. A body mass index >24.9 kg/m ² , diabetes mellitus, smoking, and cardiovascular disease were identified as relevant risk factors. A Charlson Comorbidity Index ≥3 was considered a relative contraindication for phalloplasty but not metoidioplasty. Multidisciplinary preoperative assessment was strongly endorsed. No consensus was reached regarding perioperative testosterone suspension. In urethral complications, staged reconstruction with a 6‐month interval and consideration of perineostomy in high‐risk patients were preferred. Penile prosthesis re‐implantation was considered acceptable after one failure but discouraged after multiple complications. Conclusions: This international Delphi consensus provides structured, expert‐based guidance for patient selection and complication management in MGS, emphasising individualised risk assessment, multidisciplinary evaluation, and cautious surgical planning in older or comorbid patients.

Background/Objectives: Perioperative antibiotics are standard in urethral stricture surgery, but timely uncontaminated preoperative urine cultures are not always available, and empiric regimens are often selected before current susceptibility data are known. We aimed to characterize preoperative bacteriuria and antimicrobial resistance in men undergoing urethral stricture surgery and to assess associations with recorded clinical variables. Methods: We retrospectively analyzed 304 men undergoing urethral stricture surgery at two referral centers, representing the subset of the surgical population for whom a complete preoperative microbiology report, including antimicrobial susceptibility data when culture-positive organisms were recovered, was retrievable from the institutional microbiology laboratory information systems. Clinical contributors were assigned by structured chart review. The primary microbiologic endpoint was preoperative bacteriuria, defined by final local laboratory interpretation of the urine culture. Urine culture was requested at admission and repeated within 24 h before surgery if missing or non-diagnostic. MDR was defined as resistance to three or more clinically relevant antimicrobial classes, excluding expected intrinsic resistance patterns. Results: Among patients with retrievable complete preoperative microbiology data, urine cultures were positive in 164/304 patients (53.9%). The most frequent recorded contributors were iatrogenic exposure (119; 39.1%), prior endoscopic treatment (71; 23.4%), and trauma (64; 21.1%); 108/304 patients (35.5%) had more than one contributor. Among culture-positive patients, MDR occurred in 18/164 (11.0%). On exploratory multivariable analysis, suprapubic catheter status was independently associated with culture positivity (adjusted OR 4.41, 95% CI 2.47–7.87; p < 0.001), whereas PFUI was not significant after adjustment. Conclusions: In this analytic cohort, preoperative bacteriuria was common, and suprapubic catheter status was the strongest independent correlate of urine culture positivity. The observed MDR burden supports recent preoperative urine culture acquisition and stewardship-based perioperative antibiotic selection.

Objective: To achieve an international expert consensus among surgeons on the indications, contraindications, and perioperative management of feminising genital surgery (FGS) for assigned‐male‐at‐birth (AMAB) individuals, using a Delphi process. Methods: A two‐round on‐line Delphi survey (May–July 2025) followed by a final consensus meeting (September 2025) was conducted among 27 urological surgeons specialised in gender‐affirming genital surgery. The survey explored eligibility criteria, risk factors, hormone therapy, counselling, and perioperative care. Consensus was defined a priori as ≥75% agreement or disagreement, with descriptive statistics summarising results. Results: In all, 26 experts (96%) completed Round 1, and 24 (89%) completed Round 2. Consensus was achieved on 63 of 68 statements. Advanced age alone was not a contraindication but should be evaluated alongside comorbidities. Body mass index >24.9 kg/m ² , diabetes, smoking, and cardiovascular disease were identified as significant risk factors for postoperative complications. Major psychiatric disorders and spinal cord injury were relative contraindications for FGS. Previous pelvic surgery or radiotherapy, as well as Charlson Comorbidity Index ≥3, were considered relative contraindications for vaginoplasty only. No consensus was reached on the timing of hormone therapy interruption or re‐initiation. Preoperative counselling was essential for adherence to wound care and dilation protocols and for addressing complications such as infection, thromboembolism, bleeding, and bowel injury. Experts recommended genital hair removal, enoxaparin prophylaxis, postoperative dressings and catheterization for 3–5 days, and pelvic rehabilitation before and after surgery. A dilation protocol of three daily 30‐min sessions was advised. FGS improved quality of life even in older or comorbid patients, although healing and function may be less optimal. Conclusion: This study presents the first international Delphi consensus on indications and perioperative management of FGS in AMAB individuals, emphasising individualised, comorbidity‐based assessment, structured counselling, and multidisciplinary care. Unresolved issues regarding hormone therapy require further study.

Scherñuk J, et al. Investig Clin Urol. 2026 May;67(3):307-309. https://doi.org/10.4111/icu.20260111

Urethral complications following urethral lengthening in transgender men, such as strictures and fistulas, are common and frequently necessitate secondary surgical interventions. These surgeries vary significantly in their techniques and are evaluated with considerable heterogeneity, making a synthesized presentation of their outcomes valuable for guiding clinical management. This systematic review included 14 studies selected through a database search (Medline, Embase, Web of Science) that reported urethral complications after urethral lengthening. Among the 595 patients considered, 76% underwent phalloplasty and 24% underwent metoidioplasty. Our findings highlight that staged urethroplasty techniques demonstrated the lowest recurrence rates (0–25%), particularly in the management of long strictures in the pendulous urethra. In contrast, one-stage urethroplasties—especially those performed without augmentation—were associated with high recurrence rates, reaching approximately 50%, even when buccal mucosa grafts were used for augmentation. Patient-reported outcomes were documented in only one-third of the included studies, underscoring the limited functional evaluation of urethroplasty outcomes following phalloplasty. The considerable variability in urethroplasty techniques, types of genital reconstruction, and reporting standards highlights the need for more comprehensive and standardized outcome assessments. Future studies will be essential in advancing our understanding and optimizing the management of these complex cases.

Background/Objectives: Urethral stricture disease, characterized by narrowing of the urethra due to scar tissue, affects urinary and sexual health. While urethroplasty is the standard treatment, its impact on erectile function is less understood. This study examines changes in International Index of Erectile Function (IIEF) scores post-urethroplasty across various stricture etiologies, identifies predictors of erectile function outcomes, and explores recovery trajectories following surgery. Methods: This multicenter retrospective study included 103 patients who underwent urethroplasty between 2017 and 2023. Preoperative and postoperative IIEF scores at 3 and 6 or 12 months were analyzed. Stricture etiologies included pelvic fracture urethral injury, transurethral resection, catheterization, idiopathic, and hypospadias. The Wilcoxon signed-rank test and multivariate regression models were used to assess changes in IIEF scores and identify significant predictors. Results: Preoperative erectile function and patient age were significant predictors of postoperative outcomes. Younger patients and those with higher baseline IIEF scores experienced better erectile function post-surgery. Long-term outcomes (6 to 12 months) were significantly worse for strictures involving both penile and bulbar regions. Multivariate analysis showed higher pre-surgery IIEF scores and younger age were associated with better outcomes both short-term (R² = 0.562) and long-term (R² = 0.507). Diabetes was associated with worse erectile function outcomes at 3 months post-surgery. Conclusions: Younger patients and those with higher baseline IIEF scores have better erectile function outcomes following urethroplasty. Complex strictures involving both penile and bulbar regions adversely affect long-term outcomes. Additionally, the presence of diabetes is correlated with diminished erectile function in the short-term postoperative period.

Purpose: To evaluate transperineal reanastomosis (TRPA) combined with incontinence surgery as a complex treatment for recurring vesicourethral anastomosis stenosis (VUAS) after radical prostatectomy (RP). Methods: Retrospective analysis of 8 patients who underwent TRPA for recurring VUAS. Detailed preoperative and follow up data were assessed. Results: Mean follow up lasted 47 months (range 17-77) with mean age being 63.4 years (range 61-70). All patients achieved patency and 87.5% (7/8) maintained it to the end of follow up. However, four of them required additional procedures to retain patency. Six underwent incontinence surgery – artificial urinary sphincter (AUS) implantation – after which one cuff erosion occurred. In the end 62.5% (5/8) of patients achieved patent urethra and continence. Conclusions: TRPA combined with incontinence surgery is a reasonable treatment for patients with recurrent VUAS. Nonetheless, this is a set of difficult surgeries that may ultimately end in failure, i.e. the inability to restore urethral patency, urinary incontinence or urinary diversion, hence they should be performed by experienced surgeons.

In the era of antibiotic overuse and increasing antibiotic resistance, there is a gap in evidence regarding antibiotic stewardship, and in particular, perioperative antibiotic prophylaxis after urethral reconstruction. The aim of this systematic review was to evaluate the effectiveness and relevance of postoperative antibiotic prophylaxis after male pediatric and adult urethral reconstruction. An online search of MEDLINE database via PubMed was performed. The systematic review was registered in PROSPERO (CRD42022348555) and was conducted according to the PRISMA guidelines and AMSTAR 2 checklist. A narrative synthesis of included studies was performed. After the screening of 1176 publications, six studies regarding antibiotic prophylaxis after hypospadias reconstruction and two studies regarding antibiotic prophylaxis after urethroplasty in adults were eligible to be included in the systematic review. All but one of the studies on hypospadias repair showed no benefit from postoperative antibiotic prophylaxis. The level of evidence on postoperative antibiotic prophylaxis after urethroplasty in adults is low. Neither of the two studies included in the review showed a benefit from antibiotic use. Postoperative prophylaxis after hypospadias repair is not effective in preventing urinary tract infections and wound infections. It seems that the use of postoperative prophylaxis after urethroplasty in adults is also not beneficial, but there is a high need for high-quality scientific data.