Urologic trauma/reconstruction: What the future holds

The 2016 AUA clinical guideline for male urethral stricture reflects evolving management strategies for this condition, and the number of urologists specializing in reconstruction is on the rise. In this interview, Richard Santucci, MD, discusses current trends in urologic trauma/reconstruction as well as the promise of penile transplantation. Dr. Santucci is senior surgeon at Crane Surgical Services in Austin, TX. Dr. Santucci was interviewed by Urology Times Editorial Consultant Gopal H. Badlani, MD, professor of urology at Wake Forest Baptist Medical Center, Winston-Salem, NC.

Let’s discuss urethral stricture. Traditionally, urethral dilation or direct vision internal urethrotomy (DVIU), whether done with a cold knife or laser, has been part of a urologist’s practice. How does the AUA clinical guideline for male stricture suggest a change in this practice?

I think the data was finally available to see that DVIU or a dilation is almost never a lasting cure. DVIU or dilation is a very efficient surgery if the person cannot urinate and you can dilate them, pass a catheter, and they can now pass urine, but as part of a long-term repertoire, it definitely does not cure the patient.

The data reflecting that was then analyzed by the AUA Practice Guidelines Committee, which created a guideline that said, if you want to use DVIU or dilation for a stricture once, that’s probably OK. But you shouldn’t do it a second time or at least should offer the patient curative urethroplasty because the chance of success with DVIU or dilation is incredibly low.

Also see: AUA guideline positively impacts stricture management

Those suggestions become even more strident if the stricture is particularly long. In that case, you might not even bother with one DVIU or dilation because it will absolutely fail. This also applies when the stricture is any length in the penile urethra; those just don’t seem to respond in a lasting fashion to DVIU or dilation.

There are few urethroplasty surgeons in the U.S. What is the state of male reconstructive training?

This is a problem. We’ve now got a guideline that maybe our infrastructure cannot support. When I came out of a training program in 2000, there were two or three training programs in the United States. The good news is, there are now 20 training programs, and it’s much more common that an individual resident even outside of fellowship training will have some good experience in doing urethral strictures. Thank goodness there are more and more practitioners who can help with that. There are huge swathes of geographic areas in the United States that don’t have a single person who is interested in or able to do urethroplasty, and that may require referral to a center of excellence even with all the implications of how difficult that can be economically/socially, but that’s getting to be the standard.

In the past, devices haven’t worked. I’ve spent my life working on one. Is there any future hope of different treatment approaches, such as tissue engineering?

There’s always hope. There’s something challenging about placing devices in areas with urine contact. For example, you know more than anyone that the UroLume was facing two problems. One is that it was in contact with urine, so the chance of getting stones and things like that was high, and two, it was trying to fight one of the most efficient processes in the entire body-scar formation. The device simply wasn’t up to the task of fighting this really elemental process and the troubles of urine precipitating on objects in contact.

The future of urethral surgery certainly involves an off-the-shelf component so that we don’t have to harvest tissue from the cheek, for example. That would be great. Is that coming tomorrow? Sure, it just depends on when your “tomorrow” is. Another possibility is working with people like Dr. Anthony Atala for something like taking a mucosal biopsy, seeding an acellular matrix with your own cells, and then placing your own urethral tissue back in.

Next:Penile transplantWhat are your views on penile transplant versus reconstruction?

Penile transplant is a fascinating area. Obviously, the recent penile transplant performed on a seriously injured soldier has captured the news. Interestingly, the very first penile transplant, which was done by Chinese surgeons, was removed for social reasons. It was successful technically but they didn’t discuss it with the patient thoroughly enough, he didn’t want it anymore, and it was removed.

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The second and third successful penile transplants were done in South Africa, and the surgeons only announced it after 1 year of success.

It’s important to understand that the immune situation in skin is very different than that in solid organs. The first solid organ transplant was performed in 1959. The first face transplant was performed in the 1990s. Why the delay? Skin is highly immunogenic; the amount of immunosuppression you have to give patients knocks down the response in the skin to near-fatal levels, so it can be very difficult to run the immunosuppression on these patients.

This is particularly vexing because of the trauma. I’m at the VA, and I’m seeing more veterans come back from war requiring phallic reconstruction. Current reconstructive techniques are not satisfying, tissue engineering reconstruction seems to be a ways off, and transplantation is therefore certainly very attractive.

Yes, it’s an issue, and what you’re describing is a clinical situation where we can see the edge of the cure but we don’t quite have the know the best way to move forward with penile-genito reconstruction. Phalloplasty is a tried and true answer, but presents many, many problems.  Penile transplant is possible, but has extremely high barriers because of the need for lifelong major immunosuppression. The transplant program should keep moving forward. I think we’ll learn a lot about optimizing human leukocyte antigens matching, the surgical technique, and the actual immunosuppression regimen ­afterwards.

In the South Africa center that did the first two successful transplants, they are investigating penile transplant as a transgender surgery, arguing that the organ will be much more competent than a free flap from the forearm. Since they already have experience, I wonder if we’ll see a transgender penile transplant coming out of South Africa in the future.

Let’s shift to trauma. Most urology programs don’t deal with trauma, except for the consequences of it. Where do you see the genitourinary reconstructive surgeon playing a role in trauma?

I would certainly like to see every general urologist know how to handle the ABCs of trauma because they’re going to be called on to handle these issues in many cases. They may not be the number one person dealing with a renal laceration at their trauma center, but they’re definitely going to be dealing with bladder lacerations, ureteral problems, urethral problems, even hematuria after trauma. I’d like to make sure that we continue to train our residents and keep our general urologists up to date on the trauma ABCs. Just like you need to know how to identify prostate cancer, you need to know how to deal with the basics of trauma.

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As I mentioned earlier, the fact that lots of fellowship-trained reconstructionists are coming out means that highly trained people are being spread across the nation, whereas only a handful of cities had them in the year 2000. Now, almost all cities have one or two or perhaps three reconstructionists. It’s getting better in terms of the distance to get to an expert when you have a complicated trauma or its sequellae.

Next:Scrotal infectionI think the general urologist perhaps sees more emergent scrotal infection cases, which require extensive debridement. Do you have any thoughts about or tips for a general urologist who might get called in and how to not minimize the concern?

There are some real surgical emergencies in urology, and scrotal infection is definitely one of the top three. Keeping Fournier’s gangrene or mixed necrotizing infection in your top three differential for every patient you see is a good idea because you really can’t (safely) miss it.

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Also, I have seen some errors, perhaps even associated with medicolegal cases, where ­somebody says, “I don’t know if that is or isn’t Fournier’s gangrene.” They decide it isn’t, but it is.

I would argue that if you’re not sure, you probably need to do more. Consult with a colleague. Get a CT scan. That sounds silly, but the CT scan will often show gas that you can’t appreciate. I learned this as a fellow: Take the patient to the operating room and create a small incision. If you find beautiful, healthy tissue and you’re wrong, great. Most of the time, you won’t find that; you’ll find dead tissue.

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I also find some serious under-debridement problems in which the debridement is done but somehow the practitioner without a lot of experience in Fournier’s feels they’ve gone far enough. But you’ve only gone far enough when all the dead tissue is gone. I would cut tissue with abandon and let the reconstructionist worry about how they’re going to piece it together later.

Next -Transgender medicine: The urologist's scopePlease discuss your career path from reconstructive urology to transgender medicine.

I spent 18 years in the reconstructive urology space, and it could not have been more interesting and surgically fulfilling. Then out of the corner of my eye, I saw a whole “Mount Everest” of reconstructive urology problems-transgender surgery. My wife and I made the hard decision to switch practices, switch cities, and go down to Austin, TX. Most people don’t know that Austin is the home of one of the busiest transgender practices in the world. I was fortunate to fit into their hiring needs, they trained me up, and now I’m a full-time transgender surgeon.

What is the scope of transgender issues in medicine, and how is the urologist involved?

Clinically, it’s quite a large issue. Many established surgeons have year-and-a-half waiting lists because there’s a huge backlog of untreated patients.

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The urologist, as you can imagine, fits into a whole scenario of plastic surgeons and other practitioners. For a phalloplasty, which would be a female-to-male transition, there may be four surgeons operating. As the urologist, I would be doing the vaginectomy, a 10- to 14-cm urethral lengthening, vaginal closure, creation of a scrotum, and then hooking up the urethra to the skin urethra that makes up the phallus, which is actually constructed by a second plastic surgery team.

I also do male-to-female surgery-vaginoplasty-and that’s more like one surgeon with one assistant. It’s been very gratifying as a technical operation, and it’s been gratifying to work with the patients, who are highly motivated individuals.