There was an abundance of excellent presentations in urological reconstruction, trauma, and diversion at this year’s AUA meeting and it was difficult to choose those that should be highlighted in the Take Home Messages. Despite our mutual grief of not being able to get together at a live meeting, one advantage of the virtual AUA is the ability to go back and review the many excellent presentations on demand, all of which would have deserved to be highlighted.

One noteworthy presentation addressed the validation of the LSE classification system of urethroplasties by Justin Drobish from the University of Iowa on behalf of the TURNS group (MP03-02). The study cohort contained nearly 2,500 urethroplasties done between 2008 and 2018. The authors demonstrate a significant difference in recurrence-free survival of the length parameter (L1: <2 cm, L2: 2–7 cm, L3: >7 cm), segment parameter (briefly, bulbar strictures fare better than penile strictures), and etiology parameter with radiation and lichen sclerosus-related strictures having the worst prognosis. While the initial description of the LSE system is a couple of years out, this validation study highlights its ability to classify urethral strictures and encourages its adaptation by reconstructive urologists. It allows not only the comparison of urethral strictures and surgical outcomes by allowing to take complexity into account, but it is furthermore useful for clinical decision making as well as communication among urologists.

Of timely interest and practical application was a presentation about strategies to decrease narcotic requirements after urethroplasty presented by Adam Nolte from the Mount Sinai Medical Center in Miami Beach (MP03-19). In this study, the use of a buccal nerve block with a mixture of bubivacain, xylocaine, and dexamethasone injected in the buccal sulcus just behind the first molar significantly decreased the amount of opioid pain medication needed by 66% in the immediate postoperative period and by 50% in the following hours during admission. Given the still prevailing opioid epidemic in the U.S. and increasing scrutiny of opioid prescriptions after surgery, this protocol would decrease the opioid requirements and may be one small part of the solution to this dilemma.

An interesting study came from the University College in London presented by Simon Bugeja analyzing the significance of contrast leaks after urorectal fistula repair (MP53-18). These fistulas are a challenging entity and often there is contrast extravasation present after catheter removal. However, as demonstrated in this study in a large cohort of 138 urorectal fistula patients having undergone repair, this may not always be equal to failure of the repair. While contrast extravasation into the perineum or rectum indeed had a poor prognosis for further closure with conservative means such as prolonged catheter placement, those patients in which contrast was extravasating into a blind tract had a >90% chance to experience fistula closure with conservative means. This, in turn, would certainly prevent a number of unnecessary revisions which, needless to say, have a poorer prognosis already.

The number of abstracts and presentations in regards of transgender surgery has been increasing over the years, as has the number of patients presenting with complications thereof. During the GURS (Society of Genitourinary Reconstructive Surgeons) meeting at AUA2021, Geolani Dy from the Oregon Health and Science University and Joe Pariser from the University of Minnesota gave an excellent presentation on complications of vaginoplasty surgeries along with detailed guidance on how to address them. In an equally excellent presentation, Richard Santucci (Crane Surgical Services) addressed complications encountered after phalloplasty surgery as well as neo-urethral complications. A review on demand of these 3 presentations can be highly recommended as these complications will present with increasing frequency to reconstructive urologists worldwide.

Also during the GURS meeting, Reynaldo Gomez (Hospital de Trabajador, Santiago, Chile) presented on nontransecting bulbar urethroplasty, adapting and expanding a technique originally reported by Gerald Jordan over a decade ago. Unfortunately, transection of the bulbar arteries during membranous urethroplasty is near inevitable during a classic ventral approach that requires transection of the perineal body. This poses a significant risk to the urethral blood supply facilitating recurrence of the stricture. As Dr. Gomez demonstrates, the urethra can, however, also be accessed dorsally through the intracrural space after splitting of the corpora allowing for mobilization of the bulb without having to transect the perineal body and jeopardizing the bulbar arteries. While this technique was initially developed for pelvic fracture-related strictures, this technique is applicable for all membranous and proximal bulbar strictures combining the advantages of an excision and primary anastomosis in this area with avoiding its major disadvantage, transection of the bulbar arterial blood supply. This is of particular importance in patients with membranous strictures who often need artificial urinary sphincters due to uncontrolled stress incontinence postoperatively, and the preservation of the blood supply likely decreases risk of erosions.

Lastly, an important presentation was given by Margit Fisch from the University of Hamburg, Germany about complications occurring in adult patients who received bladder augmentation or urinary diversion as children. Transitional care is an important aspect of reconstructive surgery, and as children who have received bladder augmentations and diversion become adults complications that arise with time need to be addressed. This not only includes complications associated with augmentations such as ruptures or stone formation, ureterointestinal anastomotic strictures, and renal failure in patients with ileal conduits, but also secondary malignancy, specifically if colon had been used for reconstruction. This presentation is a comprehensive overview of what needs to be monitored and addressed in the transitional population and underscores the variety of patients reconstructive urologists are currently caring for and increasingly will care for in the future.