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To describe our own approach using buccal mucosal grafting and to assess the outcome of this approach. A total of 42 patients underwent ventral onlay BMG by a single surgeon between 2017 and 2022. A longitudinal incision along the length of the urethra was made through the anterior vaginal wall and the periurethral fascia was incised to create 2 flaps. This ventral urethrotomy ran from the meatus into the proximal healthy urethra above the level of the stricture. A buccal mucosal graft was harvested and sutured to the margins of the urethral mucosa itself and the flaps of periurethral fascia. The vaginal wall was then closed. The mean age of the patients was 53.6 ± 12.8 years. There were no perioperative or postoperative complications. At a mean follow-up of 38.1 months, 41 patients (98%) were stricture-free. Peak flow rate improved from a mean of 7.7 ± 3.2 mL/s preoperatively to 25.9 ± 5.9 mL/s postoperatively. No patient developed incontinence. One patient developed a recurrent urethral stricture which was treated by redo urethroplasty. The surgical technique applied has proved efficiency. The ventral BMG preserves the urethral sphincter and so avoids postoperative incontinence. The use of periurethral fascia represents a good vascular and mechanical support for the graft. [ABSTRACT FROM AUTHOR]

To present long-term experience with buccal mucosa posterior urethroplasty (BMPU) for refractory posterior urethral stenosis (PUS) or vesicourethral anastomosis stenosis (VUAS) either by perineal approach (PA) or by endourethroplasty (EUP). A single-center retrospective study of 38 consecutive patients operated on between 1999 and 2022. BMPU consisted of the transfer of onlay or tubular buccal mucosa grafts into dilated and/or incised strictures through an open or endourological approach. If VUAS or PUS recurred with short stenosis within the first 12 months after surgery, it was transected by a cold-knife direct vision internal urethrotomy (DVIU), referred to as an "auxiliary" DVIU. The primary outcome was 3-year stricture recurrence-free survival (SRFS). BMPU by perineal approach and EUP were performed in 27 (71%) and 11 (29%) patients, respectively. The 3-year SRFS was 65% for the whole cohort, with rates of 63% for the perineal approach and 73% for endourological approach. With permitted auxiliary DVIU, 3-year SRFS for the whole cohort was 81%. De novo incontinence occurred in 2 out of 18 preoperatively continent patients. Limitations include the retrospective nature of the single-center study and a small, heterogenous cohort of patients. We present 2 techniques of substitution urethroplasty with BMG in the management of PUS and VUAS with a low rate of recurrence or de novo incontinence. A novel endourological approach (EUP) is a promising minimally invasive alternative to the perineal approach. [ABSTRACT FROM AUTHOR]

To determine urethral outcomes of single-stage metoidioplasty and radial forearm free flap (RFFF) phalloplasty using the labia minora ring flap for urethral lengthening (UL). A retrospective review was performed of patients undergoing single-stage metoidioplasty and RFFF phalloplasty utilizing the labia minora ring flap technique. The ring flap consists of endodermal labia minora tissue ventral to the clitoris and surrounding the vaginal introitus. During metoidioplasty, the ring flap accounts for the entirety of UL. During RFFF phalloplasty, the ring flap becomes the pars fixa (PF) urethra. The primary outcomes measured were rates of fistula, stricture, and surgical revision. Between November 2017 and August 2023, 311 patients underwent metoidioplasty or RFFF phalloplasty (mean follow-up 37 months). Of the 69 metoidioplasties, urethrocutaneous fistulas developed in 11 patients (16%); strictures occurred in 4 (6%). Of the 242 phalloplasty patients, there were 71 fistulas (29%), 56 of which resolved spontaneously. Strictures developed in 44 patients (18%). Twenty-five patients (10%) developed both a stricture and fistula. Surgical repair was required in 8/69 (12%) metoidioplasty patients and in 46/242 (19%) RFFF phalloplasty patients for an overall revision rate of 17%. UL during metoidioplasty or RFFF phalloplasty can be accomplished in a single stage using the labia minora ring flap with comparable surgical revision rates to previously described techniques. This approach can also be applied to other phalloplasty techniques. Many fistulas of the PF urethra resolve spontaneously. Higher urethral revision rates were seen in phalloplasty compared to metoidioplasty. [ABSTRACT FROM AUTHOR]

To assess the impact of posterior urethral stenosis or defect on outcomes following rectourethral fistula (RUF) repair, we present a cohort of 23 men who underwent posterior urethroplasty concurrent with RUF repair. We identified 130 men who underwent RUF repair at our institution between 2003 and 2021. Of these, 23 (18%) underwent simultaneous posterior urethroplasty. Fifteen men received prior radiation for prostate cancer. Of the 8 men who were not radiated, 4 had a history of radical prostatectomy, 2 pelvic trauma, and 3 inflammatory bowel disease. All 23 men underwent fecal diversion prior to surgery (median, 6 months preoperatively), and 20 men suprapubic catheter placement (median, 5.5 months preoperatively). RUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). Intraoperatively, 20 men (87%) had urethral stenosis, and 3 (13%) had significant urethral defects due to cavitation and tissue loss. There was stenosis/stricture involving the prostatomembranous urethra in 18 cases (78%) and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (78%) and using a buccal mucosal graft in 5 (22%). Gracilis flap interposition was performed in 21 cases (91%). At a median follow-up of 55.7 months (interquartile range (IQR), 23-82 months), 20 men (87%) had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. Fourteen men (61%) reported postoperative urinary incontinence, with 7 (30%) ultimately undergoing artificial urinary sphincter placement. There were no isolated stricture recurrences requiring instrumentation. Posterior urethral stenosis associated with RUF complicates an already challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis or defect. [ABSTRACT FROM AUTHOR]

Urethral atresia is a rare but clinically significant cause of congenital lower urinary tract obstruction. Initial management options include urinary diversion until definitive urethral reconstruction or progressive urethral dilation. Given the overall rarity of the condition, there are no evidence-based guidelines for the immediate and long-term management of urethral atresia, and clinical practice varies widely. We present an illustrative case managed with progressive urethral dilation alongside urinary diversion to highlight key factors in shared clinical decision making. Ultimately, pooled multi-institutional long-term outcomes data are needed to better guide practice for these patients and their families. [ABSTRACT FROM AUTHOR]

To describe and present the results of the use of urogenital mobilization extended by two flaps from the redundant distal part of the urethra in the correction of a severe form of distal vaginal agenesis. During the past 4 years (from December 2018 to March 2023), we have performed 2 vaginoplasties using the described procedure. The age of the patients at surgery was 13 years. Two girls presented with primary amenorrhea associated with cyclic pelvic pain evolving over several months. Clinical examination revealed a blind vagina and an anterior pelvic mass. Ultrasound and magnetic resonance imaging showed a severe form of distal vaginal agenesis. One patient had a 47,XX+mark karyotype and right vesicoureteral reflux. Two patients underwent urogenital mobilization, guided by a tube introduced into the upper part of the vagina through an abdominal approach, and the use of two flaps from the redundant distal part of the urethra to extend the neovagina to the perineum. The esthetic results were very satisfactory with the disappearance of pelvic pain, and the restoration of a regular flow of menstrual blood without pain. Urinary continence was preserved in two patients. This is the first report of the use of urogenital mobilization extended two flaps from the redundant distal part of the urethra in the correction of a severe form of distal vaginal agenesis. This procedure yielded a very satisfactory esthetic and functional results. [ABSTRACT FROM AUTHOR]

To present a unique series of children with previously repaired anorectal malformations (ARM) with subsequent urethral pathology repaired via a posterior sagittal exposure and highlight the associated technical advantages. Using a retrospective review of all procedures performed in our pediatric colorectal and pelvic reconstruction program from January 2020 through December 2022, we compiled a case series of patients with a history of ARM and prior posterior sagittal anorectoplasty (PSARP) who had urethral pathology and concurrent indication for redo-PSARP. Clinical features, operative details, and postoperative outcomes were collected. Six male patients presented at a median age of 4.3 years, all born with an ARM of recto-urinary fistula type, of which 3 were recto-prostatic, 1 recto-bladder-neck, and 2 unknown type. In addition to redo-PSARP, 2 underwent remnant of the original fistula excision and 4 had urethral stricture repair. One required post-operative Heineke-Mikulicz anoplasty. Patients underwent cystoscopy 4-6 weeks post-reconstruction, and none showed urethral stricture requiring treatment. Post-procedurally, 5 patients were able to void urethrally and 1 required additional bladder augmentation/Mitrofanoff. Redo-PSARP completely mobilizes the rectum, thereby providing excellent exposure to the posterior urethra for repair. This approach also allows the option of a rectal flap for augmented urethroplasty as well as harvest of an ischiorectal fat pad for interposition. [ABSTRACT FROM AUTHOR]

To assess whether tamsulosin may aid emptying of the lower urinary tract in posterior urethral valves patients, mitigating the likelihood of progressing to clean intermittent catheterization (CIC) or need for renal replacement therapy. We reviewed a prospective institutional database containing posterior urethral valves patients treated between January 2000 and January 2022. After assessing baseline characteristics, Kaplan-Meier survival curves and log-rank tests were generated to assess differences in clinically significant outcomes (progression to CIC, dialysis, or kidney transplantation) between those prescribed tamsulosin and those who were not. A total of 179 patients were included. Fifty-nine patients received tamsulosin prior to initiation of CIC (group 1), and 120 did not (group 2). The baseline characteristics were similar between the two groups, except for anticholinergic use (tamsulosin group – 35/59 vs no tamsulosin – 32/120, P <.001). The median age at tamsulosin initiation was 26.0 months (IQR 15.5-48.6) and the median time from initiation of tamsulosin to progression to CIC was 52.6 months (IQR 10.1-69.3). Kaplan-Meier survival curves showed that patients on tamsulosin were less likely to progress to CIC (P =.021), however, there was no difference in progression to dialysis or kidney transplantation. A Cox-regression analysis controlling for baseline characteristics, including age, anticholinergic use, vesicoureteral reflux severity, and CKD stage at 1-year of life, showed a consistent effect of tamsulosin in delaying progression to CIC (HR 0.444 95%CI 0.218-0.902, P =.025). While tamsulosin may delay CIC, it does not appear to delay progression to end-stage renal disease. Additional studies exploring specific patient factors are required to determine the timing and subset who may benefit the most from tamsulosin. [ABSTRACT FROM AUTHOR]

Exstrophy variants are uncommon developmental anomalies of the bladder; the variants involving only the bladder neck are extremely rare. There are only three case reports of inferior vesical fissure (IVF) to date, and usually it's uncommonly associated with other malformations. A combination of inferior vesical fistula (IVF) as an exstrophy variant with urethral atresia and anorectal malformation has not been described previously. We report a case of IVF in a 4-year-old male previously operated for anorectal malformation who was managed with fistula closure with bladder neck reconstruction of lay open of stenosed urethra. Recognition of the exstrophy variant is important because the treatment and prognosis are very different. [ABSTRACT FROM AUTHOR]

We present a case of recurrent episodes of foreign body insertion into the urethra, ultimately resulting in urethral defect at the penoscrotal junction. We have decided against treating the urethral defect as it facilitates nonoperative retrieval of the urethral foreign bodies. We present our experience and rationale for the clinical management of this complex patient.

To report the technique and outcomes of tissue expansion (TE) for generating additional penile skin for urethroplasty and/or skin coverage during primary or redo hypospadias repair in penoscrotal transposition (PST) patients with a proximal hypospadias. Proximal hypospadias and PST patients with a lack of penile skin, congenitally or after failed repair, who underwent TE assisted reconstruction were reviewed. TE were placed under the penile shaft and expanded skin was used for tubularized incised plate repair. Success was defined as urethral advancement to the corona or more distal with tension free skin coverage. A total of 24 patients underwent reconstruction including 16 as part of primary repair and for redo repairs in 8. Nine patients experienced expander extrusion and posturethroplasty complications occurred in 43.8% of primary repairs and 75.0% of redo repairs; a urethrocutaneous fistula was most common (n = 8). Overall, success was achieved in 87.5% of patients with postoperative meatal locations almost all coronal (45.8%) or glanular (50.0%). Proximal hypospadias reconstruction is challenging, and complications are not infrequent. TE is a useful alternative for complex patients with a skin paucity such that cutaneous coverage would be difficult following urethroplasty. Although the complication rate was 43.8% for primary repair, TE generated sufficient residual skin for success after additional reconstruction. For redo repair early use is most beneficial as there is more expandable skin. The pseudocapsules provide vascularized coverage to reinforce the urethra while there is sufficient skin to minimize the need for a skin graft for penile coverage. [ABSTRACT FROM AUTHOR]

To present 2 clitoroplasty techniques—the preputial skin and urethral flap—and describe our rationale for using each technique to construct the clitoro-urethral complex in gender-affirming vaginoplasty. For uncircumcised patients or circumcised patients with greater than 2 cm of inner preputial skin and at least 8 cm of shaft skin proximal to the circumcision scar, we use the preputial skin clitoroplasty, a modification of the Ghent style clitoroplasty. The entire corona is used after medial glans and urethral mucosa is excised. The corona is brought together 1 cm from midline to create the visible ovoid clitoris; the remaining coronal tissue remains lateral to the clitoris for erogenous sensation as clitoral corpora. The clitoris is anchored to the proximal tunica, positioned at the level of the adductor longus tendon. The folded neurovascular bundle is fixed in the suprapubic area. The ventral urethral is spatulated and urethral flap approximated to the clitoris. Preputial skin is sutured proximally as tension allows. The clitoro-urethral complex is inset into an opening created in the penile skin flap. For patients with less skin, we use the urethral flap clitoroplasty. More corpus spongiosum is used, as the urethra creates the clitoral hood; this is described in the literature and attributed to Pierre Brassard. The clitoris is inset following a dorsal urethrotomy, with a small collar of preputial skin sewn to the spongiosum and urethral mucosa. The urethra is transected about 1 cm distally. The ventral urethra is then spatulated and the urethroplasty completed. We prefer the preputial skin flap technique for its' greater coronal tissue volume for erogenous sensation and better esthetics, in our opinion. Circumcised patients should have at least 2 cm of skin distal to the circumcision scar. To avoid using skin graft for the introitus—a risk for introital stenosis—shaft skin proximal to the circumcision line should be at least 8 cm. We present 2 technical options for clitoroplasty and construction of the clitoro-urethral complex in gender-affirming vaginoplasty. [ABSTRACT FROM AUTHOR]

To demonstrate a technique for minimally invasive endoscopic management of posterior urethral strictures, including those at the bladder neck and vesicourethral anastomosis. Herein, we have included endoscopic video footage from 3 patients with posterior urethral strictures, including 1 at the bladder neck, 1 at the vesicourethral anastomosis, and 1 in the bulbomembranous urethra. In each patient, we perform a direct visualization internal urethrotomy (DVIU) with incisions at the 5 and 7 o'clock positions to widen the urethral lumen, followed by injection of 2 mg mitomycin C (MMC) in a total volume of 5 mL sterile water. Herein, we describe our technique for the endoscopic management of posterior urethral strictures, including those in the prostatic urethra and bladder neck. MMC injection, in conjunction with traditional DVIU, adds minimally to the complexity and length of the procedure but may substantially improve long-term surgical outcomes. Bladder outlet obstruction due to stenosis or stricture of the posterior urethra is a common urologic diagnosis whose etiology can often be traced to prior urethral manipulation or iatrogenic trauma. While Americal Urological Assicuation (AUA) guidelines state that dilation or direct visualization internal urethrotomy (DVIU) should be offered for bulbar strictures measuring less than 2 cm in length, recent evidence suggests that DVIU with or without MMC injection may have utility in the management of bladder neck or vesicourethral anastomotic contractures. We have found that DVIU with subsequent MMC injection is a viable minimally invasive approach for the treatment of posterior urethral strictures. While more data are needed to better understand the long-term success rates of these procedures, this approach should be considered for patients with a bladder outlet obstruction secondary to a short stricture of the posterior urethra, bladder neck, or vesicourethral anastomosis. [ABSTRACT FROM AUTHOR]

To develop an imaging modality for the postoperative phalloplasty urethra. Despite high urologic complication rates after masculinizing genital surgery, existing methods for postsurgical evaluation after phalloplasty have drawbacks. Fluoroscopic studies like the retrograde urethrogram have limitations like user-dependence and need for meticulous positioning but also are inadequate for the evaluation of the anatomically complex postphalloplasty urethra. We developed a novel protocol utilizing CT urethrography with 3D reconstruction using cinematic rendering (3DUG) for neo-urethral imaging. Patients who underwent 3DUG after either phalloplasty, metoidioplasty, or prior to revision surgery were included. Low-dose imaging protocols were used to avoid any increases in radiation exposure. The first iteration of our protocol utilized retrograde contrast administration via the penile urethra, whereas the second iteration of our protocol utilized an antegrade technique with contrast instillation via the suprapubic catheter and a voiding scan. Imaging was initially obtained according to symptoms and then per protocol at 3 weeks after urethral lengthening. Twenty-six patients were included in the series. Among postoperative phalloplasty patients imaged for symptoms, contrast extravasation/fistula was identified in 5 (63%), vaginal remnant in 3 (38%), and stricture in 2 (25%) compared to 5 (45%), 1 (9%), and zero respectively for patients imaged routinely. When intervention was required, operative findings correlated to anatomy on imaging. We present a new protocol for the use of 3D CT urethrography with cinematic rendering for neo-urethral reconstruction. This technique has the potential to improve surgical planning and surveillance of urologic complications in postphalloplasty patients. [ABSTRACT FROM AUTHOR]

To test the hypothesis that genital skin and male urethra affected by lichen sclerosus (LS) has increased collagen content and altered collagen structure. We used picrosirius red to stain and image collagen in human urethral, vulvar, and foreskin specimens with and without LS. Using Image J software, we quantified and compared (1) collagen content (using 2o metrics: collagen proportionate area [CPA] and collagen fiber count), (2) collagen fiber length and width, and (3) collagen structure using the texture analysis technique gray level co-localization matrix (GLCM) with respect to LS status and tissue type. We analyzed 23 LS specimens (vulva n=9, urethra n=7, foreskin n=7) and 29 non-LS specimens (vulva n=9, urethra n=7, foreskin n=13). Fiber count and CPA were significantly higher in all LS specimens compared to non-LS specimens (CPA: mean±SD 0.971±0.03 vs 0.948±0.02, P <.007; fiber count: mean±SD = 2906±127 vs 2509±78 fibers; P =.003). Collagen fiber width and length were similar with respect to LS status. GLCM analysis showed decreased inverse difference moment and increased entropy in LS tissues indicative of less homogeneous and more disorganized tissue structure (P <.001). LS tissues have greater collagen content compared to non-LS tissues. Quantitative assessment of collagen organization, using GLCM, revealed less homogeneity and more disorganization of collagen in LS compared to non-LS tissues. Taken together, our findings suggest that alterations in physical tissue properties seen in LS may be due to both increased collagen abundance and altered structure. [ABSTRACT FROM AUTHOR]

Objective: To determine long-term kidney outcomes in boys with posterior urethral valve (PUV) undergoing either primary valve ablation or urinary diversion with matched baseline kidney function.Methods: After retrospective review of patients managed for PUV at our institution, propensity score matched analysis was conducted using nadir serum creatinine with logistic regression analysis. Nearest neighbor matching was used to allocate boys to primary urinary diversion and primary ablation groups. Primary outcomes included kidney function by creatinine or estimated glomerular filtration rate (eGFR), chronic kidney disease (CKD), and end-stage renal disease (ESRD). Comparative statistics by odds ratio (OR) and hazard ratios (HR) on survival analysis were calculated.Results: A total of 21 boys undergoing primary diversion were matched with 42 boys undergoing ablation using nadir serum creatinine and follow-up time with a median follow-up of 4.8 years. After matching, there was no significant difference in last follow-up kidney function by creatinine (p=0.99) or eGFR (p=0.98). Primary diversion was not associated with increased likelihood of developing CKD stage 3 (OR 1.33; p=0.31) or ESRD (OR 1.88; p=0.35 and HR 1.85; p=0.30) compared to primary ablation.Conclusions: Our propensity matched study suggests that long-term kidney function and kidney outcomes are similar between primary ablation and primary diversion after adjusting for baseline kidney function in boys with PUV. [ABSTRACT FROM AUTHOR]

OBJECTIVE:To understand the prevalence of chronic perineal pain, activity limitations, and patient satisfaction after urethroplasty. METHODS:From 2014 to 2016, we prospectively enrolled men undergoing urethroplasty for bulbar urethral strictures. Patients, before and after surgery, completed questions from the Core Lower Urinary Tract Symptom Score assessing pain frequency in the bladder and penis or urethra, as well as nonvalidated questions assessing perineal pain. Overall satisfaction with their current urinary condition and pain-related activity limitations at home, work, or during exercise were also measured. Patients with

Objective: To evaluate the functional and surgical impact of CIC protocols in men with a bulbar AUS in place. Stress urinary incontinence (SUI) and poor bladder emptying are both sequelae of prostate cancer treatment, though there is sparse data to guide concomitant management. The safety of intermittent catheterization (CIC) in men with an artificial urinary sphincter (AUS) at the bulbar urethra remains unclear.Methods: We performed a retrospective review of all bulbar urethral AUS procedures at our institution. Inclusion criteria were patients with a history of prostate cancer treatment, AUS placement for SUI, and a history of CIC before and/or after AUS placement. All eligible cases were retrospectively reviewed. Surgical and continence outcomes were analyzed.Results: 57 patients were identified with a history of CIC and AUS placement under the care of two surgeons. Eighteen continued to perform CIC or first initiated CIC after AUS placement and 39 discontinued CIC protocol prior to AUS placement. The incidence of erosion was no different amongst patients who continued or discontinued CIC after AUS placement (17.9% vs 22.2%, p=0.79). There was no difference in future AUS removal or replacement (56.4% vs 44.4%, p=0.41). Both groups experienced improvement in urinary incontinence after placement of an AUS.Conclusion: Bulbar AUS placement in the setting of continuous intermittent catheterization can be considered in patients who are not surgical candidates for definitive treatment of their outlet obstruction. [ABSTRACT FROM AUTHOR]

Congenital bladder underdevelopment has detrimental genitourinary effects. We present a male infant with declining renal function, recurrent urinary tract infections, and epididymo-orchitis, in the setting of bilateral high grade hydronephrosis and vesicoureteral reflux. Cystoscopic evaluation revealed the presumed "bladder" to be a massively dilated prostatic urethra. The small dysplastic "true bladder" was found at the anterior surface of the prostatic urethra with massively dilated ureteral orifices. Temporizing diversion was performed in the form of bilateral cutaneous ureterostomies, with an ultimate plan for reconstructive bladder surgery. This case presents diagnostic challenges utilizing current modalities due to a massively dilated prostatic urethra in the rare case of bladder dysplasia. [ABSTRACT FROM AUTHOR]

Objective: To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury.Methods: Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score.Results: There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (P < 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (P < 0.001).Conclusion: In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed. [ABSTRACT FROM AUTHOR]

Objectives: To identify predictors of early artificial sphincter (AUS) erosion among a cohort of men with erosion, who underwent AUS placement by either university or community-based surgeons.Methods: The records of all patients with AUS erosions, including men who underwent AUS placement at outside facilities, were retrospectively reviewed. A Cox proportional-hazards model for time to erosion was performed with the predictors being the components of a fragile urethra (history of radiation, prior AUS, prior urethroplasty), androgen deprivation therapy (ADT), trans-corporal (TC), and 3.5 cm cuff, controlling for other risk factors. Kaplan-Meier survival curves and log-rank test compared "fragile" urethras with "not fragile" urethras. All statistical analysis was done using R version 3.5.2.Results: Of the 156 men included, 36% had undergone AUS placement in the community. Median time to erosion was 16.0 months (1.0-240.0 months), and 122 (78%) met at least one fragility criteria. Radiation (HR 2.36, 95% CI 1.52-3.64) and prior urethroplasty (HR 2.12, 95% CI 1.18-3.80) were independently associated with earlier time to erosion. The Kaplan-Meier estimates demonstrate 1- and 5-year survival rates of 76.5% and 50.0%, respectively, for "non-fragile" and 44.1% and 14.8% for "fragile" urethras (P < .0001).Conclusion: In a diverse cohort of men with AUS erosion, men with "fragile" urethras eroded sooner. Radiation and prior urethroplasty were independent risk factors for earlier time to erosion, but prior AUS, ADT, TC and 3.5 cm cuff were not. [ABSTRACT FROM AUTHOR]

Objective: To describe the novel gullwing technique for artificial urinary sphincter (AUS) placement. The transcorporal technique for AUS placement is beneficial in patients with 'fragile urethras' (previous failed AUS, urethroplasty or history of radiation) however limitations include insufficient lateral and ventral urethral support in addition to potential cinching during corporotomy closure which, in the absence of additional grafting may restrict our ability to conserve internal corporal capacity and limit options for future preservation of erectile function via penile prosthesis placement. The gullwing variation of the technique offers the potential to circumvent these disadvantages.Materials and Methods: This case describes the gullwing variation of transcorporal AUS placement in a complex patient with a history of abdominopelvic trauma and prior failed AUS placements secondary to urethral erosion.Results and Conclusion: Transcorporal AUS placement in patients with prior urethral compromise has been shown to result in lower revision and erosion rates. The gullwing modification of the technique is a novel variation providing improved circumferential urethral protection and, with the addition of corporal grafting, aims to enable the preservation of the three-dimensional corporal volume necessary for ease of subsequent penile prosthesis implantation. However, studies assessing the long-term functional outcomes and durability of this technique are needed. [ABSTRACT FROM AUTHOR]

Objective: To compare the effects of periurethral and intravenous injection of adipose-derived stem cells (ADSCs) on voiding function and tissue recovery in a stress urinary incontinence (SUI) rat model.Methods: Sixty-four postpartum rats were randomly allocated to a normal group and the SUI model was established in 48 rats by vagina balloon dilation and bilateral ovariectomy. The SUI rats were randomized into 3 groups and received urethral injection of PBS (SUI group), periurethral injection of ADSCs (PU group), and intravenous injection of ADSCs (IV group) in 10 days after the ovariectomy. After 1, 7, and 14 days, ADSCs were tracked in urethra specimen. The urinary function of the remaining rats was analyzed at day 28, and urethral tissues were harvested for Western blotting and histochemical analyses.Results: Alpha smooth muscle actin, myosin heavy chain, vascular endothelial growth factor, and neurofilament protein expression was increased in the IV and PU groups. Voiding function was also improved, with no significant differences between the IV and PU groups. The cell retention rate in rat urethral tissues was higher in the PU group than that in the IV group. Compared with the IV group, myosin heavy chain, vascular endothelial growth factor, neurofilament and transforming growth factor-β1 (TGF-β1)/Smad pathway protein expression levels were significantly higher in the PU group, while alpha smooth muscle actin expression was significantly lower (P < .05).Conclusion: Periurethral and intravenous injection of ADSCs induces different degrees of recovery of the urethral sphincter, cytokine secretion levels and cell retention rates in the urethral tissues in SUI rats, however, there was no significant difference in 2 methods. [ABSTRACT FROM AUTHOR]

Objective: To compare the long-term outcomes of initial management of pelvic fracture urethral injury (PFUI) in a large cohort of trauma patients undergoing urethral reconstruction.Materials and Methods: 119 patients underwent urethral reconstruction by a single surgeon for PFUI at our center between 1998-2018. We compared initial PFUI management - primary realignment vs suprapubic tube (SPT) insertion alone. Multivariable Cox proportional hazard analysis was used to assess the association between primary intervention and the risk of having a complication.Results: PFUI was initially managed with primary realignment (57%) or SPT alone (43%). Ultimately, all patients underwent a primary perineal urethral anastomosis after a median of 7 months (IQR: 5-14). Overall, 27 patients (23%) had 1 or more long-term complications after a median 25 months (IQR:7-66), including urethral stricture, de novo erectile dysfunction, and urinary incontinence. On multivariable analysis, initial PFUI management did not predict for complications.Conclusion: No difference was found in long-term outcomes after urethral reconstruction when comparing initial PFUI management of primary realignment vs SPT insertion. [ABSTRACT FROM AUTHOR]

Congenital anterior urethral diverticulum (CAUD) is an uncommon abnormality of the male urethra. In the literature, cases of CAUD affecting both children within a set of identical twins or presenting concomitantly with another urethral condition are exceedingly rare. We describe 2 cases of CAUD in identical twins: a pair of newborns in which Twin 1A and Twin 1B both present with CAUD, and a second pair of newborns in which only Twin 2A presents with CAUD along with a partial collateral urethral duplication. In doing so, we aim to add to the incomplete literature on the embryological development of CAUD. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the safety, feasibility, and tissue response of a novel device for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia, using the first-generation Urocross Expander System (Mercury Expander System).Methods: The implant was deployed and retrieved using flexible cystoscope in 8 adult male canines, separated into three study arms by retrieval date (1-, 6-, and 12- months post-deployment). Cystoscopy and urethrograms verified implant position/diameter; bladder neck and external sphincter function/changes; prostatic tissue response; and implant condition. One-month post-retrieval, the prostate and surrounding tissue was sectioned and evaluated by a veterinary pathologist.Results: All implants were successfully deployed in the prostatic urethra. Urethral width was increased (6.9 ± 1.8 mm to 10.2 ± 0.6 mm, P = .012) and preserved through the dwell period. Urethral length and sphincter diameters didn't significantly change. All subjects (n = 8) remained continent without obstruction or retention. Adverse events included incisional site bleeding (n = 2) and transient hematuria (n = 3). One implant migrated into the bladder and spontaneously repositioned into the prostatic urethra. Post-retrieval, explant surfaces demonstrated no tissue growth, encrustation or stone formation. Imaging revealed contact site erythema and indentation, but no stones, strictures, perforations, erosions, nor ulcerations. Histopathology revealed glandular acinar changes, inflammation, and fibrosis.Conclusion: The first generation of the Urocross Expander System demonstrated a favorable safety profile in the canine model. Changes in the prostatic urethra shape were noted with an increase in urethral width during the dwell period with minimal tissue changes. Further, the implant didn't demonstrate any encrustation, tissue growth or stone formation. [ABSTRACT FROM AUTHOR]

Objective: To share the cases of pelvic fracture urethral distraction defect (PFUDD) in preschool boys and evaluate the transperineal anastomotic urethroplasty strategy for the treatment of these cases.Materials and Methods: Between January 2010 and May 2021, 8 preschool boys (<6 years) with PFUDD underwent the transperineal anastomotic urethroplasty in our center were retrospectively reviewed. Etiology was traumatic pelvic fracture in all boys. The type of trauma included: fall injury in 1 and vehicle crush injury in 7. Urethroplasty was performed at least 3 months after initial trauma or the last failed intervention. One of them suffered from PFUDD associated with urethrorectal fistula received urethroplasty combined with fistula repair. A successful urethroplasty was defined as restoring the patency and continuity of urethra and no further interventions were needed.Results: Follow-up was obtained in all the 8 preschool boys for 3-135 (median: 65) months. The average age was 4.1 years old (range 1-5). After operation, the final success rate was 100%. Neither stenosis recurrence nor urinary fistulas were reported during follow-up. Of the 8 boys, 1 developed urinary incontinence, only occurring after high-intensity exercise such as running. Potency state could not be evaluated for all boys due to the young age. One boy reported having normal morning erection after a follow-up of 135 months.Conclusion: PFUDD in preschool boys is a challenge for both the urologist and parent. Our study preliminarily confirmed that the progressive anastomotic urethroplasty strategy can ensure a high success rate. [ABSTRACT FROM AUTHOR]

Congenital posterior urethroperineal fistula (CUPF) is a urothelium-lined tract between the posterior urethra and perineum. This condition is rare and has been proposed to be a urethral duplication variant. A case of CUPF that was misdiagnosed and surgically treated as a rectourethral fistula is presented. The clinical presentation, diagnosis, and treatment of CUPF are discussed and compared with those of Y-type urethral duplications and H-type rectourethral fistulas. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To evaluate the treatment effect of collagenase Clostridium histolyticum (CCH) in a rat model of urethral fibrosis. MATERIALS AND METHODS: Thirty male Sprague-Dawley rats (300-350 g) were divided into 5 groups. The rat urethra was injected with normal saline in the sham group and, in the other 4 groups, the rat urethra was injected with 10 μg of transforming growth factor beta 1 to create fibrosis of the urethra. Two weeks following transforming growth factor beta 1 injection, the rats were injected with varying doses of CCH or vehicles, depending on their group. The rats were then euthanized at 4 weeks after CCH or vehicle injection. Urethral tissue was harvested for histologic and molecular analyses. Type I and III collagen levels were evaluated by Western blot analysis. RESULTS: There was urethral fibrosis and to significant increase in collagen type I and III expressions in the urethral fibrosis group compared with the sham group (P

ObjectiveTo determine variability in urethral stricture surveillance. Urethral strictures impact quality of life and exact a large economic burden. Although urethroplasty is the gold standard for durable treatment, strictures recur in 8%-18%. There are no universally accepted guidelines for posturethroplasty surveillance. We performed a literature search to evaluate variability in surveillance protocols, analyzed costs, and reviewed performance of each commonly used modality.MethodsMEDLINE search was performed using the keywords "urethroplasty," "urethral stricture," and "stricture recurrence" to ascertain commonly used surveillance strategies for stricture recurrence. We included English language articles from the past 10 years with at least 10 patients, and age >18 years. Cost data were calculated based on standard 2013 Centers for Medicare and Medicaid Services physician's fees.ResultsSurveillance methods included retrograde urethrogram or voiding cystourethrogram, cystourethroscopy, urethral ultrasound, American Urological Association Symptom Score, and postvoid residual and urine flowmetry (UF) measurement. Most protocols call for a retrograde urethrogram or voiding cystourethrogram at the time of catheter removal. After this, UF or PVR, cystoscopy, urine culture, or a combination of UF and American Urological Association Symptom Score was performed at variable intervals. The first-year follow-up cost of anterior urethral surgery ranged from $205 to $1784. For posterior urethral surgery, follow-up cost for the first year ranged from $404 to $961.ConclusionPractice variability for surveillance of urethral stricture recurrence after urethroplasty leads to significant differences in cost.

ObjectiveTo determine national urethroplasty trends based on type of surgery and patient and hospital characteristics. We hypothesized that the number of complex urethroplasty procedures performed has increased over time and may be associated with increased periprocedure complications.MethodsThe National Inpatient Sample from years 2000 to 2010 was queried for patients with urethroplasty-associated International Classification of Diseases, Ninth Revision, Clinical Modification codes. We analyzed trends in urethroplasty procedures, patient demographics, comorbidities, and hospital characteristics. We evaluated the relationship between patient demographics and comorbid disease, length of hospital stay, hospital charges, and inpatient complications.ResultsDuring the study period, an estimated 13,700 men (95% confidence interval, 9507-17,894) underwent urethroplasty nationally. Excision with primary anastomosis, buccal graft, and other graft or flap urethroplasty comprised 80.3%, 14.3%, and 5.4%, respectively. Buccal mucosa graft procedures increased over time (P = .03). Only 1.6% of hospitals have ≥ 20 urethroplasties performed annually. Urethroplasty type and urethroplasty volume were not associated with immediate complication rates. Hypertension, diabetes, chronic pulmonary disease, and obesity were the most common comorbidities in urethroplasty patients. Complications during urethroplasty hospitalization occurred in 6.6% of men, with surgical or wound complications being the most common (5.2%). Postoperative mortality was exceedingly rare. Older patients, African Americans, and patients with increased comorbidities were more likely to have complications.ConclusionAn increasing number of buccal mucosa graft urethroplasties occurred over time. Urethroplasty patients have low immediate perioperative morbidity (6.6%) and mortality (0.07%). Patients who are older, African American, or have more comorbid conditions have greater risk for complications.

Objective: To report survival trends and oncological outcomes of penile cancer surgically treated patients, at a high-volume center, treating more than 25 patients each year, in a high incidence country.Methods: Clinical charts of all patients that underwent surgical management for penile cancer were reviewed. The primary end points were cancer specific survival (CSS), progression-free survival, and local recurrence free survival. Kaplan-Meier plots were used for survival analyses. Multivariate analysis was performed using cox proportional hazard age-adjusted models to determine the effect of pN, pT, lymphovascular invasion for CSS.Results: A total of 209 patients were identified, with a median follow up of 96 months (IQR 49-133). Organ-sparing surgerywas performed in 72.7%, 56.9% underwent dynamic sentinel lymph node biopsy, 110 patients underwent inguinal lymph node dissection, and 45 (21.5%) pelvic lymph node dissection. A total of 75 (35.8%) of patients relapsed, median time to relapse of 12 months (IQR 6-25). Overall estimates of CSS showed an 8-year CSS of 68.9%. Eight-year CSS was 90.5% for N0, and 32.8% in pN3 (P <.001). The Cox proportional hazard model showed that pN1-3, pT2-4, lymphovascular invasion and positive dynamic sentinel lymph node biopsy were the variables associated with worse 8-year CSS.Conclusion: To the best of our knowledge, we report one of the largest cohorts on the survival outcomes of penile cancer surgical treatment, in a single institution, over a long period of time, were most patients are referred with high-risk, locally advanced or nodal disease. [ABSTRACT FROM AUTHOR]

Aphallia is an exceedingly rare condition often associated with an array of genitourinary anomalies. Classically, aphallia was thought to have to co-exist with a urethral fistula for adequate urine outflow to avoid the sequelae of oligohydramnios, while the absence of a fistula has historically been incompatible with life. We report the first case of a prenatally unrecognized aphallia with complete urethral atresia in a full-term baby, without an associated fistula or ectopic urethra. We postulate a urachal cyst noted on prenatal ultrasound resolved into a patent urachus providing sufficient outflow to avoid sequelae of oligohydramnios and allowed for term birth. [ABSTRACT FROM AUTHOR]

Objective: To report the clinical data in a large population of patients affected by inflammatory encephalomyelopathy.Material and Methods: We retrospectively reviewed the medical history, imaging studies and urodynamic findings in a series of 87 consecutive patients with inflammatory encephalomyelopathy. Age at disease onset ranged from 3 to 76 years with an average of 35.4 years. The type of bladder dysfunction, neurological impairment and spinal magnetic resonance imaging were assessed. Upper urinary tract was evaluated. The urological complications and subsequent management were reported.Results: The mean follow-up was 3.0 years (range from 0.5 to 6.6 yrs). Initial evaluation revealed detrusor overactivity in 53 patients (61.1%), detrusor underactivity in 34 patients (39.1%), detrusor leak point pressure greater than 40 cm water and decreased compliance in 29.9% of patients. At the latest follow-up, a total of 64 patients (73.6%) had persistent bladder dysfunction requiring treatment, mainly presenting as urinary incontinence and incomplete bladder emptying. Around 18.8% patients (13/69) experienced upper urinary tract changes. The location of spinal lesions may correspond with the type of bladder dysfunction. Higher abnormal sensory levels are associated with poor bladder recovery.Conclusion: Persistent bladder dysfunction is common in inflammatory encephalomyelopathy and tend to change with the progression of disease. Evaluation must be instituted at early onset of the disease and ongoing surveillance should be offered through the entire disease process. Management can be tailored individually to the urodynamic findings for optimal preservation of bladder and renal function. [ABSTRACT FROM AUTHOR]

Objective: To analyze renal glomerular and tubular function and their association in patients operated for posterior urethral valves and to prognosticate the risk for end-stage kidney disease (ESKD) METHODS: Sixty-three previously treated patients were evaluated for renal function during 1987-1991. The patients' age at evaluation was 11 years (range 2-24). Glomerular function was assessed by measuring glomerular filtration rate (GFR) and urine albumin excretion. Tubular function was determined by measuring urine concentration capacity and excretion of electrolytes (Na, K, Cl, Ca, P, Mg) and β-2-microglobulin. Additionally, the prevalence of hypertension and serum parathyroid hormone and aldosterone values were registered. Tubular function was compared with GFR and the risk of developing ESKD before November 2018.Results: Twenty of the study patients (32%) had decreased GFR. In addition, 19% had proteinuria and 56% were hypertensive. Those without proteinuria or hypertension had better GFR values (P < .01 for both). There was a significant correlation between GFR and all the tubular function (P < .05) variables (except excretion of chloride) measured. Compared to the patients with favorable renal outcome, the patients (n = 10) who later developed ESKD had significantly (P < .01) lower GFR and reduced urinary excretion of all measured electrolytes except calcium. Consistently, urine β-2 microglobulin and serum parathyroid hormone and aldosterone values were significantly higher in the patients who developed ESKD (P ≤ .01).Conclusion: Both glomerular and tubular function decline was common and several parameters were likely to predict ESKD in posterior urethral valves patients. [ABSTRACT FROM AUTHOR]

Objective: To determine the adulthood outcomes of bladder, kidney, and sexual functions of posterior urethral valve (PUV) patients.Materials and Methods: The records of patients who were treated for PUV between 1980, and 2001 and aged ≥18 years by the end of 2019 were retrospectively reviewed. Patients with complete adulthood data were included in the study. Renal, bladder, and sexual functions were assessed. Adulthood uroflowmetry results of 22 patients were also evaluated.Results: Thirty-nine patients with complete adulthood data out of 89 were included. The median follow-up time was 22.7 years (15-33 years). Median age at initial surgery for PUV was 36 months (1-168 months), and median age at last follow-up was 26 years (18-46 years). Lower urinary tract dysfunction was noted in 15 (38%) patients. In 22 patients (56%) with uroflowmetric analyses, median values of Qmax, voided volume, and post voiding residual urine volume were 20.5 mL/sec (7-43 mL/sec), 389 mL (154-1750 mL), and 18.5 mL (range 0-190 mL), respectively. Nineteen patients (48.7%) had normal glomerular filtration rate, 2 patients (5.1%) had chronic kidney disease, and the remaining 18 patients (46.1%) had end stage renal disease, 14 (35.9%) of whom underwent renal transplantation. Thirty-two patients (82%) had sexual function evaluation, none of which reported erectile dysfunction. However, 4 patients (12.5%) reported slow ejaculation. Five patients fathered a child whereas infertility was observed in 2 patients.Conclusion: After 2 decades, glomerular filtration rate was normal almost in half of the PUV patients while lower urinary tract dysfunction was detected in 38%. Furthermore, erectile dysfunction was rare. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the risk factors that pertain to stricture recurrence and oral complications.Methods: Patients with long segmented anterior urethral stricture who visited our hospital from 2009 to 2016 were treated with lingual mucosa graft (LMG) urethroplasty. The incidence of complications in all of 128 patients were evaluated. The data were analyzed using the chi-squared test and Fisher's exact test. A multi-factorial regression analysis was performed to identify the risk factors responsible for the recurrence and complications.Results: For patients having LMG urethroplasty, there were no significant difference in recurrence of urethral stricture according to the studied variables. Binary logistic regression analysis reveals that previous surgery involving the urethra was a significant predictor of urethral stricture recurrence (odds ratio [OR]=5.07; 95% confidence interval [95% CI], 1.06-24.40; P = .043). The length of the substitute was significantly related to oral morbidity (P = .020), even after controlling for the studied variables. Patients with a harvested oral mucosa longer than 7 cm had a higher risk of oral morbidity than those with a harvested oral mucosa shorter than 7 cm (OR=4.35; 95% CI, 1.35-14.06; P = .014).Conclusion: Our study shows that LMG urethroplasty is effective for patients with long segmented anterior urethral stricture. Previous urethral surgery was identified as a risk factor to cause recurrence and injury to the tip of the tongue for the oral complications. [ABSTRACT FROM AUTHOR]

Both clinical and preclinical studies have mostly shown beneficial effects for Phosphodiesterase-5 (PDE-5) inhibitors in the treatment of lower urinary tract symptoms. Molecular studies have consistently shown abundant PDE-5 expression in bladder smooth muscle. Data concerning urethral PDE-5 expression have been surprising because striated muscle was not only positively identified, but also found to express more PDE-5 than the smooth muscle. In the prostate, highly variable results have been obtained. For PDE-5 expression, the data have ranged from extremely low to highly abundant. PDE-5 has been found in the glandular epithelium, vascular smooth muscle, endothelium, and fibromuscular stroma.

ObjectiveTo report urethroplasty outcomes in men who developed urethral stricture after undergoing radiation therapy for prostate cancer.MethodsOur urethroplasty database was reviewed for cases of urethral stricture after radiation therapy for prostate cancer between June 2004 and May 2010. Patient demographics, prostate cancer therapy type, stricture length and location, and type of urethroplasty were obtained. All patients received clinical evaluation, including imaging studies post procedure. Treatment success was defined as no need for repeat surgical intervention.ResultsTwenty-nine patients underwent urethroplasty for radiation-induced stricture. Previous radiation therapy included external beam radiotherapy (EBRT), radical prostatectomy (RP)/EBRT, EBRT/brachytherapy (BT) and BT alone in 11 (38%), 7 (24%), 7 (24%), and 4 (14%) patients, respectively. Mean age was 69 (±6.9) years. Mean stricture length was 2.6 (±1.6) cm. Anastomotic urethroplasty was performed in 76% patients, buccal mucosal graft in 17%, and perineal flap repair in 7%. Stricture was localized to bulbar urethra in 12 (41%), membranous in 12 (41%), vesicourethra in 3 (10%), and pan-urethral in 2 (7%) patients. Overall success rate was 90%. Median follow-up was 40 months (range 12-83). Time to recurrence ranged from 6-16 months.ConclusionMultiple forms of urethroplasty appear to be viable options in treating radiation-induced urethral stricture. Future studies are needed to examine the durability of repairs.

Background: Metoidioplasty is a gender-affirming surgical option for individuals who desire masculine genitalia while preserving erogenous sensation and avoiding the morbidity of phalloplasty. Concurrent urethral lengthening offers patients the potential to stand to urinate.Objective: To demonstrate an adaptation of the Belgrade technique of gender-affirming metoidioplasty and describe outcomes.Methods: We identified 33 patients of which 12 underwent simple metoidioplasty and 21 underwent metoidioplasty with urethral lengthening between 2016 and 2020. Prior to surgery, all patients underwent at least 1 year of testosterone therapy to maximize clitoral growth. The clitoris is degloved and the superficial suspensory ligament divided to maximize phallic length. Labia minora flaps are developed and the urethral plate is divided to allow for maximal ventral extension. The resultant urethral defect is bridged with a buccal mucosa graft. To construct the ventral aspect of the urethra, an anterior vaginal wall flap and labia minora flap are sutured to the urethral plate and tubularized over a 16 Fr catheter. The medial aspect of the contralateral labia minora is de-epithelialized and overlaps the urethra, serving as ventral skin coverage for the phallic shaft. Bilateral labia majora flaps are then rotated anteriorly and superiorly to create a neoscrotum using the Ghent technique.Results: For metoidioplasty with urethral lengthening, the median operative time was 408 minutes, estimated blood loss 400 mL, and length of stay 3 days. Of the 21 patients, 10 (47%) elected to undergo second stage scrotoplasty, 7 (33%) underwent testicular implant placement, and 2 (9%) required revision urethroplasty. Of the 10 patients (48%) who experienced postoperative complications, 7 were Clavien-Dindo grade I-II. There were no fistulae at a median follow-up time of 5.5 months (range 1-27.2).Conclusion: We provide a stepwise approach to metoidioplasty with urethral lengthening using a modified Belgrade technique, which was associated with a low rate of urethral complications. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether anesthesia of the meatal orifice reduces pain during cystoscopy in women, known to cause significant pain, discomfort and anxiety in women. Secondary end-point was to compare pain between rigid and flexible cystoscopy.Methods: A total of 120 women, median age 66 (interquartile range 57-69), referred for office cystoscopy were prospectively randomized into 2 groups according to meatal orifice exposure: (1) 5-minute meatus exposure with 2% lidocaine gel; (2) 5-minute meatal exposure with water soluble gel. In each group a pad soaked by the gel was externally placed on the meatal orifice. Each group was further divided to flexible or rigid cystoscopy. Exclusion criteria included urethral stricture, urinary tract infection, chronic pain disease (e.g., IC/PBS), neurogenic disorder, allergy to lubricant, and concurrent pain medication. In all patients, a water-based lubricant applied on the cystoscope, was used for lubrication. A 0-10 visual analogue scale was performed at 4 checkpoints: before examination, immediately following urethral penetration, immediately at end of procedure and 15 minutes after completion RESULTS: Study groups did not significantly differ in clinical or demographic parameters. Pain level prior to procedure was 0 in all patients. Mean visual analogue scale immediately after urethral penetration was 4.2 ± 2.3 in both groups 1 and 2 (P= 1). No significant differences in other checkpoints was reported. Further subanalysis by cystoscope type did not demonstrate significance.Conclusion: Meatal analgesia does not increase tolerance to cystoscopy in females. Pain level is not reduced by the use of flexible cystoscope in the female population. [ABSTRACT FROM AUTHOR]

Objective: To determine the ability of testosterone and estrogen to reverse urethral hypovascularity secondary to hypogonadism, we analyzed the effects of testosterone and estrogen supplementation on castrated Sprague Dawley rats.Materials and Methods: Twenty four Sprague-Dawley rats were divided into 4 groups: (1) non-castrate (NC) controls; (2) castrate (C) unsupplemented rats; (3) castrate rats that received testosterone (T), or (4) castrate rats that received estradiol (E). With immunohistochemistry, we measured vessel density (endothelial cell marker CD31), expression levels of androgen receptor (AR), TIE-2, and estrogen receptors ER-alpha and GPER1.Results: Urethral vascularity was significantly increased after both testosterone and estrogen supplementation (T: 8.92%, E: 7.66%, vs C: 3.62%; P <0.001 for both), surpassing that of NC (5.86%, P <0.001 for both). Testosterone restored AR expression to physiologic levels (T: 5.21%, NC: 4.54%, P =0.135), and upregulated expression of TIE-2 (T: 0.20%, NC: 0.43%, P <0.001), neither of which was expressed in the absence of testosterone. Expression levels of nuclear ER-alpha was nearly undetectable (0.06%-0.38%), while membrane-bound GPER1 expression was upregulated by estrogen (3.30%) compared to other groups (T: 2.01%, NC: 1.02%, C: 0.37%, P <0.01 for all). Increased vessel density was significantly associated with increased AR (r = 0.22, P = 0.019) and GPER1 expression (r = 0.25, P = 0.018) suggesting a mechanistic relationship.Conclusion: Testosterone and estrogen exposure both restore periurethral vascularity in castrate (hypogonadal) rats via upregulation of AR/TIE-2 and GPER1 expression. Our results provide a foundation for testosterone or estrogen replacement in hypogonadal men to reverse atrophic effects of hypogonadism on the urethra. [ABSTRACT FROM AUTHOR]

Objective: To present a novel urethral catheter design with a pilot balloon to reduce intraurethral retention balloon inflation pressures and to provide a visual alert during catheter placement.Methods: We manufactured our pilot balloon prototype from both molded and extruded silicone components. Various pilot balloon thicknesses were tested in order to determine the ideal compliance. We studied the filling pressures of the retention balloon of our prototype in a mechanical urethral model. The prototype catheter was then tested in ex-vivo human penis specimens obtained from gender affirming surgery and changes in the size of the retention balloon were measured under fluoroscopy.Results: The thickness of the pilot balloon was directly related to the inflation pressure of the retention balloon in the mechanical urethral model. The thickness chosen for the pilot balloon in our prototype was based on a retention balloon pressure of 70 kPa. In the ex-vivo human penis model, the presence of the pilot balloon resulted in a 40% reduction in the cross-sectional area of the retention balloon compared to a standard urinary catheter.Conclusion: The prototype urinary catheter appears to decrease the filling pressure and size of an improperly positioned retention balloon inside a urethra. This can potentially reduce the risk of iatrogenic urethral catheter injuries. In addition, the prototype urinary catheter may act as a visual warning sign for the healthcare practitioner. [ABSTRACT FROM AUTHOR]

Objective: To investigate the histomorphological changes of the divergent corpus spongiosum surrounding the urethral plate in hypospadias.Methods: Seventy boys with hypospadias were divided into the distal (n = 44) and proximal (n = 26) groups by the location of the ectopic meatus. The morphology of the divergent corpus spongiosum was evaluated and the histopathological studies were carried out by HE staining, Masson staining, and immunohistochemical analyses of α-SMA, CD34, TGF-β1 and androgen receptor. Western blotting was performed to measure the expression of TGF-β1 and androgen receptor.Results: The divergent corpus spongiosum was significantly thicker in the distal group than the proximal group (distal 3.14 ± 1.12 mm, proximal 1.74 ± 0.87 mm, P <.0001). Histological evaluation suggested the cavernous sinus in the hypospadias group had an abnormal structure, which was characterized by an increase in the width of the vascular lumen (control 7.20 ± 1.12 μm, hypospadias 13.75 ± 8.08 μm, P = .0068), an increased vascular wall thickness (control 5.40 ± 1.28 μm, hypospadias 14.11 ± 7.59 μm, P = .0006), a decreased vascular density (control 15.66 ± 1.17, hypospadias 7.24 ± 4.19, P <.0001) and a decreased trabecular density (control 9.80 ± 1.92, hypospadias 3.68 ± 2.87, P <.0001). The severity of the structural abnormalities was greater in the proximal group than the distal group. Immunohistochemical analysis and Western blotting showed decreased TGF-β1 and androgen receptor expression in the hypospadias group (P <.0001).Conclusions: Histomorphological analysis showed that the divergent corpus spongiosum in hypospadias is abnormal. The structural variation is positively correlated with the severity of hypospadias. [ABSTRACT FROM AUTHOR]

A 3-year-old boy presented to our pediatric urology with a history of urine flow under the scrotum when voiding in a squatting position but not when standing. And the ventral side of the front penis became enlarged during urination and dribbled afterward. Physical examination revealed the boy had 2 urethras opening at the tip of glans, and another accessory urethra opening at perineum. Rigid cystoscopy and voiding cystourethrography confirmed it to be a urethral triplication malformation. This condition, the combination of urethral diverticulum and urethral triplication, consisting of urethro-perineum fistula, has not been previously reported. [ABSTRACT FROM AUTHOR]

We performed a systematic review to examine the efficacy and outcomes of Botulinum Toxin A (BoNT-A) as the primary intervention strategy for patients with detrusor external sphincter dyssynergia. Eleven studies were included in the analysis (n = 353; 16% female, 84% male). BoNT-A was effective in 60%-78% of patients for reducing postvoid residual, mean detrusor pressure, detrusor leak point pressure, and mean urethral pressure 1 month after injection. Most patients required reinjection after an average of 4-9 months. BoNT-A was not associated with any significant adverse events, and may improve quality of life, as well as urodynamic parameters for detrusor external sphincter dyssynergia. [ABSTRACT FROM AUTHOR]

Objective: To assess the current practice of routine preoperative testing before urethroplasty and to determine if the results are clinically significant.Methods: Data was obtained from the National Surgical Quality Improvement Program (NSQIP) database. We identified 1527 patients who underwent urethroplasty from 2010 to 2017. Chi-square and one-way ANOVA tests were used to compare categorical and continuous variables, respectively. Multivariable logistic regression analyses were utilized to assess the rate of complications between testing groups.Results: A total of 8455 individual laboratory tests were performed on 1156 patients (average of 7 tests per patient), with only 959 labs (11.3%) showing abnormal results. Of the 1156 patients, 629 (54.4%) patients had at least one abnormal lab. Patients who had at least one abnormal preoperative lab were found to be significantly older (51.49 ± 16.57 years vs 48.14 ± 16.32 years; P < .001), and to be smokers (112 [17.8%] vs 63 [12%]; P = 0.005). Additionally, they were more likely to have diabetes mellitus (112 [17.8%] vs 63 [12%]; P < 0.001), dyspnea (18 [2.9%] vs 16 [3.0%]; P = .029), and ASA class ≥3 when compared to the group with normal preoperative labs. On a multivariable logistic regression, abnormal preoperative tests were not predictive of intra- or postoperative complications in patients with ASA ≤2 (n = 1112) when adjusted for age and race. In patients with ASA class ≥3, the only lab predictive of postoperative complications was an abnormal coagulation profile.Conclusion: Obtaining routine preoperative labs, especially in patients with ASA ≤2, does not affect postoperative outcomes in patients undergoing urethroplasty. [ABSTRACT FROM AUTHOR]

Objectives: To explore indications for a definitive perineal urethrostomy (PU). To objectify the proportion of patients not completing the final stage procedure in an intended multi-stage urethroplasty. To analyze the incentives for both of these scenarios.Materials and Methods: Since 2000, data of all men undergoing urethroplasty at our center have been collected in a database. This study included patients with a definitive PU and patients after ≥1 stages of an intended multi-stage urethroplasty. Patients <18 years or with a follow-up <3 m were excluded. Descriptive statistics were used and groups were compared with nonparametric statistical tests.Results: Among 1015 urethroplasties, 34 patients underwent a definitive PU and 63 underwent ≥1 stages of an intended multi-stage urethroplasty with a median (IQR) follow-up of respectively 57 (31-120) and 32 (14-101) months. In the definitive PU group, patients were significantly older (P < .001) and had more cardiovascular comorbidity (P = .01), panurethral stricture disease (P = .02) and longer strictures (P = .02) than patients in the multi-stage urethroplasty group. Half of the definitive PUs were surgeon driven and 33% were patient driven. Final stage procedures were completed by 35/63 (56%) patients. Patients not completing the final stage were significantly older (P = .001).Conclusion: Definitive PU is particularly performed in older patients with worse cardiovascular condition, panurethral stricture disease and longer strictures. PU is often explicitly chosen by well informed patients and as nearly half of the patients refuse closure of the urethrostomy after the first stage, a definitive PU should be proposed as reasonable alternative to complicated urethral reconstruction from the start, especially in older patients. [ABSTRACT FROM AUTHOR]