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Urinary leak following ileal conduit after a radical cystectomy is a rare yet serious complication which presents early in the postoperative period. We herein present a case of a 38-year-old man diagnosed with recurrent high-grade non-muscle invasive bladder carcinoma. He underwent robot-assisted radical cystectomy and bilateral pelvic lymph node dissection. Postoperatively, the patient developed a high output urinary fistula (800–1000 mL/day) which was confirmed by fluid creatinine levels and a contrast study. He was managed successfully with a conservative approach. The leak subsided in 6 weeks and on follow-up patient is doing well. Most of the literature favours a surgical approach in such cases, however with optimal nutritional support (enteral/parenteral), adequate diversion of urine, percutaneous drainage of undrained collections, adequate intravenous antibiotics and good nursing care, resurgery with its associated morbidity can be avoided resulting in successful outcomes.

The use of barrier layers between the neourethra and skin is associated with lower rates of post-operative urethrocutaneous fistula (UCF) following hypospadias surgery. Recent studies have evaluated the ability of biologic adjuvant urethral coverings (BAUCs) - namely acellular matrix (AM), tissue adhesives (TAs), and autologous platelet-rich plasma or fibrin (PRP/PRF) - to prevent wound complications following hypospadias surgery. In general, however, these studies are small and conducted at single institutions.To assess the effect of BAUCs on the rate of UCF following single-stage primary hypospadias repair.We conducted a systematic review of studies reporting the rate of postoperative UCF in pediatric patients undergoing single-stage, primary hypospadias repairs using either AM, TA, or PRP/PRF as a layer interposed between the neourethra and skin. We then performed a pooled proportional meta-analysis of post-operative UCF. Patients within each study who underwent comparable surgery but did not receive a BAUC were used as controls.10 studies were included in our review. The meta-analysis included 280 patients from 7 studies who underwent hypospadias repairs with BAUCs. The pooled incidence of UCF was 10% (95% CI 6-14%). Mean follow-up ranged 5-23.5 months in the 5/7 studies reporting specific durations, and ≥6 month and 14-30 months, respectively, in the other two studies. Patients in whom a BAUC was used had significantly lower odds of UCF than control patients (OR 0.39, 95% CI 0.24-0.64, p = 0.0002). In subgroup analyses, significant superiority held for AM and TA; proximal or penoscrotal cases; transverse preputial island flap (TPIF) technique; when both cases and controls had local flaps; and when neither cases nor controls had flaps.The use of BAUCs was associated with decreased rates of post-operative UCF in single-stage primary hypospadias repairs and may be most beneficial in more severe cases and when used in addition to local flaps or when using a flap is not possible. In 2/3 studies of PRP/PRF and 2/4 studies of tubularized incised plate (TIP) technique, dartos flaps were used in controls but not BAUC patients, which may explain the lack of benefit demonstrated for these subgroups. This meta-analysis is limited by the quality of evidence in the included studies, which are not uniformly randomized. Furthermore, the follow-up durations and methods for assessing complications are not standardized between included studies.The meta-analysis herein suggests that using BAUCs may reduce UCF rates following hypospadias surgery. Rigorous prospective evaluation is needed to validate this benefit.

To appraise the pivotal points of different modifications of labia majora fasciocutaneous flap in combating the challenges of complex urogynecological fistula repair in the form of 7 cases.Seven patients with complex urogynecological fistulas with vaginal deficit were treated over last 3 years. The challenges associated with them were non-capacious rigid vagina, irradiated and inflamed surrounding tissues, inelasticity, long-standing fistula with radiation-induced vesicovaginal fistula(VVF), an iatrogenic urethrovaginal fistula with anterior vaginal wall loss with vaginal stenosis, and a case of vesicolabial fistula with a history of forceps delivery and transvaginal VVF repair. Transvaginal repair with labia majora fasciocutaneous flap along with fat pad with relevant technical modifications was contemplated in all.All radiation-induced VVF patients demonstrated no leak in the postoperative period barring one who became dry after transvaginal colpocleisis later. The patient with urethrovaginal fistula and vaginal stenosis was continent, had capacious vagina, and without any leak with regular menstrual periods. The female with vesicolabial fistula remained dry at the end of 6-month follow-up.Transvaginal repair using the labia majora fasciocutaneous flap and the demonstrated technical modifications can be a feasible option in repairing complex urogynaecological fistulas associated with vaginal wall deficit.

To investigate the impact of pelvic exenteration (PelvEX) on patient-reported pain, distress, and quality of life along with physiologic indicators of health in cancer survivors with radiated, non-repairable rectourethral fistula (RUF).We reviewed a prospectively maintained quality improvement database of RUF patients at our institution from 2012 to 2020. Patients with radiated, non-repairable RUF who underwent PelvEX and had follow up to 1 year were included. Pain and distress scores were collected preoperatively and at 1-year follow up. Number of narcotic prescriptions in the 3 months before surgery and the year after surgery were abstracted. Short Form 12 surveys were administered in the postoperative period. Serum albumin, creatinine, carbon dioxide, hematocrit, and glucose were abstracted from electronic health records. Statistical analysis was performed using Wilcoxon signed-rank and Mann-Whitney tests.Eleven patients met inclusion criteria. Patient-reported pain significantly decreased at 1 year follow-up compared to preoperative scores (median pre: 4 vs 1 year post: 0, P = .0312). Patient-reported distress significantly decreased pre- versus post-PelvEX (median pre: 5 vs post: 0, P = .0156). At the time of postoperative pain and distress surveys, 9 (82.8%) patients did not have narcotic prescriptions. Postoperative Short Form 12 scores were similar to an age-matched United States population (mental: P = .3125; physical: P = .1484). Serum-based indicators of health were not different in the pre- versus postoperative period (all P.05).PelvEX may be a valuable treatment option to decrease patient-reported pain and distress without compromising quality of life or physiologic health in patients with radiated, non-repairable RUF.

Background Urosymphyseal fistula (USF) is an uncommon but painful and devastating condition typically occurring after radiotherapy for pelvic malignancy, with a delayed diagnosis and a risk of opioid dependence. Objective To characterize our institutional experience and determine the impact of intervention for USF on pain control and opioid use. Design, setting, and participants We evaluated data for 33 adult patients diagnosed with USF and managed at a quaternary institution between 2009 and 2021. Outcome measurements and statistical analysis We assessed chronic opioid use, pain scores, prior therapy for pelvic malignancy, prior endoscopic procedures, microbiology and histology congruence, and postoperative complications. For comparative analyses we used a χ2 test or Fisher’s exact test for categorical variables and a Wilcoxon signed-rank test for continuous variables. Results and limitations Nearly 94% of the patients had received prior pelvic radiotherapy and >80% occurred in 2016–2021 but were not diagnosed until a median of 10 mo (interquartile range [IQR] 3.5–19.5) following endoscopic procedure(s). Osteomyelitis was suspected in 78.8% of imaging reports and nearly 70% had a positive preoperative urine culture. Over 90% of patients underwent cystectomy, pubic bone debridement or resection, and a soft-tissue pedicle flap. Preoperative urine cultures were concordant with 60% of intraoperative tissue/bone cultures. Histologic osteomyelitis was identified in 85% and concordant with 80% of preoperative imaging. Clavien-Dindo grade ≥3 complications occurred in 15.6%. The median pain score decreased from 4 (IQR 0–8) preoperatively to 0 (IQR 0) postoperatively (p Conclusions Pelvic osteomyelitis may complicate USF and commonly manifests with severe, persistent pain. USF incidence may be increasing or at least increasingly recognized, but diagnosis is delayed. Definitive management results in significant improvements in pain perception and a decrease in chronic opioid use. Patient summary We examined features of urinary fistulas, which are abnormal openings or connections between part of the urinary tract and another structure. Patients with a urinary fistula involving the pelvic bones can present with severe pain, but diagnosis of the condition is often delayed. Removal of some pelvic bone with bladder removal or repair can result in a decrease in long-term pain and in the use of opioid drugs for pain relief.

We aimed to perform a systematic review of randomized trials to summarize the evidence on the safety and stone-free rate after Tubeless percutaneous nephrolithotomy (PCNL) (ureteral stent/catheter, no nephrostomy) compared to Standard PCNL (nephrostomy, with/without ureteral stent/catheter) to evaluate if the tubeless approach is better. The inverse variance of the mean difference with a random effect, 95% Confidence Interval (CI), and p values was used for continuous variables. Categorical variables were assessed using Cochran–Mantel–Haenszel method with the random effect model, and reported as Risk Ratio (RR), 95% CI, and p values. Statistical significance was set at p p p p = 0.0005). This systematic review shows that tubeless PCNL can be safely performed and the standout benefits are shorter operative time and hospital stay, and a lower rate of postoperative urinary fistula.

Purpose Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but potentially lethal. Although the number of reports has increased over the past two decades, the true incidence and contemporary urologists’ experience and approach in clinical practice remains unknown. This research is conducted to provide insight in the incidence of AUF in The Netherlands, and the applied diagnostic tests and therapeutic approaches in modern practice. Methods A nationwide cross-sectional questionnaire analysis was performed by sending a survey to all registered Dutch urologists. Data collection included information on experience with patients with AUF; and their medical history, diagnostics, treatment, and follow-up, and were captured in a standardized template by two independent reviewers. Descriptive statistics were used. Results Response rate was 62% and 56 AUFs in 53 patients were reported between 2003 and 2018. The estimated incidence of AUF in The Netherlands in this time period is 3.5 AUFs per year. Hematuria was observed in all patients; 9% intermittent microhematuria, and 91% presenting with, or building up to massive hematuria. For the final diagnosis, angiography was the most efficient modality, confirming diagnosis in 58%. Treatment comprised predominantly endovascular intervention. Conclusion The diagnosis AUF should be considered in patients with persistent intermittent or massive hematuria.

The aim of this study was to analyze the efficacy of segment urethroplasty to treat severe chordee with congenital short urethra and compared one-stage and two-stage segment urethroplasty. This procedure involved urethral transection to correct the chordee, and urethroplasty was performed to restore natural penile length.We retrospectively studied a cohort of patients with severe chordee and congenital short urethra who underwent one- or two-stage segment urethroplasty at our institution between February 2006 and May 2020. We evaluated the efficacy of the procedures based on the incidence of complications.A total of 37 children were included in this study: 25 were treated with two-stage segment urethroplasty and 12 were treated with one-stage segment urethroplasty. The median length of neourethra in the one-stage repair group (3.21 cm) was similar to that in the two-stage repair group (3.23 cm; P 0.05). Of the 37 patients, 32 (86.5%) were cured after urethroplasty. There were three patients with complications in the one-stage repair group (one urethral fistula and two urethral strictures) and two patients with fistula in the two-stage repair group. Among the five patients with complications, the three fistulas were successfully repaired through reoperation and the two urethral strictures were cured after urethral dilatation. No patient had diverticulum or recurrent chordee.Segment urethroplasty achieved satisfactory outcomes in the treatment of severe chordee with congenital short urethra. This can restore natural penile length, and the recurrence rate of severe chordee is low. The overall success rate of the two-stage procedure tends to be better than that of the one-stage procedure.

Purpose:Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but increasingly reported and potentially lethal. This systematic review comprehensively presents risk factors, pathophysiology, location and clinical presentation of AUF aiming to increase clinical awareness of this rare but life-threatening condition, and to put this entity into a contemporary perspective with modern diagnostic tools and treatment strategies.Materials and Methods:This review was performed according to the PRISMA (Preferred Reporting Items for a Systematic Review and Meta-Analysis of Individual Participant Data) guidelines. A literature search in PubMed® and EMBASE™ was conducted. In addition, retrieved articles were cross-referenced. Data parameters included oncologic, vascular and urological history, diagnostics, treatment, and followup, and were collected using a standard template by 2 independent reviewers.Results:A total of 245 articles with 445 patients and 470 AUFs were included. Most patients had chronic indwelling ureteral stents (80%) and history of pelvic oncology (70%). Hematuria was observed in 99% of the patients, of whom 76% presented with massive hematuria with or without previous episodes of (micro)hematuria. For diagnosis, angiography had a sensitivity of 62%. The most predominant location of AUF was at the common iliac artery ureteral crossing. AUF-specific mortality before 2000 vs after 2000 is 19% vs 7%, coinciding with increasing use of endovascular stents.Conclusions:AUF should be considered in patients with a medical history of vascular surgery, pelvic oncologic surgery, irradiation and/or chronic indwelling ureteral stents presenting with intermittent (micro)hematuria. A multidisciplinary consultation is necessary for diagnosis and treatment. The most sensitive test is angiography and the preferred initial treatment is endovascular.

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.

Retrograde intrarenal surgery (RIRS) is being actively implemented in the treatment of renal stones and other diseases. If necessary, RIRS can be combined with percutaneous procedures.To study the results of RIRS in patients with nephrolithiasis and various renal disorders.A total of 106 patients who undergone RIRS were included in the study. There were 66 men (63.4%) and 40 women (36.6%). Mean age was 46.8+/-15.6 years. The indication for RIRS in 84 (79.2%) patients was renal stones. Calculus in calyceal diverticulum were diagnosed in 6 (5.7%), encrusted stents in 8 (7.7%), urinary fistulas after partial nephrectomy in 5 (4.7%), pelvis tumors in 2 (1.9%), pelvis perforation after marsupialization of parapelvic cyst in 1 (0.9%) patient, respectively. Simultaneous retro- and antegrade procedures were performed in 27 (25.5%) cases. In those with nephrolithiasis and encrusted stents, lithotripsy was done with the removal of stone fragments. Two patients underwent endoscopic resection of the pelvis tumor. In six patients, the neck of the diverticulum was incised after lithotripsy, while in five cases retrograde endoscopically controlled percutaneous treatment urinary fistulae was performed. In one case, laser fulguration of the pelvis defect with stenting was done.RIRS was effective in 72 (85.7%) of 84 patients with renal stones. The operation time was 70.8+/-10.2 minutes. In 12 (14.3%) cases with residual fragments, extracorporeal shock-wave lithotripsy (n=7) and repeated RIRS (n=5) were performed. The efficiency of RIRS after two sessions was 91.7%. Complications were observed in 11 (10.4%) patients. With encrusted stents, the operation time was 95.0+/-16.5 min. After laser fragmentation of encrustations in the lower part of the stent, percutaneous lithotripsy was performed with antegrade removal of its upper half. The time for RIRS in those with diverticula was 60.0+/-8.5 min, the average stone size was 8 mm (from 6 to 10 mm). In all cases lithotripsy with mucosal fulguration was successfully done. The procedures for urinary fistulae were also effective (operation time was 45.0 +/- 20.5 minutes) and there were no complications.RIRS is a safe and effective treatment for patients with nephrolithiasis and other kidney disorders. Modern flexible ureteroscopes allows to examine the collecting system and to perform lithotripsy and removal of stone fragments.

The rate of genitourinary tract injury (GUTI) following pelvic organ prolapse (POP) surgery is presently ill-defined and based on relatively small trials with short follow-up time. Given the potential for higher risk of injury with POP, a better understanding of this type of injury is important for patient counseling.The objective of this study was to identify the incidence and risk factors of GUTI related to POP surgery.Women undergoing POP surgery between 2010 and 2019 were identified using Current Procedural Terminology codes in the Premier Healthcare Database. The primary outcome was GUTI, defined as bladder or ureteral injury, and vesicovaginal or ureterovaginal fistula within 1 year of surgery. Genitourinary tract injury was identified using International Classification of Diseases and Current Procedural Terminology codes. Patients were divided into those with and without GUTI. Differences between groups were evaluated using the Student t test, Wilcoxon rank-sum test, and Fisher exact test as appropriate. Multivariable logistic regression was used to evaluate the independent predictors of GUTI.One hundred thirty-nine thousand one hundred fifty-eight surgical procedures for POP were captured between 2010 and 2019. The rate of GUTI was 1.10%: 0.48% bladder, 0.64% ureteral injuries, and 0.01% fistulas. The most significant variables associated with any GUTI were as follows: adhesiolysis (adjusted odds ratio [aOR], 2.64; 95% confidence interval [CI], 1.07-6.51), blood transfusion (aOR, 3.67; 95% CI, 1.34-10.04), and low-volume surgeons (12 cases per year) (aOR, 1.68; 95% CI, 1.60-1.77), nonurologic or gynecologic surgeon specialty (aOR, 1.62; 95% CI, 1.49-2.00), and uterosacral suspension (aOR, 1.30; 95% CI, 1.13-1.49).The rate of GUTI following POP surgery is lower than has previously been reported. Surgeon experience and specialty and surgical approach may affect GUTI incidence.

Summary Aim Secondary uretero-arterial fistulas (SUAF) are uncommon, underrated and threatening for any patient. Gross hematuria is a clinical symptom of this pathology for patients with history of pelvic radiotherapy, complex pelvic surgery or long-term ureteral stenting. The purpose of this work is to assess risk factors, diagnosis and treatment of SUAF. Methods Monocentric and retrospective series of 6 new cases illustrated by a literature review through MedLine and Pubmed using the keywords “arterio-ureteral fistula”, “arterio iliac fistula” and “ilio-ureteral fistula”. We excluded uretero-arterial fistula following vascular surgery. Results Our series included 4 men and 2 women. All patients had a history of complex pelvic surgery and long-term ureteral stenting. Three patients had history of pelvic radiotherapy. They all had inaugural macroscopic haematuria episode. Two fistula cases were diagnosed on 5 repeated CT-scans. In 2 out of 5 cases, arteriography highlighted the fistula. Fistulas were generally located at the left common iliac artery. An endovascular stent was placed in 5 out of 6 cases. One patient needed open surgery. After treatment, 3 patients remained alive, 3 patients died either by a fistula relapse or by complications late in the treatment. Conclusion SUAF are uncommon, but serious. Today, there is no specific recommendation regarding complex treatment of these fistulas. Endovascular stents seem to be a good therapeutic option. Level of proof 3.

Purpose The aim of this study was to determine and analyze the stricture rate in patients who underwent a PSARP or PSARVUP and followed a post-operative protocol of anal dilation (Fig. 1). Methods A retrospective review of patients with anorectal malformation (ARM) who underwent a primary PSARP or PSARVUP from February 2016 to October 2021 was performed. Data collected included patients’ demographics, type of ARM, age at the time of operation, postoperative complications, with emphasis on whether there were any strictures or any difficulties during dilations, and on follow-up. During the surgical repair, emphasis was placed on preserving the blood supply of the bowel and performing a tension-free bowel-to-skin anastomosis. Results Eighty-four patients met the inclusion criteria. Forty-four patients were females: 21 recto-perineal fistula, 12 cloaca, 9 recto-vestibular fistula, one imperforate anus without fistula, and one patient had a complex anorectal and vaginal malformation with an anal stricture and a rectovaginal fistula. Forty patients were males: 14 recto-perineal fistula, 11 recto-urethral bulbar fistula, 6 recto-urethral prostatic fistula, 6 imperforate anus without fistula, and 2 bladderneck fistula. One patient had an anal stenosis with sacral agenesis, without a presacral mass. Patient ages ranged from 0–79 months (mean 7.5 months, median 5 months) at the time of surgery. Follow-up time ranged from 7–73 months (mean 38 months, median 35 months). No patient suffered of a postoperative anal stricture. Six patients suffered of a rectal prolapse that required a surgical repair. Conclusion Post-operative anal stricture after PSARP and PSARVUP can be avoided with proper surgical technique and post-operative care. Namely, by preserving adequate blood supply of the bowel and avoiding tension at the anoplasty, and by adhering to a structured protocol of anal dilations.

Rectourethral fistula (RUF) and puboprostatic fistula (PPF) are potentially devastating complications that can develop after various pelvic insults, most notable treatment of prostate cancer. Both entities represent surgical challenges given the complex anatomy, risk of injury to adjacent structures, and poor tissue quality and wound healing. While extirpative surgery may be necessary for some patients, meticulous surgical dissection and interposition of healthy muscle allow for fistula repair in a high proportion of appropriately selected patients, especially in RUF. Herein the authors describe the nature, management, and outcomes of RUF and PPF with a full review of the literature.

International audience; INTRODUCTION: Surgical techniques of radical and partial nephrectomy have changed over the last 20years. Indications for partial nephrectomy have widened and mini-invasive surgery (laparoscopy and robotic assistance) has become widely used. However, both still have a significant morbidity. The objective of this article is to review complications of renal surgery and their predictive factors and to offer algorithms of management. METHODS: Recent literature regarding complications of radical and partial nephrectomy was queried using Pubmed engine search. The most relevant articles were analyzed and served as a basis for this work. RESULTS: The literature on complications of radical and partial nephrectomy has a low level of evidence. There are only retrospective series. The most frequent complications of radical nephrectomy occur during surgery in 5-10% of the cases: wound of the pedicle or of an adjacent organ. The management can often be conservative. Laparoscopy has a similar morbidity compare to the open approach but has greatly increased postoperative outcomes and comfort. Partial nephrectomy has a 20% complication rate. Many factors have an impact on the risk of complications (tumor size, inflammation of perirenal fat, access, surgeon experience, centre volume, comorbidities and age of the patient) and must be taken into consideration before advising partial nephrectomy. The two most feared complications of partial nephrectomy are bleeding (per- or postoperative, 10% of the cases) and urinary fistula (

Background Arterioureteral fistula (AUF) is a rare, life-threatening condition wherein communication occurs between a ureter and the common, internal, or external iliac artery. The sensitivity of common clinical imaging examination for AUF is low, which leads to a delayed diagnosis and increased mortality. In addition, the increased use of ureteral stents contributes to the growing frequency of AUF. Case presentation Our two patients were 74 and 65 years old males respectively. They both had a medical history of bladder cancer and underwent radical cystectomy with ureterocutaneostomy. The patients underwent routine catheter exchange during over 1 year postradical cystectomy and subsequently experienced intermittent gross pulsatile haematuria. After a series of imaging examinations failed to identify the cause, the patients were ultimately diagnosed with AUF and treated with interventional radiotherapy, followed by broad-spectrum antibiotics. Positive effects were found. Conclusions The incidence of AUF is increased with the prolongation of survival in patients with related risk factors. This case report aims to highlight early diagnosis and management of AUF to lower the mortality.

Background Genito-urinary fistulas may occur as complications of obstetric surgery. Location and circumstances can indicate iatrogenic origin as opposed to pressure necrosis following prolonged, obstructed labor. Methods This retrospective review focuses on 787 women with iatrogenic genito-urinary fistulas among 2942 women who developed fistulas after cesarean birth between 1994 and 2017. They are a subset of 5469 women who sought obstetric fistula repair between 1994 and 2017 in Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia, and Ethiopia. We compared genito-urinary fistula classifications following vaginal birth to classifications following cesarean birth. We assessed whether and how the proportion of iatrogenic genito-urinary fistula was changing over time among women with fistula, comparing women with iatrogenic fistulas to women with fistulas attributable to pressure necrosis. We used mixed effects logistic regression to model the rise in iatrogenic fistula among births resulting in fistula and specifically among cesarean births resulting in fistula. Results Over one-quarter of women with fistula following cesarean birth (26.8%, 787/2942) had an injury caused by surgery rather than pressure necrosis due to prolonged, obstructed labor. Controlling for age, parity, and previous abdominal surgery, the odds of iatrogenic origin nearly doubled over time among all births resulting in fistula (aOR 1.94; 95% CI 1.48–2.54) and rose by 37% among cesarean births resulting in fistula (aOR 1.37; 95% CI 1.02–1.83). In Kenya and Rwanda the rise of iatrogenic injury outpaced the increasing frequency of cesarean birth. Conclusions Despite the strong association between obstetric fistula and prolonged, obstructed labor, more than a quarter of women with fistula after cesarean birth had injuries due to surgical complications rather than pressure necrosis. Risks of iatrogenic fistula during cesarean birth reinforce the importance of appropriate labor management and cesarean decision-making. Rising numbers of iatrogenic fistulas signal a quality crisis in emergency obstetric care. Unaddressed, the impact of this problem will grow as cesarean births become more common.

OBJECTIVE. No studies or guidelines exist to direct management of ureteroarterial fistula (UAF) after ileal conduit urinary diversion in which the possible risks and complications associated with stent-graft infection from the conduit flora must be reconciled with those of open surgical repair. This study seeks to characterize the clinical presentation, pathogenesis, and optimal diagnostic and therapeutic management of this entity through a systematic review of the literature. MATERIALS AND METHODS. A systematic search of the English-language literature using the PubMed, Scopus, and ScienceDirect databases was performed: 264 abstracts were identified. From those abstracts, 32 studies comprising 40 patients with 43 UAFs were selected for analysis. Data points including demographics, clinical presentation, UAF specifications, procedural details, postprocedural complications, and clinical outcomes were reviewed. RESULTS. Predisposing factors included female sex, chronic ureteral stent placement, and past surgical intervention and irradiation for pelvic malignancy. Fistulization was overwhelmingly unilateral (95.0% of patients) and included the common iliac artery (90.7% of UAFs). Combined endovascular and endoureteral modalities presented similar outcomes compared with surgical approaches in terms of UAF-related mortality (7.1% vs 13.3%, respectively) and complication rates (28.6% vs 26.7%) during a similar median follow-up period (9.5 vs 14.0 months). Endovascular stent-graft infections were present in 14.3% of cases and represented a leading indication for reintervention after endovascular management (50.0%). CONCLUSION. Short- and intermediate-term outcomes of combined endovascular and endoureteral techniques compare favorably with those of surgical approaches in the treatment of UAF after ileal conduit urinary diversion. Although there is a relatively low stent-graft infection rate, close follow-up within the first year after the procedure is required given the propensity of complications to develop during this window. The use of postprocedural antibiotics is uncertain but is likely prudent.

Introduction: To improve the outcomes and extend the adaptation of salvage surgery for intractable urinary tract problems, this study retrospectively investigated indications and outcomes of retroperitoneal surgery based on retroperitoneal laparoscopic ureterolysis (RLU), in which the ureter is dissected with or without nephrolysis. Patients and Methods: Twenty-three salvage surgeries based on RLU were performed on 22 patients at our hospital between November 2002 and July 2017. Intractable urinary tract problems included lower urinary tract dysfunctions, refractory urinary fistulas, middle or lower ureter troubles, ureteroileal anastomotic strictures, and stomal stricture of cutaneous ureterostomy. After RLU, various urinary tract reconstructions were performed through minimal laparotomy under a retroperitoneal approach. Results: In all patients, RLU secured a sufficient length of ureter for subsequent urinary tract reconstructions, irrespective of intra-abdominal adhesions. Twelve cutaneous ureterostomies, one reconstruction of cutaneous ureterostomy, two ureteroileal reanastomoses, and five ureterovesicostomies were effectively performed after unilateral RLU. Three retroperitoneoscopic transureteroureterostomies with cutaneous ureterostomy were reconstructed after bilateral RLU. Over a median follow-up of 8 months (interquartile range, 2-80 months), two patients (8.7%) required additional procedures. Conclusions: Retroperitoneal salvage surgery based on RLU appears useful to salvage intractable urinary tract problems, avoiding intra-abdominal adhesions and securing a sufficient ureteral length for subsequent urinary tract reconstructions. This surgical procedure is minimally invasive and contributes to improving patient quality of life.

Background Surgical safety during posterior sagittal anorectal plasty (PSARP) for anorectal malformations (ARM) depends on accurate pre-operative fistula localization. This study aimed to evaluate accuracy of pre-operative fistula diagnostics. Methods Ethical approval was obtained. Diagnostic accuracy of pre-PSARP symptoms (stool in urine, urine in passive ostomy, urinary tract infection) and examination modalities (voiding cystourethrogram (VCUG), high-pressure colostogram, cystoscopy and ostomy endoscopy) were compared to final intra-operative ARM-type classification in all male neonates born with ARM without a perineal fistula treated at a tertiary pediatric surgery center during 2001–2020. Results The 38 included neonates underwent reconstruction surgery through PSARP with diverted ostomy. Thirty-one (82%) had a recto-urinary tract fistula and seven (18%) no fistula. Ostomy endoscopy yielded the highest diagnostic accuracy for fistula presence (22 correctly classified/24 examined cases; 92%), and pre-operative symptoms the lowest (21/38; 55%). For pre-operative fistula level determination, cystoscopy yielded the highest diagnostic accuracy (14/20; 70%), followed by colostogram (23/35; 66%), and VCUG (21/36; 58%). No modality proved to be statistically superior to any other. Conclusions Ostomy endoscopy has the highest diagnostic accuracy for fistula presence, and cystoscopy and high-pressure colostogram for fistula level determination. Correct pre-operative ARM-typing reached a maximum of 60–70%.

Background Augmentation cystoplasty as a third-line therapy for neurogenic detrusor overactivity performed by an open approach has long been studied. Few laparoscopic and robot-assisted series have been reported. Objective To evaluate the feasibility, safety, and functional outcomes of completely intracorporeal robot-assisted supratrigonal cystectomy and augmentation cystoplasty (RASCAC) in patients with refractory neurogenic detrusor overactivity. Design, setting, and participants We identified all patients undergoing RASCAC, as treatment for refractory neurogenic detrusor overactivity, from August 2016 to April 2018. Surgical procedure RASCAC was performed in all cases using a standardized technique with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in a four-arm configuration. Measurements Perioperative data, and functional and urodynamic results at 1-yr follow-up were assessed. Statistical analysis was performed using Stata version 15.1. Results and limitations Ten patients were identified. No conversion to open surgery was needed. The median operative time was 250 (interquartile range 210–268) min, the median estimated blood loss was 75 (50–255) ml, and the median hospitalization time was 12 (10.5–13) d. The 30-d major complication rate was 10%. Two patients presented a late urinary fistula; in one of the cases, surgical revision was needed. In both cases, low compliance to intermittent self-catheterization was identified. At 1-yr follow-up, functional and urodynamic outcomes were excellent. Conclusions Robot-assisted augmentation cystoplasty has been shown to be safe and feasible, with a reasonable operative time and low complication rate in experienced hands. A higher number of patients and longer follow-up are, however, warranted to draw definitive conclusions. Patient summary In this report, we look at the outcomes of robot-assisted supratrigonal cystectomy and augmentation cystoplasty in neurourological patients. Perioperative, functional, and urodynamic results are promising. Further studies with a longer follow-up are needed to confirm these findings.

Urethrocutaneous fistula is the most prevalent complication after hypospadias repair. The aim of this study was to evaluate whether incised urethral diversion was superior to traditional transurethral diversion in minimizing complications.We retrospectively collected and analyzed 113 cases with proximal penile or penoscrotal hypospadias that were repaired by one-stage transverse preputial island flap urethroplasty between January 2016 and January 2020. Of those cases, 60 used incised urethral diversion (group A), whereas the remaining 53 were managed by transurethral diversion (group B) for urinary drainage after surgery. Postoperative complications in both groups were assessed for fistula, urethral diverticulum, meatal stenosis, wound infection, and distal urethral breakdown.Fistula was reported in 2 patients (3.3%) in group A, while it was observed in 15 patients (28.3%) in group B (p 0.001). Wound infection occurred in one patient (1.7%) in group A, compared with six patients (11.3%) in group B (p 0.05). The incidence rates of distal urethral breakdown were 1.7% (1/60) and 11.3% (6/53) for group A and group B, respectively (p 0.05). One patient (1.7%) in group A and three patients (5.7%) in group B had a meatal stenosis (p 0.05). There were two patients who developed urethral diverticulum in either group (p 0.05).The use of incised urethral diversion for urinary drainage had an advantage over transurethral diversion in one-stage hypospadias repair with respect to the post-operational fistula occurrence, wound infection, and distal urethral breakdown.

Background Arterioureteral fistula refers to the anomalous fistulous connection between the iliac artery and the ureter. It is often associated with pelvic malignancy, abdominal surgery, and radiation. As it is a potentially life-threatening condition, prompt diagnosis and management is essential. Methods We performed a retrospective analysis of patients treated for arterioureteral fistula in a single-vascular institution from January 2013 to March 2019. Preoperative assessment included physical and laboratory examinations and medical history, with diagnosis established through computed tomography angiography, digital subtraction angiography, or ureteroscopy. Parameters analyzed included perioperative mortality and morbidity as well as treatment durability during midterm follow-up. Results Nine patients with ten arterioureteral fistulas were included in the study. Macroscopic hematuria was the main presenting symptom, with 2 patients admitted due to hemorrhagic shock. Endovascular treatment was carried out in 6 patients. In 4 cases, single stent-graft deployment inside the common iliac artery was performed, in one case in combination with plugging of the internal iliac artery. One patient underwent implantation of an iliac-branched device, whereas in another patient coiling of the internal iliac artery sufficed for management of the fistula. Open surgical repair was carried out in three cases. Perioperative mortality was zero; one patient had prolonged hospital stay due to superficial wound infection. Recurrent hematuria and stent-graft infection were observed during follow-up in three patients after endovascular repair, all of them treated through open surgery with no further complications. One patient developed an enterocutaneous fistula after open repair during follow-up and required redo surgery. Discussion Arterioureteral fistula is a challenging clinical scenario demanding prompt diagnosis and management. Open surgery remains the treatment of choice in cases of preexisting vascular reconstruction or manifest infection. Endovascular techniques offer a viable solution in significantly comorbid patients or in patients presenting with acute, life-threatening bleeding. Rigorous follow-up is required regardless of treatment modality due to the considerable rate of reinterventions.

Primary repair of hypospadias is associated with risk of complications, specifically urethrocutaneous fistula and glanular dehiscence. Caudal block may potentially increase the risk of these complications. Therefore, we studied the incidence of hypospadias complications in children who underwent correction at our institution having received either penile or caudal block.We analyzed all primary hypospadias repair cases from December 2011 through December 2018 at Texas Children's Hospital with a minimum of 1-year followup for the presence of complications: urethrocutaneous fistula and glanular dehiscence. Surgical (surgeon, operative time, block type, local anesthetic, meatal position) and patient (age at correction, prematurity) factors were additionally analyzed.For the primary aim, 983 patients underwent primary hypospadias correction with a minimum of 1 year of postoperative followup data. There were 897 patients (91.3%) in which no complications were identified and 86 (8.7%) with either urethrocutaneous fistula (81) or glanular dehiscence (5). Of the 86 identified complications, 45/812 (5.5%) were distal, 41/171 (24%) were proximal (p0.001) with a complication. Rate of complications was not associated with caudal block (OR 0.67, 95% CI 0.41-1.09; p=0.11). On univariable analysis, age (OR 1.12, 95% CI 1.04-1.20; p=0.04), surgical duration (OR 1.02; 95% CI 1.01-1.02; p0.001), prematurity32 weeks (OR 4.38, 95% CI 1.54-4.11 p0.001) and position of meatus as proximal (OR 5.38 95% CI 3.39-8.53; p0.001) were associated with an increased rate of complications. However, on multivariable analysis, associations of age (OR 1.13, 95% CI 1.05-1.22; p=0.001), surgery duration (OR 1.01, 95% CI 1.01-1.02; p0.001) and meatal position (OR 3.85, 95% CI 2.32-6.39; p0.001) were associated with increased rate of complications.Our data suggest that meatal location, older age, extreme prematurity and surgical duration are associated with increased incidence of complications (urethrocutaneous fistula and glanular dehiscence) following hypospadias correction. Analgesic block was not associated with increased hypospadias complication risk.

Background Postoperative rectourethral fistula (RUF) in patients with congenital anorectal malformation (ARM) remains a challenge for paediatric surgeons, among them persistent fistula is the most common. Various techniques have been proposed, only a few reports based on different causes are available, and there is no consensus so far. This study is to evaluate the application, advantages and limitations of transanal fistulectomy approach in repairing persistent RUF in ARM patients. Methods From January 2007 to July 2019, 78 ARM patients who received revisional surgery for RUF were reviewed, 34 persistent fistulas were identified. Examination under anaesthesia included patients with fistulas that were located within 3 cm from the anus verge, good appearance of the anus and sphincter function, and no urethral and rectoanal obstruction. Three patients were excluded because of complex urologic pathologic defects. In total, thirty-one patients underwent transanal fistulectomy to repair RUF. Results All cases were approached with transanal incision and fistulectomy to repair RUF. The average operative time was 91 ± 35 min. At a minimum six-month follow-up, 29 patients healed after the first attempt, the success closure rate was 93.5%. Two patients received redo transanal fistulectomy and healed. Two patients had postoperative complications: one patient had urethral stenosis and it was managed by dilation; one patient had urethral diverticulum but it did not require revisional surgery. No patient in this study was incontinent because of the surgery. Conclusions Transanal fistulectomy provides a simple, straightforward, and safe approach to repair persistent RUF in ARM patients, especially in those with a low-lying fistula, good anus appearance and sphincter function without obstruction in the rectum or urethra. Trial registration: Retrospectively registered.

Objective To describe the natural history, reconstructive solutions, and functional outcomes of those men undergoing pubectomy and urinary reconstruction after prostate cancer treatment. Patients and methods This study retrospectively identified 25 patients with a diagnosis of urosymphyseal fistula (UF) following prostate cancer therapy who were treated with urinary reconstruction with pubectomy. This study describes the natural history, reconstructive solutions, and functional outcomes of this cohort. Results All 25 patients had a history of pelvic radiotherapy for prostate cancer. The median (interquartile range [IQR]) time from prostate cancer treatment to diagnosis of UF was 11 (6, 16.5) years. The vast majority of men (24/25; 96%) presented with debilitating groin pain during ambulation. Posterior urethral stenosis was common (20/25; 80%), with 60% having repetitive endoscopic treatments. Culture of pubic bone specimens demonstrated active infection in 80%. Discordance between preoperative urine and intraoperative bone cultures was common, 21/22 (95.5%). After surgery, major 90-day complications (Clavien-Dindo Grade III and IV) occurred in eight (32%) patients. Pain was significantly improved, with resolution of pain (24/25; 96%) and restoration of function, the median (IQR) preoperative Eastern Cooperative Oncology Group Performance Status (ECOG PS) was 3 (2, 3) vs median postoperative ECOG PS score of 0 (0, 1). Conclusion Endoscopic urethral manipulation after radiation for prostate cancer is a risk factor for UF. Conservative management will not provide symptom resolution. Fistula decompression, bone resection, and urinary reconstruction effectively treats chronic infection, improves pain and ECOG PS scores.

Lower urinary tract reconstruction has traditionally been approached in an open fashion but select complications or disease processes may be suitable for robotic reconstruction, including bladder neck contractures, proximal urethral strictures, and genitourinary fistulas. Here, the authors discuss the novel techniques used and the feasibility of robotic reconstruction for these conditions. The robotic approach is relatively novel, and more data and studies will be required to make definitive statements regarding success rate and complications from the procedure. Preliminary data suggest that the robotic approach may offer comparable success compared with open techniques.

Background Urethral injury or erosion of an inflatable penile prosthetic (IPP) cylinder is a rare complication of IPP placement. It can present with varying symptoms and management can be difficult with risk for future complications. We present a patient with an eroded IPP who developed a secondary contralateral urethrocavernous fistula requiring repeat urethroplasty. We also describe the literature surrounding these complications and strategies to prevent them. Case presentation A 69-year-old man with poorly controlled diabetes presented to our clinic with 6 months of intermittent white urethral discharge first noted after IPP removal and replacement by an outside urologist for device malfunction. Office cystoscopy revealed an eroded right-sided prosthetic cylinder in the bulbar urethra. The patient was taken to the operating room for IPP explantation with closure of right corporal defect, left sided malleable prosthesis placement, and primary excision with anastomosis of his bulbar urethra. A catheter was left in place for two weeks postoperatively, at which time a peri-catheter retrograde urethrogram was performed which showed no evidence of contrast extravasation and his catheter was subsequently removed. Several months later, he presented with recurrent urethral discharge without evidence of recurrent erosion on cystoscopy with development of scrotal abscesses following office cystoscopy, concerning for an unidentified urethral defect. He returned to the operating room for scrotal exploration and was noted on cystoscopy to have a pinpoint fistula between his left corporal body and his bulbar urethra. He underwent left sided malleable prosthetic explant, and non-transecting bulbar urethroplasty. Peri-catheter retrograde urethrogram two weeks later showed no contrast extravasation and he has had no recurrence of urethral discharge or scrotal abscesses since. Conclusions Urethral erosion and urethrocavernous fistula formation are rare complications of penile prosthesis placement. Risks are elevated in patients with corporal fibrosis, diabetes, those undergoing penile implant revision surgery, and those requiring prolonged urethral catheterization.

Objectives To assess the histologic findings in the pubic bone resected during extirpative surgery for urinary pubic symphysis fistula (UPF). The concurrent presence of osteomyelitis and the need for bone resection at time of extirpative surgery for UPF has been debated. We hypothesized that UPF results in histopathologically confirmed osteomyelitis, underscoring the importance of bone resection at the time of surgery. Methods An IRB approved retrospective review of all patients undergoing surgery for UPF from 2012 to 2019 was performed. Demographic data were recorded. A single pathologist performed histopathologic examination of bone tissue in each case. Logistic regression and Fisher exact test were used to assess association of osteomyelitis with clinical factors. Results We identified 36 patients who underwent major extirpative surgery for UPF with bone pathology available for review. Bone histopathology findings confirmed presence of osteomyelitis in the majority (n=32, 88.9%). This was characterized as chronic osteomyelitis in 15 (41.7%), acute osteomyelitis only in 1 (2.8%) and combined chronic and acute osteomyelitis in 16 (44.4%). Osteonecrosis was seen in 11 cases (33.6%). There was no correlation between presence of osteomyelitis and age, timing from radiotherapy to diagnosis of UPF, type of radiotherapy, or history of endoscopic bladder outlet procedures. Conclusions Osteomyelitis is present on histology of the pubic bone resected during surgery for UPF in the majority of cases (88.9%). Osteonecrosis is also common. These findings underscore the critical importance of pubic bone resection at time of UPF surgery to adequately treat the diseased bone.

Aim To present the features and treatment of rectourethral fistula (RUF) and rectovesical fistula (RVF) after Hirschsprung disease (HD) operation. Methods A retrospective analysis was performed on patients with RUF and RVF after HD operation, who received repair surgery from a single surgeon between January 2005 and December 2019. Bowel function was assessed using the Rintala score. Results Seven patients were included. Six patients were referred to us after transanal endorectal pull-through (TEPT) in other centers; one RVF patient had fecal diversion at admission. Bladder-neck injury was detected during redo TEPT in our hospital in the remaining one patient and instant repair was given. 11 days later, RVF and sepsis were detected. Fecal and urine diversion was performed immediately. The fistula openings were prostatic urethra (3), membranous urethra (2), bladder triangle (1), and bladder-neck (1). Anastomotic stricture (4), bladder stone (3), hydronephrosis and ureterovesical junction obstruction (2), pelvic infection (2), distal colonic dilatation (1) and other fistulas (1) were identified before repair surgery. Fecal and urine diversion was performed before repair surgery in one RUF and one RVF patient respectively, to treat pelvic infection owing to fecal or urine leaks and accompanying problems. Five RUFs were repaired by transperineal approach, and two RVFs were repaired using the transabdominal and transanal approach respectively. Four patients with anastomotic stricture underwent redo TEPT with simultaneous fistula repair. Aside from one RUF patient, the fistula in all patients successfully resolved. Median follow up time was 81 months (range, 5–116 months). No recurrence was observed. Median bowel function score was 17.5 (range, 17–18). Conclusion The location of fistula, presence of anastomotic stricture and the association of urinary complications have significant impacts on the treatment strategy in such rare complications after TEPT for HD. The type of study Treatment study. Level of evidence Level IV.

To study delayed presentation of ARMs, management and its effect on surgical and functional complications.It is a retrospective study from March 2015 to March 2020. All the patients satisfying the criteria of delayed ARMs, i.e., presenting 7 days after birth were included. Information regarding type of ARM, mode of presentation, time of presentation, associated anomalies, management strategy, postoperative complications and functional outcome was noted. Minimum follow-up period was 6 months.Out of 102 patients with ARM, 44 patients presented late. Among the 44 patients, 9 were males and 35 were females. Associated comorbidities observed are low birth weight (n = 9) and preterm (n = 13). Associated anomalies observed were cardiac (n = 18), renal (n = 8), other gastrointestinal (n = 5) and skeletal (n = 1). (1) Male: rectourethral fistula-2 (staged repair), anal stenosis-3 (anoplasty) and anocutaneous fistula-4 (anoplasty). (2) Female: vestibular fistula: 15 (6 primary definitive surgery + 9 staged repair), ectopic anus: 3 (staged repair), anal stenosis: 2 (anoplasty), urogenital sinus: 4 (staged repair), H-type ARM: 8 (staged repair) and persistent cloaca: 3 (staged repair). Primary repair was done in 15 patients (34%), and staged repair was done in 29 patients (65.9%). Anoplasty was done in 9 patients, ASARP (modified tsuchida's procedure) in 8 patients and PSARP in 27 patients. Postoperative complications observed were constipation (n = 21, 47.7%), fecal incontinence (n = 12, 27.27%) with perianal excoriation in 2 patients, anal stenosis (n = 3, 6.8%) and rectal mucosal prolapse (n = 2, 4.5%) CONCLUSION: Delayed presentation of ARMs is not uncommon and is more common in females. Management is almost similar to those who present early. Those who present with chronic constipation and megarectum require staged repair. Complications were more frequent with delayed presentation. Hence, every newborn should have careful examination of perineum and screened for ARM to avoid possible morbidity and mortality.

Introduction: Transposition of the gracilis has been used in a large number of reconstructive procedures. Its advantage is its proximity to these defects and a good blood supply. Traditionally, the gracilis mobilization is performed by open surgery with one or more incisions. We describe our initial experience with the video-endoscopic mobilization of gracilis. Method: We described a retrospective review of all patients who underwent gracilis muscle mobilization for treatment of rectourethral fistula, performed by video-endoscopy, between March 2013 and September 2017, for treatment of rectourethral fistula. Also, our surgical technique is described in detail. Results: Three patients, with a mean age of 66.6 years, underwent the procedures. The mean time for mobilization of the gracilis was 107 min (range 60–145). There was no case of donor area infection, no change in the sensitivity of the medial aspect of the thigh or chronic pain. Conversion to open surgery was not necessary in any case. The hospital discharge occurred in average after 4 days. The bladder catheter was removed after 4 weeks after cystography was performed without evidence of leakage. One patient had a recurrence of the fistula. Discussion: The gracilis is an excellent choice of tissue to be interposed in reconstructive procedures of the perineal region, especially in the treatment of rectourinary fistulas. However, endoscopic harvest of the gracilis muscle has not yet found its way into everyday practice. The results in the treatment of rectourinary fistulas are excellent, with a success rate of 87.7%. Our rate of 67% is below, probably due to the small number of cases. In open surgery, complications are uncommon; however, approximately half of the patients expressed concern about the painful scar, which can be reduced by minimally invasive access. Conclusion: Video-endoscopic mobilization of gracilis muscle for the treatment of rectourethral fistula is feasible and safe. Studies comparing this technique with the conventional mobilization are required.

Hydatid cyst is a major health problem in developing countries. The kidney is in third position of organs affected by hydatid cyst. One of the complications of renal hydatid cyst is a urinary fistula. The purpose of this study is to identify preoperative predictive factors of urinary fistula in renal hydatid cyst and to develop a scoring system for this disorder. We retrospectively analyzed all patients operated for renal hydatid cysts between January 2000 and December 2020. We divided our patients into two groups according to whether or not the renal hydatid cysts opened in the urinary tract. Predictive factors of the presence of a urinary fistula have been studied to obtain a simple score to predict the presence of a urinary fistula. Differences were considered significant if p < 0.05. Urinary fistula was detected in 33 of 96 patients. Univariate analyses showed significant differences in patient age, cyst size, location, hydaturia, eosinophil count, and platelet count between patients with and without urinary fistula. In multivariate analyses, hydaturia (p < 0.005), eosinophil count >500/mm3, (p = 0.01), cyst diameter >5 cm (p = 0.02), and upper or lower renal pole location (p = 0.003) were significant and independent predictors of urinary fistula. A score was developed to predict the opening of the cyst in the urinary tract. The total score varies between 0 and 15. The resulting area under the receiver operator characteristic curve was 0.798 (95% CI, 0.726–0.866; p = 0.023). At a cutoff point ≥8, the specificity achieved was 100%. Preoperative detection and management of urinary fistula are important issues in the treatment of renal hydatid cyst. Developing a scoring system based on routinely measured laboratory and radiologic factors will help the clinician to manage patients with renal hydatid cysts. External studies are needed to validate this new scoring system in routine clinical practice.&nbsp

Objective This study summarizes the short-term efficacy of the one-stage tubularized urethroplasty using the free inner in proximal hypospadias. Methods A retrospective analysis was conducted on 42 patients with proximal hypospadias. All cases were treated with one-stage tubularized urethroplasty from January 2020 to June 2021. The postoperative complications like urethral fistula, urethral stricture, diverticulum, and split penis head were recorded. Results Patients were followed up for 3 to 15 months (an average of 8.5 months). A total of 26 cases (62%) were repaired without any complication. Five patients (11.9%) developed urinary fistulas and underwent secondary repair: three cases with anastomotic fistulas and two cases of coronal fistulas. Nine patients (21.4%) had stenosis of the head segment of the penis, six (14.3%) had stenosis that was relieved by urethral dilatation combined with topical mometasone furoate 1 month after urethral catheter removal. Two patients (4.8%) had severe stenosis with secondary surgical stenosis incision, and one (2.4%) had combined urethral diverticulum in which urethral stenosis incision and diverticulectomy were performed. Conclusions Tubularized urethroplasty using the free inner bears the advantages of easy access, reduced short-term complications, low incidence of diverticula.

Uretero-arterial fistula (UAF) is a rare complication of either aneurysmal disease primarily or pelvic inflammation secondary to urologic, oncologic, or vascular interventions. Diagnosis can be difficult to confirm and treatment may need to proceed on high index of suspicion alone. We present the case of a 56-year-old woman suffering from intermittent hematuria after laser lithotripsy leading to UAF between her left ureter and left Dacron aortobifemoral bypass limb. The fistula was successfully treated with endovascular intervention.

The aim of this study was to evaluate the endourologic management of post-cesarean section ureterovaginal fistula. Between February 2016 and March 2019, eight patients presented because of vaginal leakage after cesarean section. All presented within 15 days from their original operations. Three of the patients had a vague lower abdominal pain, and five had ipsilateral flank pain; all had vaginal leakage. Physical examination, ultrasonography, and IVP were done to confirm the diagnosis. Ureteroscopy was the first treatment attempt, using two or three guide wires to find the proximal part of the ureter and insert a JJ stent. In six patients, we could insert guide wires, find the proximal part of the ureter, and finally insert a JJ stent. In two patients, we could not even pass a guide wire, so we changed the position, and ureteral reimplantation was done. The stents were removed after 6 weeks, and after 3 months an IVP was planned again that showed all fistulae had resolved with no evidence of ureteral stricture. In cases of ureterovaginal fistula after cesarean section, ultrasonography and IVP with lateral view x-ray films may confirm the diagnosis. The traditional treatment for ureterovaginal fistula is ureteral reimplantation, but endoscopic management may be a viable technique with less invasiveness and faster results and recovery. Thus, retrograde stenting can be accomplished in selected patients with ureterovaginal fistula after cesarean section and may eliminate the need for reimplantation of the ureter.

Purpose We compared the protective effect of additional tunica vaginalis flap coverage combined with a dartos flap against urethrocutaneous fistulas in tubularized incised plate (TIP) urethroplasty in a randomized controlled trial. Materials and methods This prospective, randomized controlled trial in a single tertiary center enrolled 50 patients in whom it was feasible to perform single TIP urethroplasty between 2016 and 2017. Consecutive children were randomly allocated to study group A (additional tunica vaginalis flap coverage, n=25) or control group B (dartos-only coverage, n=25). All patients were examined in the outpatient clinic at 1, 3, 12, and 24 months. Postoperative cosmetic outcomes were evaluated by surgeons and parents using the Pediatric Penile Perception Scale questionnaire. Results In group B, 1 of 25 patients (4.0%) developed an urethrocutaneous fistula within 12 months. An additional two cases of fistula were found in all proximal-type hypospadias patients at 24 months in the same group without statistical significance (p=0.07). The penile cosmetic satisfaction rate was not significantly different between the groups according to scores on the Pediatric Penile Perception Scale. Conclusions Our randomized controlled trial did not show a significant decrease in the incidence of or a significant slowing of the progression of postoperative fistulas after TIP urethroplasty by the use of additional tunica vaginalis coverage. A tunica vaginalis flap is not routinely recommended but could have a selective role in proximal-type TIP urethroplasty with deficient dartos and subcutaneous tissue to cover the neourethra.

To evaluate the safety and efficacy of ureteral occlusion stents for urinary diversion in patients with inoperable urinary leakage or fistula or intractable bladder bleeding. A total of 13 ureters in 12 patients (M:F = 4:8) who underwent ureteral occlusion stenting were included in this study. The internally silicone membrane-coated occlusion stent was a self-expanding stent with constriction at the middle (M-type) or distal end (D-type) of the stent. The reasons for ureteral occlusion were surgery infeasibility for urinary leakage (n = 6), temporary ureteral occlusion for urinary leakage before surgical reconstruction (n = 2), urinary fistula (n = 3), or control of bleeding from bladder cancer (n = 1). Technical success defined as successful deployment of the occlusion stent with no contrast agent passing beyond the occlusion stent was achieved in 92.3% (12/13 ureters); in one ureter with contrast passage beyond the occlusion stent, additional n-butyl cyanoacrylate (NBCA) embolization was performed immediately so that there was no further leakage. There were no procedure-related complications. During the mean follow-up of 11.6 months, recurrence of urinary leakage was observed in two ureters (15.4%, 2/13) where a D-type occlusion stent was used on the 3-day follow-up antegrade ureterogram; the contrast agent passed through the widened constricted portion of the occlusion stent and repeat occlusion with microcoils, and NBCA was subsequently performed inside the occlusion stent and with no further urinary leakage until the last follow-up. The ureteral occlusion stent is safe and effective for ureteral occlusion. Recurrence of leakage can be managed with additional microcoil and NBCA embolization.

Objectives To evaluate the outcomes of recurrent urethrocutaneous fistula repair using tunica vaginalis graft as an intermediate protective layer. Methods We retrospectively reviewed the data of 45 children with recurrent urethrocutaneous fistula who underwent tunica vaginalis graft repair between February 2011 and January 2019. The repair was carried out at least 6 months after a previous fistula repair. Follow up at an outpatient clinic was scheduled on a weekly basis for 1 month, then monthly for 6 months and then annually. During follow up, every patient was evaluated by history taking. The site of repair and the act of micturition were inspected. Urine analyses together with culture and sensitivity tests were carried out if required. Successful repair was defined as the absence of recurrence, with good force and caliber of the urinary stream. Results This study included 45 patients with recurrent urethrocutaneous fistula who were managed with a tunica vaginalis graft as a second layer. The mean age of patients was 6.7 ± 2.8 years. The mean postoperative hospital stay was 5.5 ± 0.7 days. The repair was successful for 43 (95.6%) patients, and urethrocutaneous fistula recurrence was reported for two (4.4%) patients, which were repaired after 6 months. In all patients, the cosmetic appearance of the penis was satisfactory without torsion or ventral chordee. Conclusion Tunica vaginalis graft is a simple and fast procedure that is highly effective as a protective second layer for recurrent urethrocutaneous fistula repair.

Rectovaginal, pouch-vaginal, and recto-urethral fistulas are very challenging to treat. Gracilis muscle interposition was shown be an effective treatment for these complex fistulas. The aim of this study was to investigate the feasibility and outcomes of redo gracilis interposition for persistent and recurrent complex perineal fistulas. A retrospective analysis of all patients who had redo gracilis muscle interposition for complex perineal fistulas at our institution from 1995 to 2019 was performed. Nine patients (5 males, mean age 55 years) were included for analysis. The types of fistulas were recto-urethral (n = 5), rectovaginal (n = 2) and pouch-vaginal (n = 2). The success rate was 56% with 5 patients achieving complete healing of the fistula. Only 1 patient (11%) experienced a postoperative complication. Redo gracilis muscle interposition is feasible and safe with promising resultsin healing of complex perineal fistula.

Aim: This study aimed to compare the surgical outcomes of patients with the intermediate-type imperforate anus who underwent laparoscopically assisted anorectoplasty (LAARP; L group) with those of ...