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The management of artificial urinary sphincter (AUS) sub-cuff atrophy remains controversial and clinical outcomes are underreported. We intend to examine the impact of cuff downsizing in cases of isolated sub-cuff atrophy.We reviewed our prospectively collected, institutionally approved QI database for this study from 2011 to 2022. IRB approval was obtained for the analysis. Sub-cuff atrophy in patients with post-prostatectomy incontinence was diagnosed with a clinical presentation of recurrent urinary leakage, serial pelvic films, cystoscopy and patient evaluation. Outcomes were assessed with pad use, subjective measures and AUA-SS scores.During the study interval, 871 encounters for AUS placement were identified, 229 for revision or replacement, of which cuff downsizing for isolated cases of sub-cuff atrophy occurred in 34. Downsizing took place after a median of 6.5 years after initial AUS placement. 97% reported subjective improvement and 93% experienced a decrease in daily incontinence pad use, with a mean decrease of 2.2±1.45 pads (When diagnosed using objective criteria, cuff downsizing improves continence and patient satisfaction in cases of sub-cuff atrophy.

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.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.A total of 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 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 = .79). There was no difference in future AUS removal or replacement (56.4% vs 44.4%, P = .41). Both groups experienced improvement in urinary incontinence after placement of an AUS.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.

Posterior pelvic fracture urethral distraction defects (PFUDD) can present formidable challenges in genitourinary reconstruction. Once the acuity of trauma subsides, the patient is often faced with chronic, debilitating genitourinary injuries. Treatment requires an astute diagnostic and technical approach, with definitive repair best accomplished in the hands of experts. A delayed, stepwise approach to repair following the resolution of acute injuries remains a time-tested platform for optimal outcomes. The evaluation, relevant anatomy, and approach to surgical repair are described herein.

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: In vivo measurements of tibiotalar and subtalar joint motion following TAR are unavailable. Using biplane fluoroscopy, we tested the hypothesis that the prosthetic tibiotalar joint and adjacent subtalar joint would demonstrate kinematic and range of motion differences compared to the contralateral untreated limb, and control participants. Methods: Six patients of 41 identified candidates that all underwent unilateral Zimmer TAR (5.4 ± 1.9 years prior) and 6 control participants were imaged with biplane fluoroscopy during overground walking and a double heel-rise activity. Computed tomography scans were acquired; images were segmented and processed to serve as input for model-based tracking of the biplane fluoroscopy data. Measurements included tibiotalar and subtalar kinematics for the TAR, untreated contralateral, and control limbs. Statistical parametric mapping quantified differences in kinematics throughout overground walking and the double heel-rise activity. Results: Patients with this TAR performed walking and heel-rise activities symmetrically with no significant kinematic differences at the tibiotalar and subtalar joints between limbs. Compared to control participants, patients exhibited reduced dorsi/plantarflexion range of motion that corresponded to decreased peak dorsiflexion, but only in the late stance phase of walking. This reduction in tibiotalar dorsi/plantarflexion range of motion in the TAR group became more apparent with double heel-rise activity. Conclusion: Patients with a Zimmer TAR had symmetric kinematics during activities of walking and double heel-rise, but they did exhibit minor compensations in tibiotalar kinematics as compared to controls. Clinical Relevance: The lack of significant kinematic compensation at the subtalar joint may explain why secondary subtalar osteoarthritis is reported as being relatively uncommon in patients with some TAR designs.

Urethral slings are a good treatment option for mild male stress urinary incontinence. There are many different sling options, but herein our group describes our techniques with the Advance® and Virtue® slings. More important than technique, we strongly think that patient selection is paramount to sling success. We only offer slings to patients who have low 24 hour pad weights, high Valsalva leak point pressure, and no history of pelvic radiation. Still, like with any surgery, we recommend that the surgeons implant the device that they are most comfortable with along with their chosen techniques.

ObjectiveTo determine whether ejaculatory dysfunction (EjD) and post-void dribbling (PVD) after urethroplasty are associated, providing evidence for a common etiology.MethodsWe reviewed a prospectively maintained database for first-time, anterior urethroplasties. One item from the Male Sexual Health Questionnaire (MSHQ) assessed EjD: "How would you rate the strength or force of your ejaculation". One item from the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS-PROM) assessed PVD: "How often have you had slight wetting of your pants after you had finished urinating?". The frequency of symptoms was compared after penile vs. bulbar repairs, and anastomotic versus augmentation bulbar repairs. Associations were assessed with chi-square.ResultsA total of 728 men were included. Overall, postoperative EjD and PVD were common; 67% and 66%, respectively. There was a significant association between EjD and PVD for the whole cohort (p

Background: There is no consensus surgical treatment algorithm for talar body fractures, with authors recommending both soft tissue–only and osteotomy-based approaches. This study evaluates talar dome access via dual approaches to the talar dome through anterolateral transligamentous (ATL) and modified posteromedial (mPM) approaches. Methods: Ten cadaveric legs (5 matched pairs) were included. An mPM approach, between flexor hallucis longus and Achilles tendon, and an ATL approach, utilizing the anterolateral interval with transection of anterior talofibular ligament and calcaneofibular ligament, were performed on each specimen. Order of approach was alternated within each pair. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire at the visualized talar dome margin both with and without 4 mm of tibiotalar distraction using an external fixator. Specimens were analyzed by computed tomography (CT). Primary outcome was accessible DSA. Student t tests compared DSA accessed by different exposure methods. Results: An initial mPM approach exposed 25.6% and 33.6% of DSA without and with distraction ( P = .002). An initial ATL approach accessed 47.0% and 58.1% of DSA without and with distraction, respectively ( P = .003). Accessibility via dual approaches was 71.7% and 93% of DSA without and with distraction with an initial ATL approach and 71.3% and 87.5% of DSA without and with distraction with an initial mPM approach ( P = .96 and .37, respectively). The central talar dome was inaccessible in an almond-shaped area, tapered at the medial and lateral ends. Anterior, lateral, and posterior articular margins were able to be fully exposed, often with overlapping exposure between posterior and anterior approaches, with distraction reliably improving lateral visualization. Conclusion: Dual approaches provided access to greater than 70% and 85% of talar DSA without and with distraction, respectively. Order of approach did not significantly affect exposure and thus should be determined by surgeon discretion. These results may promote soft tissue–only treatment strategies in talar body fracture care with an extensile exposure of the talar dome surface. Careful preoperative planning optimizes the advantages of this approach. Level of Evidence: Level IV, case series.

Compare accessible area of the posterior tibial plateau through a modified posteromedial (PM) approach before and after tenotomy of the medial head gastrocnemius. We report the outcomes of 8 patients who underwent gastrocnemius tenotomy during PM approach.A modified PM approach was performed on 10 cadaveric legs, and the surgically accessible area was outlined. Next, a medial head gastrocnemius mid substance tenotomy was completed, and the accessible area was again outlined. Tibia specimens were imaged in a micro-CT scanner to measure accessible surface area and linear distance along the joint line. In addition, 8 patients who underwent tenotomy for tibial plateau fracture had outcomes recorded.The modified PM approach with tenotomy provided significantly more access to the posterior plateau than without tenotomy. The modified PM approach before tenotomy allowed access to 1774 mm 2 (SD = 274) of the posterior plateau surface and 2350 mm 2 (SD = 421, P0.0001) with tenotomy. A linear distance of 38 mm (SD = 7) and 57 mm (SD = 7, P0.00001) was achieved before and after tenotomy, respectively. In the clinical series, the average knee arc of motion was 116 degrees (95-135).The modified PM approach with medial head gastrocnemius tenotomy significantly improves surgical access to the posterior plateau. Patients who received tenotomy have acceptable functional outcomes. This cadaveric study provides an alternative approach for treatment of posterolateral tibial plateau fractures which may mitigate damage to neurovascular structures.

Historically, conventional radiographs have been the primary tool to morphometrically evaluate the talocrural joint, which is comprised of the distal tibia, distal fibula, and proximal talus. More recently, high-resolution volumetric imaging, including computed tomography (CT), has enabled the generation of three-dimensional (3D) reconstructions of the talocrural joint. Weightbearing cone-beam CT (WBCT) technology provides additional benefit to assess 3D spatial relationships and joint congruency while the patient is load bearing. In this study we applied statistical shape modeling, a computational morphometrics technique, to objectively quantify anatomical variation, joint level coverage, joint space distance, and congruency at the talocrural joint. Shape models were developed from segmented WBCT images and included the distal tibia, distal fibula, and full talus. Key anatomical variation across subjects included the fibular notch on the tibia, talar trochlea sagittal plane rate of curvature, tibial plafond curvature with medial malleolus prominence, and changes in the fibular shaft diameter. The shape analysis also revealed a highly congruent talocrural joint with minimal inter-individual morphometric differences at the articular regions. These data are helpful to improve understanding of ankle joint pathologies and to guide refinement of operative treatments.

Aims The artificial urinary sphincter (AUS), the gold standard for treatment of male stress urinary incontinence, can be filled with normal saline (NS) or isotonic contrast solution. Surgeons have voiced concerns about the impact on device malfunction and longevity, but no studies address this issue. We used industry data to identify differences in outcomes between NS and contrast-filled AUS. Methods Our analysis included all men patients in the industry who maintained the AUS database (Boston Scientific) from 2001 to 2016. Patients were divided into two groups: AUS filled with NS or contrast. Patient demographics and device characteristics were compared. Device survival was defined as time to the need for reoperation. We compared device survival between AUS filled with NS versus contrast using a Kaplan-Meier curve adjusted for age, cuff size, and pressure regulating balloon (PRB) size. Results A total of 39,363 patients were included. 34,674 (88.1%) devices were filled with NS. The reoperation rate overall was 24.5%, with no difference between groups. The mean time to reoperation overall was 3 years (±3.0). After adjustment for age, cuff size, and PRB size, Kaplan-Meier analysis demonstrated a similar time to reoperation between the two groups. Conclusion The use of contrast in the AUS does not appear to change rates of the device malfunction, fluid loss, or need for reoperation. Since filling the device with contrast does not appear inferior to saline in terms of longevity, we feel this should be considered a safe tool for the implanting surgeon.

Introduction:Urologists may be hesitant to surgically treat urinary incontinence in comorbid genitourinary cancer survivors. We assessed the relationship between comorbidities and 30-day pe...

In the field of skeletal research, accurate and reliable segmentation methods are necessary for quantitative micro-CT analysis to assess bone quality. We propose a method of semi-automatic image segmentation of the midfoot, using the cuneiform bones as a model, based on thresholds set by phantom calibration that allows reproducible results in low cortical thickness bones. Manual and semi-automatic segmentation methods were compared in micro-CT scans of the medial and intermediate cuneiforms of 24 cadaveric specimens. The manual method used intensity thresholds, hole filling, and manual cleanup. The semi-automatic method utilized calibrated bone and soft tissue thresholds Boolean subtraction to cleanly identify edges before hole filling. Intra- and inter-rater reliability was tested for the semi-automatic method in all specimens. Mask volume and average bone mineral density (BMD) were measured for all masks, and the three-dimensional models were compared to the initial semi-automatic segmentation using an unsigned distance part comparison analysis. Segmentation methods were compared with paired t-tests with significance level 0.05, and reliability was analyzed by calculating intra-class correlation coefficients. There were statistically significant differences in mask volume and BMD between the manual and semi-automatic segmentation methods in both bones. The intra- and inter-reliability was excellent for mask volume and bone density in both bones. Part comparisons showed a higher maximum distance between surfaces for the manual segmentation than the repeat semi-automatic segmentations. We developed a semi-automatic micro-CT segmentation method based on calibrated thresholds. This method was designed specifically for use in bones with high rates of curvature and low cortical bone density, such as the cuneiforms, where traditional threshold-based segmentation is more challenging. Our method shows improvement over manual segmentation and was highly reliable, making it appropriate for use in quantitative micro-CT analysis.

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.

PurposePostoperative surveillance urethroscopy has been shown to be an effective tool to predict reoperation within 1 year after urethroplasty. We aimed to evaluate early surveillance urethroscopy findings and long-term outcomes among urethroplasty patients in order to define the value of surveillance urethroscopy to predict failure.Materials and methodsWe evaluated 304 patients with at least 4 years of followup after urethroplasty performed at 10 institutions across the United States and Canada. All patients were surveilled using a flexible 17Fr cystoscope and were categorized into 3 groups: 1) normal lumen, 2) large-caliber stricture (≥17Fr) defined as the ability of the cystoscope to easily pass the narrowing and 3) small-caliber stricture (

Patients presenting with microhematuria represent a heterogeneous population with a broad spectrum of risk for genitourinary malignancy. Recognizing that patient-specific characteristics modify the risk of underlying malignant etiologies, this guideline sought to provide a personalized diagnostic testing strategy.The systematic review incorporated evidence published from January 2010 through February 2019, with an updated literature search to include studies published up to December 2019. Evidence-based statements were developed by the expert Panel, with statement type linked to evidence strength, level of certainty, and the Panel's judgment regarding the balance between benefits and risks/burdens.Microhematuria should be defined as ≥ 3 red blood cells per high power field on microscopic evaluation of a single specimen. In patients diagnosed with gynecologic or non-malignant genitourinary sources of microhematuria, clinicians should repeat urinalysis following resolution of the gynecologic or non-malignant genitourinary cause. The Panel created a risk classification system for patients with microhematuria, stratified as low-, intermediate-, or high-risk for genitourinary malignancy. Risk groups were based on factors including age, sex, smoking and other urothelial cancer risk factors, degree and persistence of microhematuria, as well as prior gross hematuria. Diagnostic evaluation with cystoscopy and upper tract imaging was recommended according to patient risk and involving shared decision-making. Statements also inform follow-up after a negative microhematuria evaluation.Patients with microhematuria should be classified based on their risk of genitourinary malignancy and evaluated with a risk-based strategy. Future high-quality studies are required to improve the care of these patients.

Weightbearing computed tomography (WBCT) enables visualization of the foot and ankle as patients stand under load. Clinical measurements of WBCT images are generally limited to two-dimensions, which reduces the ability to quantify complex morphology of individual osseous structures as well as the alignment between two or more bones. The shape and orientation of the healthy/normal subtalar joint, in particular, is not well-understood, which makes it very difficult to diagnose subtalar pathoanatomy. Herein, we employed statistical shape modeling to evaluate three-dimensional (3D) shape variation, coverage, space, and congruency of the subtalar joint using WBCT data of 27 asymptomatic healthy individuals. The four most relevant findings were: (A) talar and calcaneal anatomical differences were found regarding the presence of (a) the talar posterior process, (b) calcaneal pitch, and (c) curvature of the calcaneal posterior facet; (B) the talar posterior facet articular surface area was significantly greater than the calcaneal posterior facet articular surface area; (C) the posterior facet varied in joint space distance, whereas the anteromedial facet was even; and (D) the posterior and anteromedial facet of the subtalar joint was consistently congruent. Despite considerable shape variation across the population, the posterior and anteromedial articular facets of the subtalar joint were consistently congruent. Results provide a detailed 3D analysis of the subtalar joint under a weightbearing condition in a healthy population which can be used for comparisons to pathological patient populations. The described SSM approach also shows promise for clinical evaluation of the subtalar joint from 3D surface reconstructions of WBCT images.

To investigate the impact of extirpative surgery for pubic bone osteomyelitis with pubovesical fistula on prostate cancer survivors' physical and mental health.The Short Form 12 (SF-12) is a validated instrument for assessing health-related quality of life (HRQOL). We reviewed a prospectively maintained database of patients treated with extirpative surgery for pubovesical fistula from 2017-2021 who completed the SF-12. Wilcoxon signed-rank and McNemar's tests were used to analyze changes in SF-12 following surgery. Narcotic prescriptions in the year before and after surgery were assessed as an additional measure of pain burden.Eighteen patients were included. Four had pre-operative SF-12s, 3 had post-operative SF-12s, and 11 had both. Median age was 76.5 years (IQR 71.75-80.00). All patients had previous radiation for prostate cancer. Compared to global pre-operative scores, post-operative physical composite scores (PCS) significantly increased (29.95 ± 8.59 vs 42.48 ± 7.18; P.001), but mental composite scores (MCS) were similar (45.35 ± 9.98 vs 52.21 ± 8.23). When comparing individual, paired pre-operative and post-operative scores there was a significant improvement in PCS (30.56 ± 9.87 vs 45.45 ± 8.56; P = .005), but not MCS (47.49 ± 6.92 vs 51.60 ± 8.88). Median morphine milligram equivalent significantly decreased in the year post-surgery compared to the year prior (103.1, 33.0-250.9 vs 34.25, 0.0-105.9; P = .0008).For prostate cancer survivors with pubovesical fistula and pubic bone osteomyelitis, urinary diversion with pubic bone resection improves physical functioning and decreases narcotic prescriptions without untoward effects on mental health.

To understand the effects of reharvest on safety and long-term oral health in patients requiring buccal mucosa reharvest from a previously harvested and closed site for management of recurrent urethral stricture disease.We conducted an IRB approved retrospective chart review from 2014 to 2019 of all patients who underwent buccal graft urethroplasty at our referral based academic medical center. Surgical data was collected, and the validated Oral Health Impact Profile (OHIP-14) survey was administered to each patient. Descriptive statistics were performed and compared between patients who underwent a buccal graft reharvest and patients who underwent standard first time buccal harvest. Buccal graft beds were closed on both initial and reharvest.Four patients underwent a total of 5 ipsilateral buccal graft reharvests and 6 patients underwent first time buccal harvest. Median length of follow-up for all patients was 6 months (1-35 mo) and the median length of all grafts was 6 cm (5-6 cm) with no difference in the reharvest and first-time cohorts. For patients that underwent buccal reharvest, their median post-operative OHIP-14 score was 0 (0-9 pts) out of a possible 56 points. This compared to a median postoperative OHIP-14 score of 0 (0-10 pts) for patients who underwent first time buccal harvests with oral complications limited to one post-operative hematoma in the first-time cohort.Buccal grafts can safely be reharvested from a previous site with minimal concern for long-term oral health outcomes.

INTRODUCTION AND OBJECTIVE:The LSE anterior urethral stricture classification system has previously been validated for its interrater reliability and ability to predict urethroplasty technique. Her...

INTRODUCTION AND OBJECTIVE:Prior work has established that post-operative urethroscopy may be an effective tool to predict re-operation within 1 year following urethroplasty. Here, we examine early...

Animal models suggest POCD may be caused by brain monocyte influx. To study this in humans, we developed a flow cytometry panel to profile CSF samples collected before and after major non-cardiac surgery in in 5 patients age ≥ 60 years who developed POCD and 5 matched controls who did not. We detected 12,654±4895 cells/10 ml CSF sample (mean±SD). Patients who developed POCD showed an increased CSF monocyte/lymphocyte ratio and MCP-1 receptor downregulation on CSF monocytes 24 hours after surgery. These pilot data demonstrate that CSF flow cytometry can be used to study mechanisms of postoperative neurocognitive dysfunction. CLINICAL TRIAL NUMBER AND REGISTRY URL: , https://clinicaltrials.gov/ct2/show/NCT01993836 (This manuscript describes a nested case-control study, performed within the larger cohort study, .)

To evaluate contemporary outcomes of urethroplasty employing a pedicled skin flap for isolated pendulous urethral strictures. Inclusion of males > 18 years of age with isolated pendulous urethral strictures treated between 1996 and 2012. A total of 81 patients with isolated pendulous urethral stricture were identified. Twenty-eight patients underwent repair with a pedicled skin flap during the study period. The median age of the patients treated with a pedicled skin flap was 47 years old (range 21–74). The etiology of the strictures was considered to be idiopathic in 10 patients (35.7%), iatrogenic in 9 patients (32.1%), as a complication of prior hypospadias repair in 6 patients (21.4%), infectious in 2 patients (7.1%), and traumatic in 1 patient (3.6%). The median follow-up was 27 months (range 1–214). Urethroplasty success was noted in 19/21 patients (90.5%). Urethral stricture recurrence occurred in 2 of the 21 patients (9.5%). The pedicled skin flap repair for pendulous urethral strictures remains a durable and safe technique in patients without LS.

We evaluated the management of recurrent bulbar urethral stricture disease after urethroplasty at our institution.We performed an institution review board approved, retrospective case study of our urethroplasty database to collect stricture related and postoperative information with an emphasis on bulbar urethral stricture disease recurrence after urethroplasty between 1996 and 2012. Repair types included primary anastomotic, augmented anastomotic and onlay repair. Recurrence, which was defined as the need for intervention, was diagnosed with cystoscopy or retrograde urethrogram.We identified 437 men who underwent urethroplasty of bulbar urethral stricture disease as performed by 2 surgeons from January 1996 to December 2012. Of the men 395 had available followup data. Recurrence was identified in 25 men (6.3%), of whom all presented with symptoms, including a weak stream in 23, urinary tract infection in 1 and pyelonephritis in 1. Median time to recurrence was 10 months. Recurrence was initially treated endoscopically in 23 of 25 cases (92%), dilatation in 12 and visual urethrotomy in 11. In 5 patients (22%) further recurrence developed after endoscopic treatment, which was managed by repeat urethroplasty in 2, self-calibration only in 2 and visual urethrotomy with subsequent self-calibration in 1. We identified 2 distinct phenotypes of recurrent stricture, including type A-short focal recurrence, which may be salvaged with an endoscopic procedure, and type B-the long graft length type, which is less likely to be salvaged with endoscopy.Recurrence after urethroplasty is most likely to develop within the first 12 months. Type A short focal recurrence may be managed by a salvage endoscopic procedure, including dilation or visual urethrotomy. These data on the phenotype of recurrence may be useful for patient treatment.

In the field of skeletal research, accurate and reliable segmentation methods are necessary for quantitative micro-CT analysis to assess bone quality. We propose a method of semi-automatic image segmentation of the midfoot, using the cuneiform bones as a model, based on thresholds set by phantom calibration that allows reproducible results in low cortical thickness bones.Manual and semi-automatic segmentation methods were compared in micro-CT scans of the medial and intermediate cuneiforms of 24 cadaveric specimens. The manual method used intensity thresholds, hole filling, and manual cleanup. The semi-automatic method utilized calibrated bone and soft tissue thresholds Boolean subtraction to cleanly identify edges before hole filling. Intra- and inter-rater reliability was tested for the semi-automatic method in all specimens. Mask volume and average bone mineral density (BMD) were measured for all masks, and the three-dimensional models were compared to the initial semi-automatic segmentation using an unsigned distance part comparison analysis. Segmentation methods were compared with paired t-tests with significance level 0.05, and reliability was analyzed by calculating intra-class correlation coefficients.There were statistically significant differences in mask volume and BMD between the manual and semi-automatic segmentation methods in both bones. The intra- and inter-reliability was excellent for mask volume and bone density in both bones. Part comparisons showed a higher maximum distance between surfaces for the manual segmentation than the repeat semi-automatic segmentations.We developed a semi-automatic micro-CT segmentation method based on calibrated thresholds. This method was designed specifically for use in bones with high rates of curvature and low cortical bone density, such as the cuneiforms, where traditional threshold-based segmentation is more challenging. Our method shows improvement over manual segmentation and was highly reliable, making it appropriate for use in quantitative micro-CT analysis.

No abstract available

We evaluated the success of minimally invasive management of lichen sclerosus with topical and intraurethral clobetasol, as defined by improvement in patient reported outcome measures and nonprogression to surgery.We conducted a review of our prospective ongoing quality improvement study to determine outcomes of our current standard practice for males with penile and urethral biopsy proven lichen sclerosus. Data were collected between 2011 and 2019, and included patient demographic information, medical and surgical histories, and location and extent of lichen sclerosus related pathology. The primary outcomes for this study were voiding function and voiding related quality of life, and were assessed using the AUASS (American Urological Association Symptom Score) and quality of life bother index, respectively.We identified 42 patients with biopsy proven lichen sclerosus related urethral stricture disease. Of these patients 85.7% were treated with intraurethral steroids alone and did not require surgical intervention. Median AUASS significantly improved from 12 to 8, and median quality of life bother index improved from 4 ("mostly dissatisfied") to 2 ("mostly satisfied"). Average stricture length of those with penile urethral disease and bulbar urethral disease was 4.8 cm (SD 3.0) and 16.2 cm (SD 6.5), respectively. Median followup was 8.4 months (IQR 2.6-26.4).Lichen sclerosus related urethral stricture disease can be effectively managed with intraurethral steroids. This minimally invasive management strategy improves patient reported voiding symptoms and voiding quality of life.