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Robert Shapiro,1,2 Alec Sunyecz,3 Stanley Zaslau,1,2 Manuel C Vallejo,1,4 Tyler Trump,2 Omar Dueñas-Garcia1 1Department of Obstetrics and Gynecology, West Virginia University School of Medicine, Morgantown, WV, 26506, USA; 2Department of Urology, West Virginia University School of Medicine, Morgantown, WV, 26506, USA; 3West Virginia University School of Medicine, Morgantown, WV, 26506, USA; 4Department of Anesthesiology, West Virginia University School of Medicine, Morgantown, WV, 26506, USACorrespondence: Robert ShapiroHealth Science Center North, West Virginia University, PO Box 9001A, Morgantown, WV, 26506, USATel +1 304-293-5631Fax +1 304-293-5160Email rshapiro@hsc.wvu.eduBackground: In this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 polyglactin, poliglecaprone) versus barbed (V-LocTM 90) suture. As a secondary outcome, we analyzed factors for suture preference between the two groups.Methods: A retrospective chart review was undertaken for surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson’s Chi-square test and interval data by t-test. A p < 0.05 was significant.Results: Sixty-eight patients were identified with iatrogenic cystotomy at WVU. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p = 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index (BMI) was significantly higher in patients receiving a barbed suture repair (p = 0.005).Conclusion: Barbed suture may be comparable to standard braided suture for cystotomy repair. Barbed suture may offer a practical alternative to facilitate cystotomy repair in minimally invasive surgery, especially in patients with a high BMI.Keywords: barbed suture, cystotomy, minimally invasive surgery, obesity

Robert Shapiro,1,2 Omar Felipe Dueñas-Garcia,1 Manuel Vallejo,1 Tyler Trump,2 Makenzy Sufficool,3 Stanley Zaslau1,2 1Department of Obstetrics & Gynecology, West Virginia University School of Medicine, Morgantown, WV 26506, USA; 2Department of Urology, West Virginia University School of Medicine, Morgantown, WV 26506, USA; 3West Virginia University School of Medicine, Morgantown, WV 26506, USACorrespondence: Robert ShapiroDepartment of Obstetrics & Gynecology, West Virginia University School of Medicine, Morgantown, WV 26506, USAEmail rshapiro@hsc.wvu.eduIntroduction: Patients may develop recurrent urinary tract infections, pain syndromes, dyspareunia, and voiding difficulty after mid-urethral sling placement that can be treated by partial sling excision.Objective: The primary objective of this study was to evaluate the incidence of de novo incontinence and voiding difficulty after partial sling excision. A secondary objective was to assess risk factors associated with future incontinence surgery in this subset of patients.Methods: From 2009 to 2017, 95 female patients with subjective complaints of pelvic pain, dyspareunia, or voiding difficulty following synthetic mid-urethral sling placement for stress urinary incontinence underwent partial sling excision at a single institution. The incidence of urinary incontinence was assessed 6 months after partial sling excision. Patients were also assessed for resolution of voiding difficulty and future incontinence surgery. Primary endpoints were examined by Pearson’s Chi-square test and interval data by t-test. A p < 0.05 was significant.Results: About 72% of patients were more likely to be continent after partial sling excision irrespective of initial symptoms prior to surgery. No difference was seen in voiding difficulty between the continent and incontinent patients after partial sling excision (p=0.09). Patients with a retropubic mid-urethral sling were more likely to be continent after partial sling excision (p=0.03). Preoperative maximum flow rate > 16 mL/sec was associated as an independent variable to develop incontinence surgery after partial sling excision (p=0.009).Conclusion: In conclusion, partial sling excision poses a low risk for de novo urinary incontinence regardless of preoperative symptoms. Stress urinary incontinence may be less likely to reoccur in those patients having a retropubic approach. A preoperative maximum flow rate of > 16 mL/sec is a risk factor for future incontinence surgery after partial sling excision and should be taken into consideration when formulating a treatment plan.Keywords: sling excision, mesh, incontinence, mid-urethral sing

A minimum number of index procedures is required for graduation. Without thresholds for surgical technique, it is unclear if robotic and open learning is balanced. We assessed the distribution of robotic and open surgeries performed by residents upon graduation.Voluntary Accreditation Council for Graduate Medical Education resident case logs from 11 institutions were de-identified and trends in robotic and open major surgeries were compared using Wilcoxon rank sum and 2-sample t-tests.A total of 89,199 major cases were recorded by 209 graduates from 2011 to 2017. The median proportion of robotic cases increased from 2011 to 2017 in reconstruction (4.7% to 15.2%), oncology (27.5% to 54.2%) and pediatrics (0% to 10.9%) (all values p0.001). Robotic and open cases remained most divergent in reconstruction, with a median of 12 robotic (IQR 9-19) to 70 open cases (IQR 55-106) being performed by residents in 2017. Similar observations occurred in pediatrics. In oncology the number of robotic procedures superseded that of open in 2016 and rose to a median of 148 robotic (IQR 108-214) to 121 open cases (IQR 90-169) in 2017, with the driver being robotic prostatectomy. Substantial differences in surgical technique were observed between institutions and among graduates from the same institution.Although robotic volume is increasing, the balance of surgical technique and the pace of change differ in reconstruction, oncology and pediatrics, as well as among individual institutions and graduates themselves. This raises questions about whether more specific guidelines are needed to ensure equity and standardization in training.

Overactive bladder (OAB) affects up to 43% of women. Treatment ranges from lifestyle modification to invasive therapies. Nearly 75% of patients report using the internet to gain health information creating a need for interpretable, online resources. This study is aimed at evaluating the readability of online resources for OAB treatment in the US population.Google and Bing were queried regarding "sacral neuromodulation," "peripheral tibial nerve stimulation (PTNS)," and "bladder botox." The first 20 results from each search engine were assessed, representing over 90% of accessed search results. Websites were categorized as institutional/reference, commercial, nonprofit, or personal. The Gunning fog (GF), Simple Measure of Gobbledygook (SMOG), and Dale-Chall (DC) validated readability scores were used to assess results.Sacral neuromodulation yielded 27 eligible results. The associated mean readability scores correlated with levels of college senior (GF), high school junior (SMOG), and college level (DC). PTNS yielded 31 eligible results. The associated mean readability scores correlated with levels of college senior (GF), high school senior (SMOG), and college level (DC). Bladder botox yielded 17 eligible results. The associated mean readability scores correlated with levels of college sophomore (GF), high school junior (SMOG), and college level (DC). There was no difference between the therapies regarding readability. Sixty-one percent of websites were institutional/reference, 24% were commercial, 13% were nonprofit, and 2% were personal.High levels of reading comprehension are required by the general US population to understand OAB information obtained through the internet. These findings highlight a need for simplification of online resources pertaining to OAB.

INTRODUCTION AND OBJECTIVE:The landscape of urologic training has shifted dramatically with the emergence of robotic surgery. Increased utilization of robotic surgery may alter the level of trainin...

Background In this study, we aim to compare outcomes after cystotomy repair between standard sutures (910 polyglactin, poliglecaprone) versus barbed (V-Loc™ 90) suture. As a secondary outcome, we analyzed risk factors for suture preference between the two groups. Methods A retrospective chart review was undertaken for surgeries complicated by cystotomy, identified by ICD-9/10 codes from 2016 to 2019 at West Virginia University (WVU) Hospital. Comparisons were made between cystotomy repair using barbed suture versus standard braided suture. Injuries were categorized by procedure, surgeon specialty, surgical route, type of suture used in repair, and subsequent complications related to repair. Primary endpoints were examined by Pearson’s Chi-square test and interval data by t-test. A p

Background. Vesicovaginal fistula is a rare and distressing urological condition. It is especially prevalent in developing countries with the predominant etiology secondary to obstructed labor. Radiation therapy in female patients with cervical cancer is a risk factor for vesicovaginal fistula formation in the United States. Case Presentation. A 53-year-old woman with a history of cervical cancer and radiation presented with continuous urinary incontinence. Following diagnostic vaginoscopy, a 1 cm vesicovaginal fistula was diagnosed at the vaginal apex. The patient elected for surgical repair. She subsequently underwent successful transvaginal fistula closure using colpocleisis to optimally address the systemic factors of poor wound healing associated with irradiated tissue. Because of the adjacent tissue having been compromised by pelvic radiation, we opted to use a biologic graft made of human cadaveric pericardial tissue (CPT) instead of a native tissue flap to provide additional support for the fistula repair. Conclusion. A transvaginal approach for surgical repair of vesicovaginal fistula can be successful in patients with a prior history of pelvic radiation. Transvaginal colpocleisis is a viable option to augment vesicovaginal fistula repair for patients with significant comorbidities when sexual intercourse is no longer desired.

INTRODUCTION AND OBJECTIVE:Neuromodulation of the tibial nerve has been found to be an effective therapy to treat overactive bladder (OAB) while eliminating all the systemic side effects found with...

The surgical treatments for neurogenic bladder are extremely variable. The lack of specific treatment guidelines makes this disease process even more challenging to treat. We present a case of a 55-year-old female with neurogenic bladder secondary to spinal cord injury (SCI). Her incontinence was conservatively managed with indwelling Foley drainage. Despite continued upsizing of the Foley catheters, the patient continued to have urinary leakage. The patient subsequently underwent a transvaginal bladder neck closure (BNC) with suprapubic bladder neck diversion (SPC). The urethra was successfully closed and uniquely supported with the use of cadaveric pericardial tissue (CPT). This surgical approach of neurogenic bladder provides durable continence with short operative times, minimal patient morbidity, decreased hospital length, and low risk of progressive renal dysfunction. BNC with SPC can provide an excellent management solution for neurogenic bladder from spinal cord injury refractory to conservative management.

It is estimated that almost half of patients affected with Crohn disease (CD) experience a dermatologic manifestation of the condition. Metastatic CD (MCD) is a rare dermatologic entity, with as few as 100 cases reported in the literature. As such, MCD presents a clinical dilemma in diagnosis and management. The etiology of MCD is not well defined; however, prevailing theories agree that the underlying mechanism is an immunologic response to gut antigens. Diagnosis requires a high index of suspicion and usually is made by exclusion of other processes. Treatment success has been reported with the use of antibiotics, immunosuppressants, and sometimes surgical treatment. We review the etiology/epidemiology, diagnostic criteria, and treatment of this uncommon condition.

Video Objective To demonstrate a robotic approach to identify the surgical planes, exposure and mesh removal from the vagina in a patient with a sacral colpopexy performed more than 2 decades ago and vault prolapse recurrence. Setting Tertiary care center. Interventions A-63- year old G3 P3 with history of a total vaginal hysterectomy with uterosacral ligament suspension with prolapse recurrence that was treated by an abdominal sacral colpopexy 20 years ago, presented to our practice with vault prolapse recurrence. Considering her prior mesh procedure decision was made to perform another sacral colpopexy through a minimally invasive approach. In addition to her condition patient had bladder stones for no apparent reason. Urology performed a bladder stone extraction prior to the prolapse procedure. Careful examination of the urothelium revealed no mesh or suture fibers from the previous colpopexy. Mesh and suture removal from the vagina was performed to allow the placement of the new mesh. A type I polypropylene mesh was attached to the vagina using polydioxanone sutures. The mesh was tension and attached to the anterior longitudinal ligament in regular fashion with a polypropylene suture. Conclusion Newer generations of surgeons should be trained to expect how to handle prolapse recurrences when a prior mesh procedure was performed. This procedure can be challenging but feasible through a robotic minimally invasive approach.

Background. Synthetic mid-urethral mesh slings are the most common primary surgical treatment for stress urinary incontinence (SUI) and have been designated as the standard of care by the American Urogynecologic Society. In recent years, synthetic mesh has come under increased scrutiny by the Federal Drug Administration (FDA) due to concerns over patient safety. This has led to more surgeons and patients preferring Burch colposuspension to treat SUI. Case. We discuss two cases of suture erosion into the urethra and bladder. They presented with irritative voiding symptoms and recurrent urinary tract infections. Both were discovered years after a Burch colposuspension. Conclusion. As reported in the literature as early as 1999, erosion is a complication associated with many types of incontinence surgery and not unique to mesh based sling operations. Burch colposuspension should not be favored solely to avoid erosion and patients should be counseled accordingly. Teaching Point. Cystourethroscopy performed intraoperatively or postoperatively is essential for early diagnosis and treatment of complications related to incontinence surgery.

Paratesticular sarcomas are a rare entity and provide a unique clinical challenge due to their slow growing, often painless natural course. Adding to this challenge is the complex anatomy of the scrotum that allows these masses to mimic other conditions, including inguinal hernia, cysts, or fluid collections. We report such a case and our approach to an 83-year-old male with dedifferentiated liposarcoma of the spermatic cord with a history of inguinal hernia. In doing so, we highlight the need for thorough evaluation of scrotal masses and the management of these rare, though well-described, tumors.

To determine the age of pediatric patients who underwent surgical intervention for undescended testicles (UDT) at our institution.We retrospectively reviewed all pediatric patients who underwent orchiopexy and/or diagnostic laparoscopy for undescended or non-palpable testicles with our pediatric urologist from January 2013-March 2014. Patients were separated into those undergoing surgical intervention at 6-12 months, 13-24 months, 25-48 months, and48 months of age.70 patients underwent surgical intervention. Only 15 patients (21.4%) underwent surgical intervention within the recommended time period of 6-12 months. Orchiopexy was performed on 21 patients (30.0%) from 13-24 months, 12 patients (17.1%) from 25-48 months, and 22 patients (31.5%) after 48 months of age.Current American Urologic Association (AUA) recommendations advocate orchiopexy between 6-12 months of age. Improved parent and primary care education and access to pediatric urological evaluation of UDT will hopefully improve the timeliness of intervention within our state.

Polypropylene (PP) mesh has come under increased scrutiny owing to previous FDA safety communications regarding the risks of mesh in trans-vaginal surgery and ensuing class action litigation for post-operative complications. Additional concerns have been raised regarding a possible link between implanted PP mesh and the long-term development of malignancy. Until recently, no research was specifically committed to the exploration of such a link. Our objective was to provide an overview of the recent literature focusing on any association between the use of PP mesh for midurethral sling procedures and the development of malignancy. Multiple online research databases were searched for information related to any possible carcinogenic potential of PP mesh. There was no increased incidence in the development of malignancy after midurethral sling procedures using PP mesh in any of the studies. Given the scarcity of evidence suggesting otherwise, the likelihood of PP mesh causing malignancy is exceptionally low. However, with few studies and an unknown latency period between exposure and diagnosis, more observational data would prove useful to exclude causality.

The most recent American Urologic Association (AUA) guidelines concerning prostate-specific antigen (PSA) screening have caused much controversy. One particular guideline, in regard to testing elderly men, is the center of intense debate. Currently, the AUA recommends against PSA screening in men aged 70 and older. West Virginia faces the challenge of a population aging at a rate that far exceeds the projected national rate. With such a substantial future proportion of older men, and increased life expectancy within this group, careful consideration of PSA screening in elderly men is warranted. Given the uncertainty surrounding the basis for the AUA guidelines, and the increased quality of life and remaining life expectancy for older men, we propose a view that supports PSA screening in carefully selected elderly men, and offer background to assist clinicians in arriving at a sound clinical decision in concert with the patient.

Introduction: We hypothesized that inositol hexaphosphate (IP6) would modulate cell cycle and cellular growth in bladder cancer. Materials and Methods: Bladder ca

Elmiron (ALZA Corp, Mountain View, CA) is the only Food and Drug Administration-approved oral therapy for interstitial cystitis. We hypothesized that Elmiron would affect the growth of prostate cancer in vitro.Prostate cancer cell lines (LnCaP, PC3, and DU145) were treated with Elmiron. Cell viability was measured by MTT (3-4, 5-dimethylthiazol-2-yl-2,5-diphenyltetrazolium bromide), whereas vascular endothelial growth factor (VEGF) was measured by a commercial enzyme-linked immunosorbent assay.Inhibition of cell growth was observed in all cell lines tested. LnCaP exhibited a mean inhibition of 12% +/- 7% at 24 hours (P = .025) and 20% +/- 15% at 72 hours (P.001). PC3 exhibited a mean inhibition of 26% +/- 13% at 24 hours (P.001) and 44% +/- 5% at 72 hours (P.001). DU145 exhibited a mean inhibition of 9% +/- 6% at 24 hours (P.015) and 30% +/- 5% at 72 hours (P.001). PC3 cells exhibited a significant reduction in VEGF levels (P.001).The reductions in cell growth and VEGF indicate that Elmiron may act as an antiangiogenic agent and may have application in the treatment of prostate cancer.

Background We hypothesized that combined treatment with cyclooxygenase (Cox)-1 (catechin) and Cox-2 (NS398)–specific inhibitors would reduce cellular proliferation synergistically in genitourinary cancer. Methods Bladder (T24 and TCCSUP) and prostate (DU145, LnCaP, and PC3) cancer cell lines were treated with catechin and NS398 at a dose of 100 μmol/L as single and combined treatments. Viability was measured by MTT assay at 24 and 72 hours. Results Significant synergism of Cox-1 and Cox-2 inhibitors was observed in both bladder cancer lines at both 24 and 72 hours. Synergism of Cox-1 and -2 inhibitors also was noted in the DU145 cells at 72 hours, LnCap cells at 24 hours, and PC3 at both 24 and 72 hours. Conclusions Significant synergistic effects exhibited by the combination of Cox-1 and Cox-2 inhibitors suggest that these could become a highly effective treatment modality for carcinoma of both the bladder and prostate.

Hydronephrosis and ureteral obstruction are rare sequelae of Crohn’s disease. Chronic obstruction can ultimately lead to dysfunction of the affected kidney, and atypical presenting symptoms create pitfalls in diagnosis. Few reviews in the literature focus on this process and are limited to isolated case reports and case reviews. We performed a PubMed search using such terms as “Hydronephrosis” AND “Crohn’s disease” AND/OR “ureteral obstruction.” References from selected papers were reviewed for relevance and used for information-gathering as well. Ureteral obstruction most commonly occurs on the right side, due to ileal involvement. Clinical diagnosis is difficult, as symptoms are notably not genitourinary in origin; rather they are more musculoskeletal in nature. Treatment centers on disease control and temporary drainage of the affected kidney. Though rare, hydronephrosis and ureteral obstruction may develop as a result of inflammatory bowel disease. Due to atypical presenting symptoms, a high clinical suspicion is needed to affirm the diagnosis and ensure proper treatment.

Myelolipomas are rare tumors consisting of both adipose and hematopoietic tissue and are typically found within the adrenal gland. Extra-adrenal involvement is rare, especially those tumors involving the perirenal space and collecting system. We report a case of a patient with an incidentally discovered perirenal mass that was initially concerning for a retroperitoneal liposarcoma. Following surgical resection and pathological analysis, the lesion was found to be an extra-adrenal myelolipoma. This case report and review of the literature demonstrates the importance of the proper work-up and management of perirenal lipoma variants while addressing the issues of tissue biopsy, surgical intervention, and pre- and post-operative surveillance.

Urinary fistulae develop as abnormal connections between the gastrointestinal (GI) and genitourinary (GU) tracts, and occur in multiple disease processes including diverticulitis, malignancy, and Crohn's disease. Crohn's disease is now the most common cause of fistula formation between the ileum and bladder and the third most common cause of fistulae between the colon and the bladder. Few articles provide a comprehensive review of this process.We performed a PubMed search using such terms as "fistula" and "Crohn's disease" and/or "enterovesical fistula." We reviewed references from selected papers and relevant articles were used for information-gathering and cited accordingly.Fistulae in Crohn's disease generally occur due to preformed abscess formation or bowel perforation from the development of aphthous ulcers. The most common type of urinary fistula is enterovesical, due to the close proximity of the ileum and bladder dome. Computed tomography and cystoscopy are the most common diagnostic tools utilized. Surgical treatment is usually definitive; however medical treatment has been used with some success as well.Urinary fistulae represent an uncommon, yet serious problem to patients with Crohn's disease. Patient symptoms and imaging direct the practitioner to proper diagnosis, with direct visualization via cystoscopy confirming the presence of a urinary fistula. Treatment is aimed at relieving symptoms and may be medical or surgical depending on the clinical presentation.

Clinically significant iatrogenic ureteral injuries, excluding ureteroscopy, are likely underreported but considered a rare occurrence in pelvic surgery. An intraoperative consult for double ureter injury has never been documented in the medical literature. Presented herein is a case of a 53-year-old female undergoing conversion from a laparoscopic to open sigmoid resection for diverticular disease. There was an injury to a pelvic left ureter, which was then identified intraoperatively as left double ureter. Reconstruction was performed with left double side-to-side stented ureteroureterostomy followed by ureteroneocystotomy.

INTRODUCTION AND OBJECTIVES Intracavernosal injection (ICI) of vasoactive agents has been successfully used in the treatment of erectile dysfunction (ED). The authors' pharmacologic erection program, using a fixed combination of prostaglandin E1 (PGE1) and papaverine, is notable for its simplicity and acceptance by patients who have suffered spinal cord injuries (SCIs). METHODS Patients undergo baseline questionnaire, physical examination, and hormone profile followed by instruction and injection of a fixed combination of PGE1 and papaverine. On successive visits, the patient injects himself and the dosage is titrated until a satisfactory erection is obtained. Patients who do not respond to injection of 1.0 cc are considered treatment failures. Patients return periodically for routine follow-up. RESULTS From May 1994 to March 1997, 37 patients with SCI underwent initial evaluation and 28 (76%) responded to injection therapy and were successfully using self-injection therapy at 3-month follow-up. Twenty-three patients are still on injection therapy. Five patients have dropped out for several reasons including a lack of a current sexual partner (60%) and pain with injection (40%). Patient age ranges from 24 to 72. The dosage range was 0.10 to 0.50 cc (mean = 0.29 cc). The average duration of erection was 43 minutes. At 3-month follow-up, 85% of the patients rated their erections as good or excellent. Forty-three percent of patients are using ICI 1 or more times per week. Seventy-seven percent of patients are moderately or extremely satisfied with their treatment and 89% said that they would recommend this program to a friend. CONCLUSIONS This simplified pharmacologic erection program offers safe, well accepted, and effective therapy for ED to a SCI population with very high patient satisfaction.

Testicular torsion is an emergent condition requiring prompt surgical intervention to avoid permanent testicular compromise and death. As its symptoms overlap with other disease processes, diagnosis is sometimes difficult. When considering the presenting symptoms, one must be careful not to ignore unusual causes of torsion and misdiagnose the patient. In this case report we describe an unusual etiology of testicular torsion (traumatic) with an atypical patient presentation (mildly painful) which presented many obstacles before proper diagnosis and treatment.

Inositol Hexaphosphate (IP6) is a naturally occurring polyphosphorylated carbohydrate that is found in food sources high in fiber content. We hypothesized that IP6 would inhibit the cell growth rate of bladder cancer in vitro.T24 and TCCSUP bladder cancer cell lines were treated with titrating doses of IP6 (0.3, 0.6 and 0.9 mM/well). Cell viability and vascular endothelial growth factor levels were measured.Significant reductions (p0.001) in cellular growth were noted in both cell lines at all doses and time points tested, with the exception of 0.3 mM IP6 at 24 hours in the T24 cell line. The percent inhibition of vascular endothelial growth factor was significantly higher than that observed in the TCCSUP cell line at 48 and 72 hours with 0.3 mM IP6 (p0.001). The T24 cells exhibited the same level of inhibition at 24 and 48 hours with 0.6 mM dose of IP6 and at 72 hours with the 0.3 mM dose (p0.001).In vitro treatment of bladder cancer with the common dietary polyphosphorylated carbohydrate IP6 significantly decreased cellular growth by anti-angiogenic mechanisms. We feel that this data warrants further investigation and consideration for initiation of clinical trials to evaluate the safety and clinical utility of this agent.

There are multiple reports of foreign bodies inserted into the lower urinary tract. We report the case of an incidentally discovered foreign body identified within the bladder in a male patient presenting with a radio antenna protruding from the urethra attached to a head set. On workup patient was found to have an additional foreign body within the bladder and second radiolucent object within the urethra. This case demonstrates the importance of complete evaluation of the lower urinary tract during workup of inserted foreign bodies and the value of the bedside ultrasound as a diagnostic tool in distinguishing between rectal and genitourinary tract insertion.