Improved early continence following laparoscopic radical prostatectomy: the urethral hammock technique.

PURPOSE: To introduce and illustrate a novel urethral reconstruction technique-the 'urethral hammock-technique'-and to assess its impact on early postoperative continence following laparoscopic radical prostatectomy (LRP). METHODS: 119 patients who underwent LRP between January 2020 and May 2022 (hammock group: n = 43, control group: n = 76) were included in the study. The primary outcome was continence (zero pads or max. one security pad) at 1, 3, and 6 months following surgery. Secondary outcomes were operative time, complications, and histological findings. Univariate and multivariate regression analyses were performed to reveal predictors for continence. p values < 0.05 with a two-sided 95%-confidence interval were considered statistically significant. RESULTS: Baseline characteristics were comparable among both groups. The number of patients achieving complete continence in both the hammock and control groups at various time intervals was: 4 weeks 37.2% (16/43) vs. 19.2% (14/73) (p = 0.047); 3 months 60.5% (26/43) vs. 37.3% (28/75) (p = 0.021) and 6 months 72.1% (31/43) vs. 60.3% (44/73) (p = 0.23), respectively. Adjusting for bladder neck preservation status and age, the hammock technique was a significant predictor for continence for the 4-week (OR 0.33, 95% CI 0.13-0.83, p = 0.019) and 3-month (OR 0.28, 95% CI 0.12-0.66, p = 0.004) interval but not for the 6-month interval (OR 0.64, 95% CI 0.27-1.5, p = 0.31). Operative time, complication rates, time till catheter extraction and histological findings were comparable between both groups (all p > 0.05). CONCLUSIONS: The hammock technique is a simple and reproducible technique to improve early postoperative continence for at least 3 months following surgery. However, these promising results warrant confirmation through a randomized controlled trial.

Urethral Stricture Disease Guideline Amendment (2023).

PURPOSE: The symptoms of urethral stricture are non-specific and may overlap with other common conditions that can confound diagnosis. Urologists play a key role in the initial evaluation of urethral stricture, currently provide all accepted treatments, and must be familiar with the evaluation, diagnostic tests, and surgical treatments for urethral stricture. MATERIALS AND METHODS: A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates January 1, 1990 to January 12, 2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture in men. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. The search for the 2023 Amendment was modified to included females and males (search dates December 2015-October 2022 for males; January 1990-October 2022 for females) and a new Key Question on sexual dysfunction was added (search dates: January 1990-10/2022). After inclusion and exclusion criteria were applied, 81 studies were added to the existing evidence base. RESULTS: Once a urethral stricture is diagnosed, clinicians should determine the length and location of the stricture in order to inform treatment. After a period of urethral rest, patients with short (<2cm) bulbar urethral stricture may be treated endoscopically. Urethroplasty may be performed by an experienced surgeon in patients with first time or recurrent anterior and posterior urethral strictures. The best treatment option for urethral stricture in female patients is urethroplasty using oral mucosa grafts or vaginal flaps rather than endoscopic treatment. CONCLUSION: This guideline provides evidence-based guidance to clinicians and patients regarding how to recognize symptoms and signs of a urethral stricture/stenosis, carry out appropriate testing to determine the location and severity of the stricture, and recommend the best options for treatment. The most effective approach for a particular patient is best determined by the individual clinician and patient in the context of that patient's history, values, and goals for treatment.

Optimizing decision-making after ventral onlay buccal mucosa graft urethroplasty failure.

OBJECTIVES: To evaluate factors predicting recurrence after treatment and to assess the best rescue option for patients failing buccal mucosa graft (BMG) urethroplasty. MATERIALS AND METHODS: We evaluated the data from 575 patients treated with ventral onlay BMG urethroplasty. Multivariable Cox regression analysis was performed to identify predictors of BMG urethroplasty failure, and their effect on failure risk was estimated using the Kaplan-Meier method and compared using log-rank tests. Then, for those patients who underwent a rescue treatment, namely, direct visual internal urethrotomy (DVIU) vs open urethroplasty, we assessed the probability of success after retreatment using the Kaplan-Meier method and regression tree analyses. RESULTS: On multivariable Cox regression analysis, only stricture length ≥5 cm (hazard ratio 3.46, 95% confidence interval 1.50-7.94; P = 0.003) was a predictor of failure. A total of 103 patients had at least one re-intervention. Notably, 12-month success rates after first rescue DVIU, second rescue DVIU, third rescue DVIU, and fourth rescue DVIU were 66.3%, 62.5%, 37.5% and 25%, respectively. Conversely, for those patients who underwent open urethroplasty retreatment, success rates at 12 months were 83.3%, 79%, 92.3% and 75% after BMG ventral onlay, first rescue DVIU, second rescue DVIU and third rescue DVIU, respectively. These data were confirmed in regression tree analyses. CONCLUSION: Ventral BMG urethroplasty fails in approximately one out of five patients. Despite DVIU as a rescue treatment being a good option, its success rate becomes lower as the number of DVIU treatments performed increases. Conversely, open urethroplasty improves patient outcomes in almost three out of four patients, even in the case of previous failed DVIU treatments for stricture recurrence.

Outcomes of transecting versus non-transecting urethroplasty for bulbar urethral stricture: a meta-analysis.

OBJECTIVES: To assess outcomes of transecting vs non-transecting urethroplasty for bulbar urethral stricture in terms of stricture recurrence rate, sexual dysfunction, and patient-reported outcome measures (PROMs) related to lower urinary tract (LUT) function. METHODS: Electronic literature searches were conducted using PubMed, Cochrane Library, Web of Science and Embase databases. The studied population was limited to men with bulbar urethral stricture included in studies that compared outcomes after transecting and non-transecting urethroplasty. The main outcome appraised was the stricture recurrence rate. Additionally, the incidence of sexual dysfunction appraised in three domains (erectile function, penile complications, and ejaculatory function) and PROMs related to LUT function after transecting vs non-transecting urethroplasty were assessed. The pooled risk ratio (RR) respectively for stricture recurrence, erectile dysfunction and penile complications was calculated using a fixed-effect model with inverse variance method. RESULTS: In all, 694 studies were screened with 72 identified as relevant. Finally, 19 studies were suitable for analysis. The pooled difference between the transecting and non-transecting groups relating to stricture recurrence was not significant. Overall, the RR was 1.06 (95% confidence interval [CI] 0.82-1.36) and the 95% CI crossed the line of no effect (line RR = 1). Overall, the RR for erectile dysfunction was 0.73 (95% CI 0.49-1.08) and the 95% CI crossed the line of no effect (line RR = 1). Overall, the RR for penile complications was 0.47 (95% CI 0.28-0.76) and the 95% CI did not cross the line of no effect (line RR = 1). Hence, the risk of penile complications was significantly lower in the non-transecting group. CONCLUSIONS: Our analysis of available evidence indicates that both transecting and non-transecting urethroplasties, are equal in terms of the recurrence rate. On the other hand, non-transecting techniques are better in terms of sexual function, causing less penile complications.

Single-Port Endorobotic Rectal Mucosa Harvest For Urethral Reconstruction.

BACKGROUND: Colorectal mucosal grafts for substitution urethroplasty are alternatives for patients when buccal mucosa is not adequate for long urethral strictures. IMPACT OF INNOVATION: This study presents the first cases of single-port endorobotic rectal mucosa harvesting for urethral reconstruction. TECHNOLOGY MATERIALS AND METHODS: The patients are 43- and 57-year-old men with medical histories of lichen sclerosis. The urethrograms demonstrated panurethral strictures requiring long mucosal grafts. The single-port robot was docked under general anesthesia in the modified lithotomy position. The procedure began with a submucosal injection of a lifting agent. After achieving an adequate lift of the mucosa, the dissection was started 2 cm proximal to the sphincter complex with a hook and continued cephalad. The semiflexible robotic platform eased and facilitated the dissection providing the required traction and counter traction. The injecting needle and aspiration device were directed with the help of a silk knot at the tip of the tools to create a handle for robot arms. The procedure was continued with a spatula tip thinner than the hook, which delivers less energy to the dissection field and creates a precise cut. The harvested graft was provided to the urology team after pinning it for measurement. The urologists prepared and completed the reconstruction of the urethra with the autograft. PRELIMINARY RESULTS: The patient had no complications related to his rectal mucosa harvest. CONCLUSIONS: We report the first 2 cases of single-port robotic rectal mucosal harvesting for long panurethral strictures with single-port endorobotic submucosal dissection technique. FUTURE DIRECTIONS: The technique seems promising to facilitate the precise submucosal dissection with meticulous control of traction and delivered energy.

Urethral Bulkamid® injection after failed midurethral sling: a step-by-step video.

INTRODUCTION AND HYPOTHESIS: Bulking agents are a minimally invasive treatment option for women with stress urinary incontinence (SUI) or stress-predominant mixed urinary incontinence (MUI). Recurrent SUI is a major challenge for most clinicians because there is little evidence in the literature on the best option after midurethral sling (MUS) failure. METHODS: Bulkamid® (Contura International A/S), a urethral bulking agent, is a homogenous gel without particles, consisting of a polyacrylamide hydrogel that is nonbiodegradable. RESULTS: In this video case report, we demonstrate the Bulkamid® injection procedure. This procedure can be carried out as an office-based procedure under local anesthesia, with no down time and only minor possible complications. CONCLUSIONS: We consider it a valid option for patients with recurrent or persistent SUI after failed MUS surgery.

Magnetically controlled artificial urinary sphincter: An overview from existing devices to future developments.

BACKGROUND: Urinary incontinence is a common clinical problem in the world today. Artificial urinary sphincter is a good treatment approach for severe urinary incontinence, which is designed to mimic the action of the human urinary sphincter and assist patients to regain urinary function. METHODS: There are many control methods based on artificial urinary sphincter, such as hydraulic control, electromechanical control, magnetic control, and shape memory alloy control. In this paper, the literature was first searched and documented based on PRISMA search strategy for selected specific subject terms. Then, a comparison of artificial urethral sphincters based on different control methods was conducted, and the research progress of magnetically controlled artificial urethral sphincters was reviewed, and their advantages and disadvantages were summarized. Finally, the design factors for the clinical application of magnetically controlled artificial urinary sphincter are discussed. RESULTS: As magnetic control allows for non-contact force transfer and does not generate heat, it is proposed that magnetic control may be one of the more promising control methods. The design of future magnetically controlled artificial urinary sphincters will need a variety of considerations, including the structural design of the device, manufacturing materials, manufacturing costs, and convenience. In addition, validation of the safety and effectiveness of the device and device management are equally important. CONCLUSIONS: The design of an ideal magnetically controlled artificial urinary sphincter is of great importance to enhance patient treatment outcomes. However, there are still great challenges to be faced for the clinical application of such devices.

'Waterproofing layers' for urethrocutaneous fistula repair after hypospadias surgery: evidence synthesis with systematic review and meta-analysis.

OBJECTIVE: To summarize the available evidence and to quantitatively evaluate the global results of different waterproofing layers in substantiating the UCF repair. MATERIAL AND METHODS: After defining the study protocol, the review was conducted according to the PRISMA guidelines by a team comprising experts in hypospadiology, systematic reviews and meta-analysis, epidemiology, biostatistics and data science. Studies published from 2000 onwards, reporting on the results of UCF closure after hypospadias repair were searched for on PUBMED, Embase and Google Scholar. Study quality was assessed using Joanna Briggs Checklist (JBI) critical appraisal tool. The results with different techniques were compared with the two samples independent proportions test with the help of Microsoft Excel, MedCalc software and an online calculator. RESULTS: Seventy-three studies were shortlisted for the synthesis; the final analysis included 2886 patients (71 studies) with UCF repair failure in 539. A summary of various dimensions involved with the UCF repair has been generated including time gap after last surgery, stent-vs-no stent, supra-pubic catheterization, suture material, suturing technique, associated anomalies, complications, etc. The success rates associated with different techniques were calculated and compared: simple catheterization (100%), simple primary closure (73.2%), dartos (78.8%), double dartos flaps (81%), scrotal flaps (94.6%), tunica vaginalis (94.3%), PATIO repair (93.5%), biomaterials or dermal substitutes (92%), biocompatible adhesives (56.5%) and skin-based flaps (54.5%). Several techniques were identified as solitary publications and discussed. CONCLUSIONS: Tunica vaginalis and scrotal flaps offer the best results after UCF closure in the synthesis. However, it is not possible to label any technique as ideal or perfect. Almost all popular waterproofing layers have depicted absolute (100%) success sometimes. There are a vast number of other factors (patient's local anatomy, surgeon's expertise and technical perspectives) which influence the final outcome.

Is colorectal mucosa a reasonable graft alternative to buccal grafts for urethroplasty?: A comparison of graft histology and stretch.

OBJECTIVE: To compare the histological properties and stretch of colorectal mucosal grafts (CMG) and buccal mucosal grafts (BMG) and to evaluate the impact of age, medical comorbidity and tobacco use on these metrics. MATERIALS AND METHODS: Samples of BMGs from patients undergoing augmentation urethroplasty were sent for pathologic review. CMGs were collected from patients undergoing elective colectomy. CMGs were harvested fresh, at full thickness from normal rectum/sigmoid. Patients with inflammatory bowel disease, prior radiation, or chemotherapy were excluded. RESULTS: Seventy two BMGs and 53 CMGs were reviewed. While BMGs and CMGs were both histologically composed of mucosal (epithelium + lamina propria) and submucosal layers, the mucosal layer in CMG had crypts. The outer epithelial layers differed significantly in mean thickness (BMG 573µm vs. CMG 430µm, p=0.0001). Mean lamina propria thickness and submucosal layer thickness also differed significantly (BMG 135µm vs. CMG 400µm, p<0.0001; BMG 1090µm vs. CMG 808µm, p = 0.007, respectively). Mean delta stretch, as to length and width, was greater for CMG (118% x 72%) compared to BMGs (22% x 8%), both p<0.001. CONCLUSION: CMGs and BMGs significantly differ histologically in layer composition, width and architecture, as well as graft stretch. Given its elastic properties, CMG may be useful in covering large surface areas, but its thin epithelium, thick lamina propria and additional muscularis mucosal layer could impact graft take and contracture.

[Iatrogenic hypospadias a preventable rare complication with two-stage repair with buccal mucosa graft: a case presen- tation].

Urethral catheterization is a common procedure, but it is associated with a number of complications. Iatrogenic hypospadias can rarely occur. There is a limited literature dedicated to this condition. We report a young patient with COVID-19 with iatrogenic hypospadias of grade 3. He was undergone to a two-stage procedure with acceptable outcome. Surgical repair should be offered and performed for young patients to ensure good function with acceptable penile appearance. A surgical treatment will improve psychological, sexual and social outcomes.

Quantifying Glans Width Changes in Response to Preoperative Androgen Stimulation in Patients Undergoing Hypospadias Repair.

PURPOSE: Testosterone (T) administration prior to hypospadias surgery to increase glans size remains controversial. Understanding T's effect on glans width (GW) is essential to understanding its potential impact on surgical outcomes. We hypothesized that preoperative T in prepubertal boys significantly increases GW at the time of hypospadias surgery. MATERIALS AND METHODS: Our single institutional database was queried to identify patients who underwent hypospadias surgery from 2016 to 2020, in which data for T administration and GW were available. Descriptive, nonparametric and categorical statistics were performed as indicated. RESULTS: A total of 579 patients were eligible for analysis. Median age at surgery was 0.9 years (IQR 0.6-1.6). A total of 247/579 patients (42.7%) received T. The median GW at surgery was 15 mm (IQR 13-17). When comparing patients who had T administered to those who did not, we found a significant difference in GW at surgery (16 mm vs 14 mm, p <0.001). The median change in GW from the office to surgery was 4 mm for those receiving T vs 0 mm for those not receiving T (p <0.001). We identified a greater change in GW from preoperative to intraoperative measurements in patients who received 2 doses of T vs 1 dose (4 mm vs 2 mm, p <0.001). A histogram plot revealed the distribution of GW change at surgery. CONCLUSIONS: In our prospectively collected cohort of patients undergoing hypospadias surgery, we were able to quantitate the change in GW from preoperative T. Two doses of T resulted in a significant increase in GW vs 1 dose.

Transobturator tape versus single incision sling: how are they different? Clinical outcomes and ultrasonographic features of two mid-urethral slings.

PURPOSE: Stress urinary incontinence (SUI) is usually treated with mid-urethral slings. The best approach is still debated and the relationship between slings and pelvic structures is not completely understood. The aim of this study is to identify any difference between trans-obturator tape (TOT) and single incision sling (minisling). METHODS: Patients submitted to TOT or minisling were included in the study. Q-tip and stress test, ICIQ-SF questionnaire, PGI-I validated score, and 2D/3D transvaginal ultrasound parameters were collected at 1- and 6-month follow-up. Correlations between ultrasound parameters and clinical outcomes, PGI-I and ICIq-SF, were performed. RESULTS: 61 patients were included in the study. PGI-I score was significantly lower in the minisling group than in TOT group at 1-month (p = 0.016) and 6-month follow-up (p = 0.076). The median distance between the sling and the lumen of urethra was significantly higher and the angle between the branches of the sling was significantly narrower in the minisling group. There were significant differences in distances between the sling and the bladder neck at 1-month and 6-month follow-up. An inverse correlation between angle of the branches and the Q-tip test was observed (p = 0.059 Pearson's Rho - 0.578). PGI-I correlated also with angle of the branches (p = 0.009, Pearson's Rho 0.503). CONCLUSION: Patients undergoing TOT or minisling are similarly satisfied but show differences at ultrasound exam at 1- and 6-month follow-up. Pelvic floor ultrasound could be used in a short-term follow-up to visualize the sling position and to plan the most appropriate follow-up strategy.

Comparative review of the guidelines for anterior urethral stricture.

PURPOSE: We aimed to provide a detailed comparison between the American Urologic Association (AUA), Société Internationale d'Urologie (SIU), and the European Association of Urology (EAU) guidelines on the evaluation, management, and follow-up of the patients with anterior urethral stricture disease (USD). METHODS: The urethral stricture guidelines from SUI, AUA, and EAU were collected and evaluated regarding the recommendations on diagnosis, evaluation, and treatment of anterior USD. The strength of evidence for each statement was included and discussed when guidelines differed. RESULTS: While the guidelines remarkably align in terms of the diagnostic workup and follow-up, there is discordance in the management of anterior urethral strictures, specifically for the use of endoscopic treatment and stenting. Further, the EAU offers more comprehensive recommendations regarding urethroplasty techniques and patient follow-up. The EAU guidelines are the most recent and first to offer guidance for USD in transgender people and women. CONCLUSION: Reconstructive urology is a rapidly adapting field, and best practices change accordingly. Guideline statements have become more inclusive and expansive but will require further research to improve the level of evidence and continue to provide patients and providers with the best treatment plans.

Pre-prostatectomy membranous urethral length as a predictive factor of post prostatectomy incontinence requiring surgical intervention with an artificial urinary sphincter or a male sling.

AIMS: To ascertain whether the membranous urethral length (MUL) is predictive of postprostatectomy incontinence (PPI) that requires surgery such as artificial urinary sphincter (AUS) or male sling (MS). METHODS: Men who had undergone AUS or MS for PPI were identified from a prospectively maintained database and compared to a control group of men who were continent at 12 months after radical prostatectomy. MUL in sagittal and coronal planes, sphincter height and width were measured on prebiopsy T2-weighted MRI scans. Sphincter volume was estimated as an ellipsoid cylinder. RESULTS: A total of 95 patients (64 AUS and 31 MS) were compared to 60 continent controls. There was no statistical difference in presenting PSA, prostate volume, and T-stage. The mean MUL in sagittal and coronal planes was 11.31 mm (SD: 2.6, range: 6-17 mm) and 11.43 mm (SD: 2.94, range: 5-17 mm) in patients who had AUS and MS, respectively; 15.23 mm (SD: 4.2, range: 8.25-25 mm) and 15.75 mm (SD: 4.1, range: 8-24 mm) in controls (p < 0.01). No men in the PPI surgery group had an MUL >17 mm compared to 35% (20/57 sagittal, 20/58 coronal) of controls. The odds ratio for requiring surgery for PPI was 13.4 for sagittal MUL <9 mm and 3.2 if the MUL <12 mm. CONCLUSIONS: Patients who had surgery for PPI had a significantly shorter MUL and sphincter volume than continent controls. Men with an MUL >17 mm are unlikely to require surgery for PPI whereas an MUL <12 mm significantly increases the risk of requiring surgery for PPI. MUL should be considered when discussing treatment options for prostate cancer.

Transurethral dorsal buccal graft urethroplasty for proximal female urethral strictures.

INTRODUCTION AND HYPOTHESIS: We present a novel outpatient transurethral dorsal buccal graft urethroplasty for managing proximal female urethral strictures. METHODS: A 69-year-old female presented with a 2.5-year history of slowing urinary stream. After discussing treatment options, she opted for transurethral dorsal buccal graft urethroplasty. The procedure begins with buccal graft harvest, and care is taken to avoid Stetson's duct. A nasal speculum is placed transurethrally, distal to the stricture. The full length of the dorsal urethra is incised superficially. A suture-passing device is used to place three sutures at the bladder neck and then through the buccal graft. The sutures are tied transurethrally using a laparoscopic knot pusher, parachuting the graft into place. The distal aspect of the buccal graft is secured to the urethral meatus with interrupted suture and surgical glue used to secure the midportion of the graft. RESULTS: Following the outpatient procedure, she had an uneventful recovery, including catheter removal at 3 weeks. At 3 months she had significant improvement in her urinary stream and no stress incontinence. CONCLUSIONS: The transurethral approach to dorsal buccal graft urethroplasty is technically feasible and, in the short term, effective. Longer follow-up and larger series are needed to validate this procedure.

Quality of life is improved after urethroplasty in women with urethral stricture.

INTRODUCTION AND HYPOTHESIS: To evaluate the quality of life (QoL) in women who underwent urethroplasty for urethral stricture. METHODS: Twenty-two women who underwent ventral labium minus graft urethroplasty were included. Patients were assessed with uroflowmetry, urethral caliber and post-voiding residual urine (PVR). American Urological Association (AUA) symptom score, Urogenital Distress Inventory (UDI)-6 and Short Form-36 (SF-36) were used to evaluate QoL. Preoperative values were compared with patients' last visit data. The cure of the surgery was defined as a maximum flow rate > 15 ml/s in uroflowmetry and no need for any further intervention. RESULTS: Median age was 55 (40-66) years. Cure was achieved in 20 (90.3%) patients with median 37 (13-52) months follow-up duration. The median Qmax increased from 4 (0-5) ml/s to 27.5 (8-55) ml/s (p < 0.001). Median post-void residual volume (PVR) decreased from 52.5 (0-120) ml to 20(0-60) ml (p = 0.011). Both AUA symptom score [from median 30 (24-35) to 4.5 (0-20), p < 0.001] and AUA-QoL score [from median 5 (4-6) to 0(0-3), p < 0.001] decreased after surgery. Median UDI summary score at the last follow-up was 0 (0-44.4), which was 33.3 (22.2-61.05) at baseline visit. Improvement was observed in all domains except the 'Energy/Fatigue' domain of the SF-36. CONCLUSIONS: Urethroplasty is an effective surgical method to improve patients' QoL which is impaired because of female urethral stricture.

Effectiveness and safety of bulking agents versus surgical methods in women with stress urinary incontinence: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the efficacy and safety of bulking agents compared with surgical methods for female stress urinary incontinence. METHODS: Inclusion and exclusion criteria: women with stress urinary incontinence. Bulking agents versus any surgical treatment as a comparison. Patients with other types of incontinence and treatment were excluded. Electronic databases (PubMed, MEDLINE, and the Cochrane Library) were searched from 2000 until 2021 to identify articles evaluating the effectiveness and safety of urethral bulking agents versus surgical methods. Risk-of-bias assessment tools recommended by the Cochrane Society were used to evaluate the risk of bias in the studies included. RESULTS: Six studies were included in the quantitative synthesis for a total of 710 patients. Our systematic review and meta-analysis showed that bulking agents are less effective than surgical procedures according to subjective improvement after treatment (RR = 0.70, 95% CI: 0.53 to 0.92, p = 0.01). There was no statistically significant difference between these two methods with regard to complications after the intervention (RR = 1.30, 95% CI: 0.30 to 5.66, p = 0.73). CONCLUSION: The main limitation of this systematic review and meta-analysis was the absence of a common objective outcome measure to evaluate effectiveness. However, it shows that bulking agents are less effective than surgical procedures in subjective improvement. Safety analysis showed no significant difference between these methods. Hence, we believe that the first and final surgery is considered to be the best.

Update on Urethral Bulking for Stress Urinary Incontinence in Women.

PURPOSE OF REVIEW: Urethral bulking agents are an effective treatment for stress urinary incontinence in select females. The material and techniques used for urethral bulking are constantly evolving. With the introduction of several new agents, there is an ongoing debate over which agent is the most effective, durable, and safe. RECENT FINDINGS: Current available bulking agents include Bulkamid®, Macroplastiue®, Durasphere®, Coaptite®, or Urolastic®. Each of these agents has its own biophysical properties that affect its efficacy and safety. Evidence evaluating bulking agents has increased over time but there is no definitive data that suggest superiority of one agent over another. The ideal urethral bulking agent for female stress incontinence has yet been identified. Currently available agents have acceptable short-term and medium-term efficacy with few adverse events.

Introduction of a modified single stage reconstruction technique of male penopubic epispadias.

OBJECTIVE: To represent the long-term outcomes of our modified single-stage technique for the reconstruction of isolated penopubic epispadias in male patients. PATIENTS AND METHODS: Data from 113 patients were obtained from bladder-exstrophy-epispadias database of our tertiary center. A total of seven boys with isolated penopubic epispadias with no prior history of surgery and any other anomaly underwent our modified surgical approach from February 1997 to September 2019. The mean ± SD age at surgery was 6.5 ± 2.4 years. Volitional voiding status and cosmetic appearance were evaluated at each follow-up interval. Postoperative follow-up was performed at quarterly intervals in the first year and once a year in subsequent years. RESULTS: The mean ± SD of follow-up was 8.5 ± 6 years. All boys who were incontinent achieved urinary control and the ability of normal transurethral micturition following the surgery. Four boys became completely dry, and the other three attained social dryness. Postoperative mean (SD) bladder capacity was significantly increased from 54.5 (11) to 124 (40.0) within 6 months, and to 194 (47.5) at 18 months after surgery. Dorsal curvature has been resolved in all cases, and no postoperative complications were noted except for surgical site infection in one patient treated with antibiotics and bilateral vesicourethral reflux resolved after injection of bulking agents. Four patients had normal erectile function and ejaculation, while the others have not reached puberty yet. Moreover, none of the patients developed urethrocutaneous fistula, stricture, or penile ischemia. CONCLUSION: The present findings suggest the safety and effectiveness of the combination of single-stage urethro-genitoplasty, bladder neck plication, and fat pad pedicled flap in management of boys with isolated penopubic epispadias that can lead to the achievement of urinary control, acceptable sexual function, and cosmetically satisfactory genitalia. Minimal morbidity, low complication rate, and promising outcomes are essential factors, supporting the notion of introducing this technique as a valid option for management of this entity.

Buccal versus skin graft for two-stage repair of complex hypospadias: an Egyptian center experience.

BACKGROUND: Urethral reconstruction in complex hypospadias poses a significant challenge. We report our 10-year experience with buccal mucosa graft (BMG) in the two-stage repair of complex hypospadias and compare its results to the skin graft. METHODS: We retrieved the data of 15 patients with complex hypospadias who underwent two-stage repair using the BMG at our institution. The data were compared to 13 patients who underwent skin graft during the same period. RESULTS: The median follow-up duration was 14 (12-17) months in the BMG group and 16 (13.5-22.5) months in the skin graft group. Patients in the BMG had a numerically lower incidence of the diverticulum, wound dehiscence, fistula, and infection than the skin graft group, however, without statistically significant difference (p > 0.05). On the other hand, the incidence of meatal stenosis and urethral stricture was significantly lower in the BMG group (0% each) compared to the skin graft group (30.8% each; p = 0.02). At the same time, there were no reported cases of graft contracture. The frequency of donor site morbidity was significantly higher in the skin graft group compared to the BMG group (p = 0.003). The BMG led to a lower incidence of postoperative straining than the skin graft (0% vs. 38.5%, p = 0.03). Only one patient needed revision surgery after skin graft, compared to no case in the BMG (p = 0.27). CONCLUSION: The present study demonstrates the feasibility and durable outcomes of the BMG in the setting of two-stage repair of complex hypospadias.