Intrinsic ureteric obstruction secondary to endometriosis: a rare clinical entity causing obstructive uropathy and renal failure.

Ureteral endometriosis is rare and can be a silent clinical entity, which can potentially lead to serious complications such as obstructive uropathy, sepsis and renal failure. A high clinical suspicion is required especially in childbearing age groups due to non-specific presentation such as renal colic, recurrent urinary tract infection (UTI), renal failure or asymptomatic hydronephrosis.A woman in her 40s presented with febrile UTI and flank pain. She reportedly suffered from recurrent UTIs in the past. Initial workup revealed an infected, obstructed left renal collecting system with gross hydronephrosis and hydroureter to the distal ureter on a significant gynaecological background of severe endometriosis requiring hysterectomy in the past.CT showed chronic obstructive changes and soft tissue nodules within the renal pelvis with no radio-opaque stones. She underwent emergent ureteric stent insertion. Functional imaging demonstrated only 1% contribution of the left kidney with a preserved estimated glomerular filtration rate of 65 mL/min/1.73 m2Endoscopic evaluation of ureters found extensive soft tissue lesions throughout the dilated left collecting system with biopsy-confirmed endometriosis. Subsequently, she underwent laparoscopic nephroureterectomy due to extensive ureteric involvement and chronically obstructed non-functioning kidney. Histopathology demonstrated completely obstructing ureteral endometriosis.Ureteric obstruction secondary to endometriosis can be due to extrinsic or intrinsic disease. In addition to initial assessment with CT urogram MRI may be helpful to evaluate soft tissue thickening. Endoscopic assessment with ureteroscopy and biopsy is required for tissue diagnosis. Surgery is often the treatment of choice, ranging from ureteroureterostomy, ureteroneocystostomy or nephroureterectomy in severe cases.Ureteral endometriosis is a rare clinical entity, clinicians should remain vigilant about common presentations of this rare entity, early diagnosis and prompt treatment is crucial to prevent progression to renal failure.

Urethral Diverticulum Marsupialization With Modified Spence-Duckett Procedure.

OBJECTIVE: To demonstrate a modified approach to the Spence-Duckett procedure for treatment of a distal urethral diverticulum. A urethral diverticulum is an outpouching of urethral mucosa occurring in 2-5% of the population.1 They are thought to commonly arise due to chronic inflammation or infection of the peri-urethral glands.2,3 MATERIALS AND METHODS: We present a 37-year-old female with vaginal bulge, dyspareunia, and dysuria. On examination, she had a 2-centimeter tender mass abutting the distal urethra. Imaging such as ultrasound or magnetic resonance imaging is critical to map the location of the diverticula along the urethra and extent of urethral involvement as it can inform surgical technique. Diverticula are typically located postero-laterally at the mid- or distal urethra; however, they can be found at any location along the urethra.2,3 Care must be taken to avoid disruption of the continence mechanism at the mid-urethra to prevent incontinence after surgery. Magnetic resonance imaging revealed a 1.7 × 1.7 × 1.8 centimeter unilocular cystic structure at the left posteromedial distal urethra consistent with a urethral diverticulum. The patient desired surgical management. RESULTS: Spence and Duckett traditionally described insertion of one blade of the Metzenbaum scissors in the urethra with incision into the diverticulum and anterior vaginal wall followed by marsupialization.4 Given the small size of the diverticular ostium identified, we opted to make an incision using a scalpel from the ostium down the posterior aspect of the urethra and proximally to the anterior vaginal wall. We then excised the diverticular sac prior to marsupialization. At 6 weeks after surgery, she had full resolution of her symptoms without development of urinary incontinence. Pathologic examination is important because while rare, cancers can originate from urethral diverticula, with a prevalence of 6-9%.5 Pathology was consistent with urethral diverticulum and negative for dysplasia. CONCLUSION: While effective, the Spence-Duckett technique is described as a "generous meatotomy" with risks of urethral shortening. Our modified approach reduces these risks, resolves bothersome symptomatology, improves cosmesis, and minimizes risk of anatomic or functional urethral compromise.

Successfully treated urethral condyloma acuminatum utilizing intraurethral self-application of 5-fluorouracil via Q-tip.

Condyloma acuminatum is a benign genital lesion associated with low-risk human papillomavirus subtypes. Approximately 20% of HPV-associated genital warts occur in the urethra. Topical treatment of urethral condyloma in women can be challenging to treat due to difficulty applying the medication such that it maintains contact with the urethra long enough to be effective. We present a case of a successfully cleared urethral condyloma acuminatum treated via self-application using a Q-tip.

Parameatal urethral cyst in a 9-year-old boy.

Parameatal urethral cyst (PUC) is a comparatively unusual pathology in children. Since its first report, approximately 100 cases have been reported in the literature, mostly in the Japanese population. We report such a case in a 9-year old boy who presented with urine stream distortion, successfully managed by complete excision of the cyst, with total removal of the epithelium, which is the treatment of choice to prevent recurrence.

Post-hypospadias urethrocutaneous fistulae: no difference in repair success between proximal and distal fistulae.

INTRODUCTION Urethrocutaneous fistulae are the most common complication after hypospadias repair. We sought to compare outcomes of proximal versus distal urethrocutaneous fistula repair and hypothesized that patients with proximal fistulae would have lower rates of success than those with distal fistulae. We also aimed to evaluate factors that affected these outcomes. MATERIAL AND METHODS: Current procedural terminology codes were used to identify patients undergoing urethrocutaneous fistula repair after hypospadias surgery between 2014 and 2017 at an academic, pediatric urology referral center. Characteristics for each initial hypospadias repair and each fistula repair were noted, including location of meatus, location of fistula, type of magnification, suture type, interposition layer and post-operative stenting. The primary outcome was successful fistula repair. Univariate and multivariate analysis was performed. RESULTS: During the study period, 416 hypospadias repairs were performed. Thirty-one of these later presented with a fistula (8% fistula rate). Sixty-eight percent of fistulae were successfully closed with a single repair. There were 17 distal fistulae and 14 proximal fistulae. There was no difference in success between distal (71%) and proximal (64%) fistulae (p = 0.73). There was no statistically significant association between the primary outcome (successful fistula repair) and fistula location (p = 0.71), magnification (p = 0.38), suture type (p = 0.49), interposition coverage layer (0.43), or postoperative stenting (p = 0.92) on univariate or multivariate analysis. CONCLUSION: There is no difference in success when repairing distal versus proximal urethrocutaneous fistulae. Neither fistula location, type of magnification, suture type, interposition layer nor stenting affected outcomes.

Female urethral condyloma acuminata mimicking urethral caruncle.

Condyloma acuminata are epidermal lesions caused by the human papillomavirus (HPV) most commonly affecting the anogenital region. Urethral involvement is uncommon, and may mimic other urethral lesions. In this case report, a 62-year-old patient presents with what was believed to be a urethral caruncle and underwent successful resection with the final pathologic diagnosis of urethral condyloma. The clinical features and diagnosis are reviewed. This condition should be considered in the differential diagnosis of females with known HPV or those who are deemed higher risk with unprotected sexual encounters.

Suprapubic Percutaneous Assisted Cystoscopic Excision of Posterior Urethral Fibroepithelial Polyps in Pediatric Patients.

PURPOSE: The aim of this study was to evaluate pediatric posterior urethral fibroepithelial polyps, their diagnosis and endoscopic treatments with suprapubic assisted transurethral polyp excision which is described by us. MATERIALS AND METHODS: We reviewed the charts of patients (n=6) who underwent suprapubic percutaneous assisted cystoscopic excision for posterior urethral fibroepithelial polyp from 2014 to 2019. Their data were retrospectively reviewed in terms of clinical features, diagnostic methods, endoscopic approaches, and postoperative results. RESULTS: The 6 patients, the mean age of 3 years (4 months-6 years), with a solitary polyp of posterior urethra diagnosed and removed by suprapubic percutaneous assisted cystoscopic excision in five years. The most common complaint was urinary tract infection (n:3). The urethral polyps were diagnosed by ultrasound and cystoscopy. There was no intraoperative or postoperative complication except for one patient with bleeding from the trocar site. All of the specimens after histopathology examinations showed fibroepithelial polyps and no recurrence was seen. CONCLUSION: Posterior urethral polyps may cause obstructive effect in the urinary tract. The treatment should be performed with the least possible invasive method without injuring urethral wall.  We believe that suprapubic percutaneous assisted cystoscopic resection, described by us is an easy, reliable and effective method for treatment procedure of posterior fibroepithelial urethral polyps.

Single-stage Simultaneous Retrograde and Antegrade Endoscopic Treatment of Giant Prostatic and Bladder Urethral Calculi.

INTRODUCTION: Calculi encountered in the lower urinary tract typically reside within the bladder, less often in the urethra. In this video, we present a minimally invasive endoscopic approach for removal of the largest total stone volume in the lower urinary tract reported in the literature to date. METHODS: A 25-year-old male (body mass index 61 kg/m2) with neurogenic bladder presented with urosepsis and acute kidney injury secondary to obstructive uropathy. Computerized tomography (CT) of the abdomen and pelvis demonstrated bilateral severe hydroureteronephrosis, a 4.2-cm bladder stone, and 3 urethral stones, including a 7.7-cm prostatic urethral stone and 2 membranous urethral stones (Fig. 1). Urgent bilateral percutaneous nephrostomy tubes were placed. The patient elected for endoscopic management. RESULTS: The patient was placed in the supine lithotomy position. His buried penis and narrow urethra only accommodated a 16-French flexible cystoscope. Multiple stones were encountered in the membranous urethra. A 60-W SuperPulse Thulium Fiber laser at 2 J and 30 Hz was utilized to dust the urethral stones efficiently. Simultaneous ultrasound-guided percutaneous access into the bladder was obtained and ultrasonic lithotripsy via shockpulse was used to clear the bladder stone and prostatic stone from above. Total stone treatment time was 240 minutes. Suprapubic and urethral catheters were placed at the conclusion. Postoperative day 1 CT scan confirmed stone-free status and he was discharged postoperative day 2. Outpatient nephrostogram demonstrated patency of bilateral ureters and nephrostomy tubes were removed. CONCLUSION: Higher morbidity procedures including open or laparoscopic approaches have been described for management of large lower urinary tract stones. In this video, we demonstrate a minimally invasive approach of combined simultaneous antegrade and retrograde lithotripsy to achieve a stone-free status in this morbidly obese and complicated patient.

Lichen planus with multiple system involvement including the mouth, vagina, urethra, and scalp: a case report.

This is a case report of lichen planus (LP) with multiple system involvement. A 35-year-old female patient was admitted in November 2014 with a 5-year history of painful/difficult sexual intercourse and loss of oral mucosa, and an 8-year history of focal hair loss. Earlier, the patient had been unable to adhere to corticosteroid therapy because of severe adverse side effects. In September 2014, labia minora mucosa defects and stricture of the urethral orifice (with dysuria), vaginal orifice, and vagina were identified. Biopsy was performed and a diagnosis of erosive LP was made. The patient was treated with an oral immunosuppressant (cyclosporine A) and urethral/vaginal dilatation. Urine flow rate and sex life were improved after 6 months and she discontinued medication. Four years later, the patient reported a good overall treatment efficacy. LP can involve multiple systems and should be considered in patients with dyspareunia. Immunosuppressive agents can achieve a satisfactory effect in patients with contraindication to corticosteroid.

Ultrastructural Analysis of Urethral Polyps against the Background of Urogenital Infection.

We performed an electron microscopic study of samples of urethral polyps obtained from 90 women (mean age 52.5±4.9 years). According to PCR and culture studies, the most common infectious agent in patients with urethral polyps is U. urealyticum (100% cases). In 70% cases, this infectious agent was present as monoinfection, of these, clinically significant concentration (>106 CFU/ml) were found in 53.3% cases. In 30% cases, associations with C. trachomatis, T. vaginalis, and M. genitalium were found. We observed significant ultrastructural heterogeneity of the epithelial cells in urethral polyps, which manifested in a combination of hyperplastic and metaplastic changes and signs of cytodestruction. Detection of mycoplasma-like bodies in connective tissue mononuclear cells and viral particles in epithelial cells during ultrastructural study, including cases with negative PCR results, indicates the pathogenetic role of latent infection in the formation of urethral polyps.

Imaging of the female urethra.

Female urethral pathology can be challenging to diagnose clinically due to non-specific symptoms. High-resolution MRI has become a powerful tool in the diagnosis of urethral lesions and staging of malignancy. Additionally, dynamic MRI, fluoroscopy or ultrasound can evaluate for pelvic floor prolapse and the effectiveness of surgical interventions. This article will review the imaging features of common benign and malignant conditions of the female urethra including diverticula, benign cystic and solid lesions, malignancy, surgical slings, and injection of bulking agents.

Balloon-Expandable Biodegradable Stents Versus Self-Expandable Metallic Stents: A Comparison Study of Stent-Induced Tissue Hyperplasia in the Rat Urethra.

PURPOSE: To compare the degrees of stent-induced tissue hyperplasia of balloon-expandable, biodegradable stents (BEBSs) with those of self-expandable metallic stents (SEMSs) in a rat urethral model. MATERIALS AND METHODS: A total of 20 rats were randomized into two groups. The BEBS group (n = 10) received a poly-l-lactic acid (PLLA) biodegradable stent. The SEMS group (n = 10) received a nitinol bare stent. All rats were killed eight weeks after stent placement. The degree of stent-induced tissue hyperplasia was assessed by comparing the results of retrograde urethrography and histologic examination between the two groups. RESULTS: Stent placement was technically successful in all rats. Two rats in the BEBS group were excluded due to procedure-related death. The mean luminal diameter of stented urethra on urethrograms was not significantly different at 4 and 8 weeks between the two groups. On histologic analysis, the percentage of granulation tissue area (p < 0.001) and the thickness of papillary projection (p < 0.001) were significantly higher in the BEBS group compared with the SEMS group. The inflammatory cell infiltration showed a clear tendency to significance (p = 0.050). There were no statistical differences in the number of epithelial layers and the thickness of submucosal fibrosis between the two groups. CONCLUSION: Formation of stent-induced tissue hyperplasia was significantly evident in the rat urethra with similar degrees between the BEBS and the SEMS. The BEBS was associated with a thicker papillary projection and larger granulation tissue area resulting from higher inflammation compared with the SEMS.

Translabial ultrasound imaging of urethral diverticula.

OBJECTIVE: Urethral diverticulum is an uncommon cause of urinary dysfunction in women, with often a significant delay in diagnosis. Urethroscopy and/or magnetic resonance imaging are/is widely used for its identification. Translabial ultrasound is an alternative, particularly since the introduction of three-/four-dimensional imaging. The aim of our study was to review 10 years' experience of urethral diverticula evaluated by translabial ultrasound. METHODS: We reviewed 4121 patients seen in a tertiary urogynecologic unit between 2008 and 2018. All women were examined using multiplanar translabial ultrasound as well as office urethroscopy. Data regarding demographics, presenting symptoms and findings on clinical examination were collected. Archived ultrasound volumes were analyzed for diverticular location, diameters, complexity and echogenicity as well as tract visualization. RESULTS: Of our study population, 23 (0.6%) were found to have a major urethral abnormality on translabial ultrasound, 15 of whom were confirmed to have a urethral diverticulum on urethroscopy. Of these, 12 had a cystic component and three were non-cystic on imaging. Mean maximum diameter was 15.3 mm (range, 4-32 mm). In 9/15 there was a simple diverticulum, while in 6/15 it was classified as complex. A communicating tract was seen in 10/15 (67%), and this was located at the 5-7 o'clock position in 7/10 (70%). Mean urethral circumference covered by the diverticulum was 39%. CONCLUSIONS: Translabial ultrasound is a valid, non-invasive method for the diagnosis of urethral diverticulum. A cystic structure crossing the urethral rhabdosphincter has high predictive value for urethroscopic diagnosis of urethral diverticulum. Multiple hyperechogenic foci may indicate the presence of a small urethral diverticulum. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Blastoid variant of mantle cell lymphoma of the female urethra mimicking a caruncle: A rare but highly aggressive subtype case with literature review.

Primary urethral lymphoma is a rare entity without a standardized treatment protocol. We report a case of an elderly woman presenting with a caruncle associated with vaginal spotting and intermittent dysuria. She underwent surgical excision of the lesion. Histological analysis revealed a blastoid variant of mantle cell lymphoma, a previously unreported subtype. The patient received chlorambucil assisting a rapid local disease progression. She died of disseminated disease 6 months after diagnosis. A review of the lymphomas of the urethra is included.

Prostatic-type polyp located in the bladder of an adolescent: A case report and overview.

Prostatic-type polyps are uncommon lesions in the urinary tract. They are sometimes found in the lower urinary tract, particularly on the posterior urethra, but are rarely found in the bladder. We report a case of 15-year-old boy who presented with dysuria. Routine ultrasonography showed a mass in the bladder arising near the internal orifice of urethra. Further inspection with cystoscopy followed by transurethral resection and pathology confirmed the lesion to be a prostatic-type polyp. An overview of other similar case studies showed that the pathogenesis of this condition is controversial, haematuria and dysuria are common clinical symptoms and endoscopic transurethral resection is the best treatment option. Since the polyp is benign, recurrence and progression of this disorder is unlikely to occur.

Fact or myth? The long shared common wall between the fistula and the urethra in male anorectal malformation with urethral bulbar fistula.

AIM: It has long been considered surgical dogma that the length of the shared common wall (CW) between a fistula and the urethra in males with anorectal malformation (ARM) and rectourethral bulbar fistula (RUBF) is considerably longer than in males with ARM and rectourethral prostatic fistula (RUPF). This belief has led surgeons who perform laparoscopic-assisted anorectoplasty (LAARP) for RUPF to avoid LAARP for RUBF for risk of potential injury to the urethra or incomplete removal of the fistula. In this study, we compared CW between RUBF and RUPF using distal colostography (DCG) and direct intraoperative measurements. METHODS: DCG of rectourethral fistula patients (n = 63; RUBF: n = 44; RUPF: n = 19) were used to measure CW retrospectively. Results were expressed as a ratio of the height of L4; i.e., CW:L4. If less than 0.7, the CW was classified as being "short"; if 0.71-1.4, as being "medium"; and if greater than 1.41, as being "long". CW that could not be measured was classified as indeterminate. 24 of these patients also had CW measured intraoperatively during LAARP as previously described. The results obtained using both techniques were also compared. RESULTS: Surprisingly, CW:L4 in RUBF patients was short in 47.7%, medium in 27.3%, long in 20.5%, and indeterminate in 4.5% on DCG, equivalent to mean lengths of 7 mm, 8.5 mm, and 10.3 mm obtained using direct intraoperative measurement for short, medium, and long CW:L4 categories, respectively. CW:L4 in RUPF was short in 73.6%, medium in 10.5%, and long in 5.2% on DCG, while mean intraoperative measurements were 5 mm, 7 mm, and 10 mm, respectively. Differences in CW measured intraoperatively were not significantly different between RUBF and RUPF (p = NS). CONCLUSION: From our findings, 47.7% of CWs in RUBF were short using two independent methods, with only 20.5% being long. Thus, LAARP should be considered actively for treating selected RUBF cases and not be excluded on the basis of CW length.