Periurethral abscess etiology, risk factors, treatment options, and outcomes: A systematic review.

Objectives: This study aimed to describe patterns of presentation, etiology, risk factors, management, and treatment outcomes of periurethral abscesses using a systematic review framework. Materials and methods: After prospective registration on the PROSPERO database (CRD42020193063), a systematic review of Web of Science, Embase, PubMed, and Cochrane scientific databases was performed. Articles published between 1900 and 2021 were considered. Extracted data included symptoms, etiology, medical history, investigations, treatment, and outcomes. Collated data were analyzed using univariate methods. Results: Sixty articles met the inclusion criteria reporting on 270 patients (211 male, 59 female) with periurethral abscess. The most common clinical features were pain (41.5%), pyuria (41.5%), dysuria (38.5%), urinary frequency (32.3%), fever (25%), and a palpable mass (23%). Predisposing risk factors included the presence of a sexually transmitted infection or urinary tract infection (55.0%), urethral strictures (39.6%), and recent urethral instrumentation (18.7%). Management approaches included open incision and drainage (64.3%), conservative management with antibiotics (29.8%), and minimally invasive techniques (needle aspiration, endoscopic drainage). Time trend analysis of etiology revealed a decreased incidence of infection (sexually transmitted infection/urinary tract infection, human immunodeficiency virus) and higher incidence of diabetes mellitus and periurethral bulking injections in recent years. Conclusions: Periurethral abscesses may display a wide range of clinical features. Presentation, risk factors and underlying etiology vary with sex. The optimal management technique is guided by abscess size. Open incision and drainage combined with antibiotics continues to be the mainstay of management. However, minimally invasive techniques are gaining favor. To the authors' knowledge, this is the first systematic appraisal and management algorithm for periurethral abscess.

Oncological and urinary outcomes following low-dose-rate brachytherapy with a median follow-up of 11.8 years.

OBJECTIVES: To examine the long-term oncological outcomes and urological morbidity of low-dose-rate prostate brachytherapy (LDRBT) monotherapy using live intraoperative dosimetry planning and an automated needle navigation delivery system for the treatment of men with low and intermediate-risk prostate cancer. PATIENTS AND METHODS: A prospective database of 400 consecutive patients who underwent LDRBT between July 2003 and June 2015 was retrospectively reviewed to assess urinary side-effects and biochemical progression, based on the Phoenix definition and also a definition of a prostate-specific antigen (PSA) level of ≥0.2 µg/L. RESULTS: Minimum patient follow-up was 5.5 years. The median follow-up of the entire cohort was 11.8 years. The median (range) PSA level was 6.1 (0.9-17) µg/L and the median Gleason score was 3 + 4. The biochemical relapse-free survival (RFS; freedom from biochemical recurrence) based on the Phoenix definition was 85.8% (343/400). The RFS using a 'surgical' definition of a PSA level of <0.2 µg/L was 71% (284/400). Of the 297 men followed for ≥10 years, prostate cancer-specific survival (PCSS) was 98% (291/297). Post-LDRBT urethral stricture developed in 11 men (2.8%, 11/400). For men with ≥10 years of follow-up, 22 men (7.4%, 22/297) required a pad for either stress or urge urinary incontinence (UI). UI was identified in only 2.2% (one of 46) of men who had a bladder neck incision (BNI) before LDRBT. CONCLUSION: LDRBT is associated with excellent PCSS, with a median follow-up of 11.8 years. The risk of post-implantation urethral stricture and UI is low and a pre-implantation BNI for management of bladder outflow obstruction does not increase the risk of UI or urethral stricture.

Magnetic resonance imaging procedure for pelvic fracture urethral injuries and recto urethral fistulas: A simplified protocol.

OBJECTIVE: The urethral gap in pelvic fracture urethral injury (PFUI) is traditionally assessed using voiding cystourethrogram (VCUG) and retrograde urethrogram (RGU). Magnetic resonance imaging (MRI) is performed in complex cases. We assessed the refined "Joshi" MRI protocol to evaluate complex urethral defects after PFUI. MATERIAL AND METHODS: A prospective study was conducted at our center from January 2018 to January 2020, involving patients aged >18 years with PFUI, suitable for MRI, and those who gave consent to perform standard RGU, VCUG, and MRI using standard and "Joshi" protocol. Forty men were included in the study. Distance between urethral/prostatic stumps was measured. Image quality was scored by four radiologists and four urologists. The surgical approach and type of PFUI repair were noted. We also established the need for inferior pubectomy by assessing the position of the posterior urethra (membranous) in relation to a horizontal line drawn from the lower edge of the pubic bone anteriorly to the rectum posteriorly in a sagittal image. RESULTS: The mean age was 30 years (SD, 5.25; range, 21-43), and the time from injury to imaging was 4 months (3-10 months); 40% of the men underwent crural separation, 57.5%, inferior pubectomy, and 2.5%, crural rerouting. There was a difference of 0.3 to 1.1 cm in the urethral gap measurements between MR images using the standard versus "Joshi" technique. MRI identified complex injuries such as rectourethral fistula, the need for inferior pubectomy, and the orientation of the posterior urethra. Urologists' and radiologists' satisfaction scores for the MR images were satisfactory to excellent. If the posterior urethra was over the defined mark, there was a 100% likelihood of inferior pubectomy (23/40 patients). CONCLUSION: MR image acquisition using the "Joshi" protocol provided high-quality anatomical information in PFUI cases to assist with surgical planning.

Trends in urethral stricture management over two decades.

OBJECTIVES: To identify trends in the management of urethral stricture disease in Australia, assess changes in the standard of care, and examine the availability of genitourinary reconstructive surgery. METHODS: Data on eight stricture management procedures were collected online via Medicare Item Reports from the Australian Government Department of Human Services, and then matched to population data from the Australian Bureau of Statistics. A survey was disseminated via the Urological Society of Australia and New Zealand (USANZ) asking whether active members performed urethroplasty and whether this was done in a rural, regional or metropolitan setting. RESULTS: Over a 22-year period, there were 140 540 endoscopic procedures and 5136 urethroplasties, with 27.4 endoscopic procedures per urethroplasty. From 1994 to 2016, the per capita number of passage of sounds and dilatation procedures decreased by 74% and 75%, respectively, with increases in use of optical urethrotomy of 70% and in single-stage urethroplasty of 144%. Overall, the ratio of all endoscopic procedures vs urethroplasty decreased from 58.9 to 16.8. There were as few as 16 surgeons in the USANZ performing urethroplasty, with seven providing this service in regional areas. Seven had formal fellowship training. CONCLUSION: There has been a clear shift from repetitive endoscopic procedures towards urethroplasty, but the former still make up the majority of interventions. This may be explained by patients not being referred for urethroplasty earlier in the course of disease and there appears to be a gap in genitourinary reconstructive expertise in regional and rural areas.

Management of complex and redo cases of pelvic fracture urethral injuries.

OBJECTIVES: Pelvic fracture urethral injuries (PFUI) result from traumatic disruption of the urethra. A significant proportion of cases are complex rendering their management challenging. We described management strategies for eight different complex PFUI scenarios. METHODS: Our centre is a tertiary referral centre for complex PFUI cases. We maintain a prospective database (1995-2016), which we retrospectively analysed. All patients with PFUI managed at our institute were included. RESULTS: Over two decades 1062 cases of PFUI were managed at our institute (521 primary and 541 redo cases). Most redo cases were referred to us from other centres. Redo cases had up to five prior attempts at urethroplasty. We managed complex cases, which included bulbar ischemia, young boys and girls with PFUI, PFUI with double block, concomitant PFUI and iatrogenic anterior urethral strictures. Bulbar ischemia merits substitution urethroplasty, most commonly, using pedicled preputial tube. PFUI in young girls is usually associated with urethrovaginal fistula. Young boys with PFUI commonly have a long gap necessitating trans-abdominal approach. Our success rate with individualised management is 85.60% in primary cases, 79.13% in redo cases and 82.40% in cases of bulbar ischemia. CONCLUSION: The definition of complex PFUI is ever expanding. The best chance of success is at the first attempt. Anastomotic urethroplasty for PFUI should be performed in experienced hands at high volume centres.

A novel method in decision making for the diagnosis of anterior urethral stricture: using methylene blue dye.

OBJECTIVE: The use of methylene blue dye (MB) to highlight anatomical structures in urology has been well-established. Urethral stricture may extend about a centimeter beyond the abnormal area seen on urethrogram. Although the current literature suggests a tension-free and end- to- end anastomosis after excision of the strictured urethral segment with spongiofibrosis and surrounding corpus spongiosum in short bulbar strictures, some centers dealing with urethroplasty prefer anastomosis for short bulbar strictures while others prefer augmentation. With this study, use of MB for delineating stricture line and assessing spongiofibrosis in the diagnosis of urethral stricture was evaluated. MATERIAL AND METHODS: Five cc MB including 10 mg/mL is diluted with 10 cc saline. In the first scenario, MB is gently injected into urethra via the meatus before the urethroplasty procedure. Meanwhile, the extent of urethral segment stained by MB is noted. In the second scenario (MB spongiosography) in short bulbar stricture, insulin needles are inserted in spongiosa of the stricture site distally and proximally. MB is gently injected with distal needle. The two remaining needles are then observed. Presence of MB efflux in proximal needle implies deficiency of significant spongiofibrosis, so buccal augmentation is performed. Absence of efflux of MB implies significant spongiofibrosis and anastomotik site excised. RESULTS: Four hundred and ninety-two consecutive cases prospectively evaluated between 2010 and 2014. Precise staining of stricture was successfully observed in 464 (94%) patients. Grossly normal appearing urothelium remained pink. Histopathology confirmed that the stained urethra had a stricture. Of the 22 short bulbar idiopathic strictures, in 18 (82%) MB was seen across the stricture and urethral transection was avoided. Anastomosis was performed in 4 (18%) cases where no MB went across the primary excision. There were no known allergic complications. CONCLUSION: MB aids in delineating the urethral lumen and exact site of stricture that needs augmentation. MB Spongiography in short bulbar strictures could be used as a beneficial guide in relation to the type of urethral repair to be performed in terms of augmentation versus excision and anastomosis.

A novel composite two-stage urethroplasty for complex penile strictures: A multicenter experience.

INTRODUCTION: Complex penile strictures are usually repaired using a two-stage urethroplasty. Buccal mucosal graft (BMG) placed in the first stage can have a significant contraction rate, which may require a subsequent revision surgery. We describe a composite two-stage penile urethroplasty using BMG for patients of complex penile strictures who have some salvageable urethral plate. METHODS: Within a multi-institutional cohort, 82 patients underwent a two-stage urethroplasty for complex stricture of the penile urethra. Of these 42 patients who underwent our composite two-stage penile urethroplasty using BMG implanted at the second-stage were included. Patients with genital lichen sclerosus or incomplete clinical records were excluded from this study. The primary outcome of the study was to evaluate stricture-free success rate. RESULTS: Of total 42, 4 patients were lost to follow-up. 42% of stricture etiology was failed hypospadias repair. Mean stricture length was 4.5 cm (range 3-8 cm). Seventeen (44.7%) patients had undergone the previous urethroplasty. At a median follow-up of 44 months, of 38 patients, 34 (89.5%) were successful, and 4 (10.5%) had a recurrence. No patient required revision surgery before the second-stage and required redo buccal graft harvesting for subsequent urethroplasty. CONCLUSIONS: The composite two-stage technique in repairing complex penile urethral strictures is a valid and reproducible surgical treatment for complex penile stricture and it may reduce the rate of contraction of the transplanted BMG.

Injury in Pelvic Fracture Urethral Injury Is Membranobulbar: Fact or Myth.

Pelvic fracture urethral injuries commonly result from motor vehicle collisions, and the mechanism of injury conventionally thought was a shearing injury at the membranous urethra, which would destroy the striated sphincter. Continence would therefore depend on the bladder neck. Striated sphincter and the site of injury have not been shown clearly on preoperative imaging. We demonstrate our protocol of performing magnetic resonance imaging whereby the membranous sphincter is seen intact and the injury is shown to be at the membranobulbar junction contrary to conventional belief. This suggests that surgical reconstruction can be undertaken, preserving both sphincter mechanisms and improving postoperative continence.

Paediatric urinary tract infections: Diagnosis and treatment.

BACKGROUND: Urinary tract infections (UTIs) commonly occur in children. An estimated 8% of girls and 2% of boys will have at least one episode by seven years of age. Of these children, 12-30% will experience recurrence within one year. Australian hospital admission records indicate that paediatric UTIs represent 12% of all UTI hospital admissions. OBJECTIVE: The aim of this article is to review the pathogenesis, clinical assessment and management of UTIs, and prevention strategies in children. DISCUSSION: Clinically, paediatric UTI presentations are challenging because symptoms are vague and variable. Young infants may present with sepsis or fever and lack specific symptoms, whereas older children present with classical features such as dysuria, frequency and loin pain. Early diagnosis with appropriate urine specimen collection techniques, investigations and treatment is necessary for prevention of renal damage and recurrence. Effective, evidence-based investigations and treatment options are available, and physicians should feel confident in identifying and managing paediatric UTIs.

Jejunal GIST with extramural hemangiomatous component presenting as an obscure lower GI bleed: a case report.

GISTS (Gastrointestinal stromal tumours) are malignant form of sarcoma of the digestive tract. Various unusual presentations and morphological variants of GIST have been described, including extramural components of GIST. The literature has no reference regarding an extramural hemangiomatous component of a GIST. Here we present a case of 54-year-old women with this unusual morphological condition presenting as an obscure lower GI bleed. Diagnosis in this case was made by subjecting the resected specimen to immunohistochemical analysis.