Ultrasound imaging of male urethral stricture disease: a narrative review of the available evidence, focusing on selected prospective studies.

PURPOSE: To synthetize the current scientific knowledge on the use of ultrasound of the male urethra for evaluation of urethral stricture disease. This review aims to provide a detailed description of the technical aspects of ultrasonography, and provides some indications on clinical applications of it, based on the evidence available from the selected prospective studies. Advantages and limitations of the technique are also provided. METHODS: A comprehensive literature search was performed using the Medline and Cochrane databases on October 2022. The articles were searched using the keywords "sonourethrography", "urethral ultrasound", "urethral stricture" and "SUG". Only human studies and articles in English were included. Articles were screened by two reviewers (M.F. and K.M.). RESULTS: Our literature search reporting on the role of sonourethrography in evaluating urethral strictures resulted in selection of 17 studies, all prospective, even if of limited quality due to the small patients' number (varied from 28 to 113). Nine studies included patients with urethral stricture located in anterior urethra and eight studies included patients regardless of the stricture location. Final analysis was based on selected prospective studies, whose power was limited by the small patients' groups. CONCLUSION: Sonourethrography is a cost-effective and safe technique allowing for a dynamic and three-dimensional urethra assessment. Yet, because of its limited value in detecting posterior urethral strictures, the standard urethrography should remain the basic 'road-map' prior to surgery. It is an operator-dependent technique, which can provide detailed information on the length, location, and extent of spongiofibrosis without risks of exposure to ionizing radiation.

What should be next in lifelong posterior hypospadias: Conclusions from the 2023 ERN eUROGEN and EJP-RD networking meeting.

BACKGROUND: A congenital disease is for life. Posterior hypospadias, the severe form of hypospadias with a penoscrotal, scrotal, or perineal meatus, is a challenging condition with a major impact on lifelong quality of life. AIM: Our network meeting is aimed to identify what is currently missing in the lifelong treatment of posterior hypospadias, to improve care, quality of life, and awareness for these patients. METHODS: The network meeting "Lifelong Posterior Hypospadias" in Utrecht, The Netherlands was granted by the European Joint Programme on Rare Diseases-Networking Support Scheme. There was a combination of interactive sessions (hackathons) and lectures. This paper can be regarded as the last phase of the hackathon. RESULTS: Surgery for hypospadias remains challenging and complications may occur until adulthood. Posterior hypospadias affects sexual function, fertility, and hormonal status. Transitional care from childhood into adulthood is currently insufficiently established. Patients should be more involved in defining desired treatment approach and outcome measures. For optimal outcome evaluation standardization of data collection and registration at European level is necessary. Tissue engineering may provide a solution to the shortage of healthy tissue in posterior hypospadias. For optimal results, cooperation between basic researchers from different centers, as well as involving clinicians and patients is necessary. CONCLUSIONS: To improve outcomes for patients with posterior hypospadias, patient voices should be included and lifelong care by dedicated healthcare professionals guaranteed. Other requirements are joining forces at European level in uniform registration of outcome data and cooperation in basic research.

Is urethral stricture really so often idiopathic? Exploring the etiology of urethral strictures in males undergoing urethroplasty: a multicenter retrospective cohort study.

Introduction: The aim of this study was to retrospectively evaluate the etiology of urethral stricture disease (USD) in a large series of patients undergoing urethroplasty. Material and methods: The multicenter retrospective cohort study was conducted at two reconstructive urology referral centers in years 2015-2022. Prior to the surgical intervention, all patients underwent diagnostic procedures including retrograde urethrography and voiding cystourethrography. We collected comprehensive demographic and medical data including the length and location of the stricture. We paid particular attention to identifying the underlying causes of USD in the medical records. Results: The study included 949 patients meeting criteria, with a mean age of 53. The primary cause of USD was identified as iatrogenic (404 cases, 42.6%), followed by trauma (210, 22.1%), previous hypospadias repair (122, 12.9%), lichen sclerosus (32, 3.4%), and infections (12, 1.3%). Notably, 169 patients (17.8%) did not have a discernible cause for their USD and were thus classified as idiopathic. Furthermore, it was observed that 66% of idiopathic USD cases were localized in the bulbar urethra. The etiology of USD varied significantly based on its localization (p <0.01). The mean stricture length differed among different causes, with the longest in patients with USD due to lichen sclerosus (41 mm), followed by previous hypospadias repair (35 mm), and iatrogenic causes (29 mm), p <0.001. Conclusions: Careful medical history-taking can identify the etiology of urethral stricture in over 80% of patients undergoing urethroplasty. The etiology of the USD impacts its location and length and thus can affect surgical treatment strategy and outcomes.

Treatment Success After Urethroplasty: The Ongoing Quest for a Pragmatic and Universal Definition.

There is no consensus on the ideal definition of success after urethroplasty, which makes research, quality control, and comparisons challenging. Ongoing research endeavors are focused on achieving consensus regarding the optimal battery of outcomes for evaluation of patients after urethroplasty.

Urethral management after artificial urinary sphincter explantation due to cuff erosion.

Introduction: The artificial urethral sphincter (AUS) is the gold standard treatment in cases of moderate-to-severe stress urinary incontinence in males. Cuff erosions are one of the most important distant complications of AUS implantation. The optimal urethral management has still not been established. Material and methods: Search terms related to 'urethral stricture', 'artificial urinary sphincter', and 'cuff erosion' were used in the PubMed database to identify relevant articles. Results: In this mini review we identified 6 original articles that assessed the urethral management after AUS explantation due to cuff erosion and included urinary diversion by transurethral and/or suprapubic catheterization, urethrorrhaphy, and in situ urethroplasty. We summarized the results of different management methods and their efficacy in terms of preventing urethral stricture formation. We highlight the need for better-quality evidence on this topic. Conclusions: The available data do not provide a clear answer to the question of optimal urethral management during AUS explantation. There is a great need to provide higher-quality evidence on this topic.

Reaching Consensus for Comprehensive Outcome Measurement After Urethral Stricture Surgery: Development of Study Protocol for Stricture-Fecta Criteria.

Urethral stricture disease is a very heterogeneous condition where different urethral segments can be involved as a result of diverse etiologies which come with variable prognosis. The surgical management of urethral strictures, and in particular urethroplasties can result in very diverse outcomes on many levels and, currently, there is absolutely no consensus about what should and what should not be considered a "success" after urethral surgery. In the wake of well-established quality criteria in urologic oncology, such as tri- or pentafecta outcomes, and given the lack of agreement on meaningful outcomes after urethral surgery, we aim to introduce our study protocol as the first step of a multistep research endeavor to reach consensus on comprehensive urethroplasty outcomes within a novel conceptual framework: the "stricture-fecta criteria". The development of stricture-fecta will be based on a Delphi consensus involving some of worldwide most influencing reconstructive urologists.

The Role of 3D Printing in Planning Complex Medical Procedures and Training of Medical Professionals-Cross-Sectional Multispecialty Review.

Medicine is a rapidly-evolving discipline, with progress picking up pace with each passing decade. This constant evolution results in the introduction of new tools and methods, which in turn occasionally leads to paradigm shifts across the affected medical fields. The following review attempts to showcase how 3D printing has begun to reshape and improve processes across various medical specialties and where it has the potential to make a significant impact. The current state-of-the-art, as well as real-life clinical applications of 3D printing, are reflected in the perspectives of specialists practicing in the selected disciplines, with a focus on pre-procedural planning, simulation (rehearsal) of non-routine procedures, and on medical education and training. A review of the latest multidisciplinary literature on the subject offers a general summary of the advances enabled by 3D printing. Numerous advantages and applications were found, such as gaining better insight into patient-specific anatomy, better pre-operative planning, mock simulated surgeries, simulation-based training and education, development of surgical guides and other tools, patient-specific implants, bioprinted organs or structures, and counseling of patients. It was evident that pre-procedural planning and rehearsing of unusual or difficult procedures and training of medical professionals in these procedures are extremely useful and transformative.

The impact of post-urethroplasty erectile dysfunction on the quality of life and treatment satisfaction.

INTRODUCTION: The aim of this article was to assess the influence of sexual disorders after urethroplasty on patient's quality of life (QoL) and satisfaction of treatment. MATERIAL AND METHODS: We studied 106 sexually active patients who underwent urethroplasty due to urethral stricture. Patients completed the Urethral Stricture Surgery - Patient Reported Outcome Measure (USS - PROM) and International Index of Erectile Function (IIEF-5) questionnaires before and after the treatment. Spearman rank correlations were used for correlation analyses. Multiple linear regression and ordinal logistic regression analyses were used for evaluating the influence of lower urinary tract symptoms (LUTS) and IIEF-5 scores on EuroQol-5D (EQ-5D) index, EuroQol-Visual Analogue Scale (EQ-VAS), and satisfaction with treatment. Both LUTS and IIEF-5 scores were independent, significant predictors of EQ-VAS in the multiple linear regression model. RESULTS: Mean follow-up was 9 months (3-24). Reduction of LUTS and micturition improvement in the USS-PROM questionnaire after the surgery was found in 90 patients (85%). The average IIEF-5 score in the whole group did not change significantly, but in 39 cases (37%) worsened, and in 42 (39%) improved. Spearman's rank-order correlation indicated a significant positive correlation between improvement in IIEF-5 and general QoL in EQ-5D and also a positive correlation between improvement in IIEF-5 and improvement in EQ-VAS, which was also statistically significant (rho = 0.377, p <0.001). CONCLUSIONS: Urethral surgery can influence sexual performance. The appearance of sexual dysfunction negatively affects the patient's quality of life, regardless of the effective restoration of the urethral patency and reduction of LUTS.

MRI in patients with urethral stricture: a systematic review.

Magnetic resonance imaging (MRI) is gaining acceptance as a diagnostic tool in urethral stricture disease. Numerous publications emphasize on the advantages of MRI including its ability to determine periurethral spongiofibrosis, thus overcoming the main limitation of retrograde urethrography (RUG). It is also becoming an alternative for sonourethrography (SUG), which is a highly subjective examination. Magnetic resonance urethrography (MRU) has become an increasingly appreciated tool for diagnosing patients with urethral stricture disease. Obtained data provides radiologists and urethral reconstructive surgeons with additional information regarding anatomical relationships and periurethral tissue details, facilitating further treatment planning. Considering the great prevalence of urethral stricture disease and necessity of using accurate, and acceptable diagnostic method, this review was designed to provide radiologists and clinicians with a systematic review of the literature on the use of MRI in the urethral stricture disease.

Challenging Visualization of Sentinel Lymph Nodes in Upper Urinary Tract Urothelial Carcinoma.

PURPOSE: The purpose of this study was to assess the possibility of detecting sentinel lymph nodes (SLNs) and to perform analysis of lymphatic outflow in patients with suspicion of upper tract urothelial carcinoma (UTUC) with the use of a radioisotope-based technique. METHODS: During 2018-2021, a prospective study was conducted on 19 patients with the suspicion of UTUC and for whom diagnostic ureterorenoscopy (URS) was planned. Technetium-99m (99mTc) nanocolloid radioactive tracer injection and a tumor biopsy were performed for staging procedures. Three-dimensional (3D) reconstruction and fusion of images were performed for better localization of lymph nodes (LNs). Detection of SLNs and the analysis of the radiotracer outflow was conducted with the use of single-photon emission-computed tomography/computed tomography (SPECT/CT) lymphangiography. RESULTS: The mean age of the patients was 73.4 years; 7 (36%) were male. Pathological staging from the biopsy was T0-8 (42%), Ta-7 (36%), T1-4 (21%). SLNs were detected in two of 19 cases (10%). In one patient a single SLN (5.3%) was visualized, and in another case (5.3%), multiple (double) radioactive lymph nodes were visualized. In 17 out of the 19 (89.5%) cases, no lymphatic outflow was observed, and out of these five cases (26.3%) of gravitational leakage of injected radiotracer to the retroperitoneal space was noted. CONCLUSIONS: We demonstrated that detection of SLNs in the upper urinary tract is possible yet challenging. Radiotracer injection in the upper urinary tract during ureterorenoscopy is difficult to perform, and the expected result of injection is unsatisfactory. Lymphatic outflow from the tumor site to the first LNs in our studied group of patients is visible in 10.5% of cases. SPECT/CT lymphangiography in cases of UTUC may provide valuable information about a patient's individual anatomy of the lymphatic system and the position of the first lymph nodes draining lymph with potential metastatic cells from the tumor.

Diagnosis and Management of Urolume Urethral Stent Complications Using Ultrasonography and Magnetic Resonance Imaging.

The UroLume urethral stent (American Medical Systems) was introduced to the market in 1988 for management of male urethral stricture and benign prostatic hyperplasia.1 However, recent reports in the literature showed long-term complications, including: urethral restenosis, urethral pain, recurrent urinary tract infections, and stent migration. Therefore, UroLume's efficacy in managing bladder outlet obstruction had to be weighed against an alarmingly high rate of long-term complications.2,3 In this report, the role of ultrasonography scan and magnetic resonance in the diagnosis and management of UroLume complications is evaluated.

Ultrasonographic assessment of male anterior urethra. Description of the technique of examination and presentation of major pathologies.

During the last years the role of sonourethrography (SUG) in the assessment of anterior male urethra pathologies, has significantly increased. The investigation is easily performed, not time consuming and should be considered the imaging technique of choice for preliminary diagnosis, without exposing the patient to X-rays. In this paper we present the technique of examination and the most common pathologies in which SUG is indicated.

Minimally Invasive Treatment of Vesico-ureteral Reflux Using Endoscopic Injection of Polyacrylate-Polyalcohol Copolymer (Vantris) in Patients After Kidney Transplantation.

BACKGROUND: Urinary tract infections (UTIs) are the most common infectious complications among kidney recipients. They occur due to the lack of an effective antireflux mechanism in the majority of techniques used during kidney transplantation. Subureteral injection of tissue bulking substance is a feasible alternative to open ureteral reimplantation. This paper, to the best of the authors' knowledge, is the first to evaluate the application of polyacrylate/polyalcohol copolymer (Vantris) as the agent for minimally invasive VUR treatment. MATERIALS AND METHODS: Between January 2018 and February 2019, 7 patients presenting with recurrent UTIs and the diagnosis of VUR (vesico-ureteric reflux) after kidney transplantation were enrolled in the study. Patients qualified for the study underwent cystoscopy and, if possible, minimally invasive, endoscopic subureteral application of 1 mL of polyacrylate/polyalcohol copolymer according to the subureteral transurethral injection (STING) technique. RESULTS: Endoscopic subureteral injection of tissue bulking substance (polyacrylate/polyalcohol copolymer) was successfully performed in 6 patients. In 1 patient it could not be completed because of an inconvenient location of the neo-orifice. In 4 patients (57%) no reduction of the reflux grade was observed in follow-up imaging. The number of UTIs in the follow-up was significantly reduced in 6 of 7 patients (86%) after polyacrylate/polyalcohol copolymer subureteral injection. CONCLUSIONS: Endoscopic treatment of VUR with polyacrylate/polyalcohol copolymer is an effective and safe method as a first-line treatment for patients with recurrent UTIs after kidney transplantation. To obtain clear conclusions, however, it is necessary to study a larger number of patients with a longer follow-up period after surgery.

Evaluation of outcomes of Urethral Stricture Surgery: psychometric validation of a Polish language version of the Patient-Reported Outcome Measure for urethral stricture surgery.

INTRODUCTION: The aim of this study is to validate the Polish version of the Urethral Stricture Surgery - Patient-Reported Outcome Measure (USS-PROM) by evaluating its psychometric properties. MATERIAL AND METHODS: Patients with urethral stricture scheduled for urethroplasty between 2014 and 2018 were prospectively enrolled. The results of the USS-PROM were obtained before the operation, and during follow-up visits. The original USS-PROM was translated into Polish and re-translated into English in accordance with the guidelines by Dawson et al. regarding the adaptation process. Psychometric assessment included internal consistency, test-retest reliability, criterion validity and responsiveness. RESULTS: One hundred twelve patients were included. 54 patients completed the USS-PROM both before and 3 months after the surgery and 39 of them completed the questionnaire 6 months after the surgery to evaluate the test-retest reliability. Cronbach's α for internal consistency of the lower urinary tract symptoms (LUTS) domain score was 0.87. The test-retest intraclass correlation coefficient was 0.82. Spearman's coefficients showed no correlation between USS-PROM's result and maximal urinary flow (Qmax) result before the surgery (rs = 0.13; p >0.05) and a positive correlation between USS-PROM's result and Qmax result at follow up: 3 months after (rs =- 0.56; p <0.05), 6 months after (rs -0.64; p <0.05), and 12 months after (rs = -0.85; p <0.05). There were statistically significant strong and positive correlations between LUTS score and International Prostate Symptom Score (IPSS). Responsiveness of the test was confirmed with non-parametric Friedman's analysis of variance (ANOVA) with Kendall's coefficient of concordance (χ2 ANOVA = 8.95, p = 0.03). CONCLUSIONS: The Polish version of the USS-PROM questionnaire has appropriate psychometric properties and can be used in the assessment of patients with urethral stricture undergoing urethroplasty.

Can the evolution of male contraception lead to a revolution? Review of the current state of knowledge.

INTRODUCTION: Great advances in medical research concerning methods of contraception have been achieved in recent years, however, more than 25% of couples worldwide still rely on condoms - a method with poor efficacy. Even though there is a spectrum of 11 different contraceptive methods for women, there are only 4 commonly used by men (condoms, periodic abstinence, withdrawal and vasectomy). In this review, advances and present, state-of-the-art, both hormonal and non-hormonal male contraceptive methods will be presented and evaluated. Potential novel targets that warrant greater research will be highlighted. MATERIAL AND METHODS: A comprehensive literature search without a time limit was performed using the Medline database on May 2017. The terms 'male contraception' in conjunction with 'reversible inhibition of sperm under guidance' (RISUG), 'hormonal', 'non-hormonal', 'vasectomy' or 'testosterone' were used. The articles were limited to those published in English, Polish or French. RESULTS: There are various contraceptives currently available to regulate male fertility. Vasectomy is still the most effective permanent form of male contraceptive with a failure rate lower than 1%. Reversible, non hormonal methods of male contraception, like reversible inhibition of sperm under guidance, are very promising and close to being introduced into the market. In regards to hormonal contraception research, the use of testosterone injections has been widely studied yet they often harbor undesirable side effects and require further development. CONCLUSIONS: Despite continuous efforts worldwide, it seems that another several years of research is needed to provide safe, effective and affordable male contraceptives which will allow both men and women to participate fully in family planning.