Ultrasound for the evaluation of the urethra in pediatric patients.

Urethral lesions in pediatric patients can be visualized using ultrasonography. Therefore, sonographers and physicians should be familiar with the technique.

[Male Refractory Urethral Diverticular Abscess Requiring Transurethral Fenestration : A Case Report].

An 85 year-old man was referred to our hospital because of a relapse of abscess after open surgical drainage of the right scrotum. Computed tomography (CT) showed fluid accumulation in the right scrotum and around the membranous urethra. The abscess was controlled by an open surgical drainage of the right scrotum, CT guided percutaneous drainage of the periurethral abscess and administration of antibiotics. However, the scrotal abscess recurred after 4 weeks. CT showed an enlarged abscess, and retrograde urethrography showed an urethral diverticulum extending into the scrotum associated with a scrotal abscess. Endoscopic urethral diverticulum unroofing and cautery were performed. The urinary catheter was removed 2 days after the operation. The abscess has been resolved without recurrence.

Indocyanine green fluorescence imaging localization: A helpful addition to laparoscopic dissection and division of rectourethral fistulae.

BACKGROUND: Rectourethral fistulae (RUF) are the most prevalent type of anorectal malformations in boys, with various surgical treatment methods investigated in recent years. Currently, research is focused on preventing urethral damage or urethral diverticulum formation caused by imprecise dissection during the laparoscopically assisted anorectal pull-through (LAARP) technique. This study aimed to determine the efficacy of indocyanine green (ICG) fluorescence imaging to improve the localization and separation of the RUF during laparoscopic surgery. METHODS: ICG was intrarectally injected through a pre-inserted gastric tube at the distal enterostomy port to locate the fistula. This retrospective analysis included children with RUF who were treated surgically with ICG fluorescence imaging localization-assisted LAARP between January and June 2022. We investigated the patient demographics, perioperative conditions, and subsequent follow-up results. RESULTS: Four patients underwent ICG-assisted LAARP. Their median age was 80 days (range, 63-120) and the median duration of each procedure was 145 min (range, 120-165). Postoperatively, the duration of catheter retention and hospital stay was eight days. The children's prognosis was based on the follow-up outcomes of gastrointestinal, urinary tract function, and imaging examination. None of the included patients was diagnosed with urinary diverticulum, urinary tract injury, anal stricture, or rectal prolapse. CONCLUSIONS: Injection of ICG at the end of the rectum during LAARP surgery is a feasible adjunct for locating the RUF, providing a greater degree of accuracy for laparoscopic separation and resection of fistulae, thereby decreasing the risk of urological complications.

A diagnostic conundrum: Is it a periurethral diverticulum/cyst or a bulking agent (Bulkamid)?

INTRODUCTION: Urethral bulking agents are commonly used to manage female stress urinary incontinence (SUI) as they have been suggested to be safe, efficacious, and a minimally invasive surgical option. Bulkamid is a newer bulking agent that has been introduced and promoted in the market for use. It is non-particulate in nature with high tissue biocompatibility, and consequently, it is difficult to differentiate between Bulkamid and a periurethral cyst on magnetic resonance imaging (MRI). This, therefore, presents a diagnostic dilemma. METHODS AND MATERIALS: Here we describe two cases with previous injections of Bulkamid referred to our Centre for management of a presumed periurethral diverticulum based on MRI findings. Both patients were reviewed and examined in outpatient clinics with MRI findings discussed at MDT, further imaging was required. RESULTS: We found that a limited noncontrast computed tomography (CT) pelvis, followed by a voiding cystometrogram (VCMG), and then a repeat limited noncontrast CT pelvis effectively differentiated between Bulkamid and these presumed periurethral diverticulae. The theory behind this was that during micturition, the contrast would pass through to the urethral diverticulum and appear as high-density (bright) material within the periurethral region (the pre-VCMG was required to prove that any high-density material was due to the contrast and not pre-existing high-contrast material). CONCLUSION: A CT scan done in conjunction with a VCMG is likely to be more effective in differentiating between Bulkamid and a true periurethral diverticulum than an MRI scan. Appropriate diagnostic evaluation of periurethral lesions can lead to time-saving and cost-effective patient management as this will bypass the need for unnecessary investigations and possible unwarranted surgical intervention.

Prediction of anorectal malformations with bladder-neck/urethral-prostatic fistula using classification and regression tree analysis.

BACKGROUND: The anorectal malformations (ARMs) with bladder-neck/urethral-prostatic fistula in males are the most complex groups in ARMs. It is essential to diagnose them effectively before the primary operation for both surgical modalities and future functional prognosis can be quite different from other types. Our study aimed to develop a classification and regression tree (CART) model for the prediction of ARMs with bladder-neck/urethral-prostatic fistula. METHODS: A total of 132 newborns with ARMs were included retrospectively and randomly assigned to the training sample and test sample in a 3:1 ratio. The pouch-perineum distance of ultrasound (PPDU), the pouch-perineum distance of invertogram (PPDI), and the rectum gas above the coccyx (RGAC) on the invertogram were hypothesized can serve as individual predictors. The CART analysis was used to determine the best combination of candidate predictors. The model's performance was assessed by the area under the receiver operating characteristic curve (AUC) and validated in the test sample. RESULTS: All three individual predictors were included in the CART model to predict the ARMs with bladder-neck/urethral-prostatic fistula in the derivation cohort with the following test characteristics (95% CI): sensitivity 75.6% (60.1 to 86.6); specificity 88.9% (76.7 to 95.4); AUC 0.909 (0.854 to 0.965). The model's predicted accuracy was validated in the test cohort (AUC = 0.883). In all 132 subjects, the AUC of the tree model was significantly superior to that of the best individual index: PPDU (0.901 vs. 0.819; p = 0.005). CONCLUSIONS: A predictive model that consists of PPDU, PPDI, and RGAC may be useful in predicting ARMs with bladder-neck/urethral-prostatic fistula.

What urethrogram sees and a surgeon does not. / Lo que una uretrografía ve y un cirujano no.

INTRODUCTION: Urethrorrhagia is an infrequent sign in childhood. It should be distinguished from hematuria, since they have a different etiology. CLINICAL CASE: 11-year-old male patient with significant urethrorrhagia. Urinary sediment analysis: red blood cells++. Pelvic ultrasonography: fusiform anechoic image in the corpus spongiosum of the penile root. Retrograde urethrogram: normal anterior urethra, extraluminal contrast passage in the ventral aspect of the bulbar urethra. Cystoscopy: no pathological findings in the urethra or the bladder. Control retrograde urethrogram: cystic dilatation of Cowper's gland duct; Maizels' type 3 perforated syringocele. DISCUSSION: Cowper's syringocele is a rare pathology. It can occur at any stage of childhood in the form of urinary infection, obstructive voiding symptoms, or urethrorrhagia. Urethrogram is key for diagnostic purposes, since most Cowper's syringoceles are detected following urethrogram or cystoscopy. Cases with functional repercussions for the urinary system require surgical treatment. Otherwise, a wait-and-see approach is feasible.

INTRODUCCION: La uretrorragia es un signo infrecuente en la infancia que debe distinguirse de la hematuria dada la diferente etiología de las mismas. CASO CLINICO: Varón de 11 años con uretrorragia franca. Sedimento urinario: hematíes++. Ecografía pélvica: imagen anecoica fusiforme en cuerpo esponjoso de raíz peneana. Uretrografía retrógrada: uretra anterior normal, paso de contraste extraluminal ventral en uretra bulbar. Cistoscopia: sin hallazgos patológicos en uretra ni vejiga. Uretrografía retrógrada de control: dilatación quística del conducto de las glándulas de Cowper; siringocele perforado tipo 3 de Maizels. COMENTARIOS: El siringocele de Cowper es una patología infrecuente que puede debutar en cualquier momento de la infancia como infección urinaria, síntomas miccionales obstructivos o uretrorragia. La uretrografía es fundamental en su diagnóstico ya que la mayoría se objetivan por este medio o cistoscopia. Los casos con repercusión funcional del sistema urinario requieren tratamiento quirúrgico. En caso contrario podrá realizarse actitud expectante.

Does a tailored magnetic resonance imaging technique affect the surgical planning and outcomes for different cystic urethral and periurethral swellings in females? Seven years tertiary center experience.

PURPOSE: To evaluate the use of magnetic resonance imaging (MRI) in preoperative delineation and surgical planning for the management of female urethral and periurethral cystic vaginal swellings, with emphasis on postoperative surgical outcomes. MATERIALS AND METHODS: This is a retrospective analysis of females complaining of periurethral and urethral cystic swellings referred to our tertiary center, who underwent MRI for preoperative planning in the period from January 2014 till January 2021, with a total number of 57 patients. Data retrieved from the medical records included: patients' demographics, presenting symptoms and signs, preoperative radiological investigations, duration of symptoms, previous surgical intervention, detailed intraoperative data, postoperative complications, and postoperative follow-up. RESULTS: Urethral diverticulum was the commonest cystic lesion representing (64.9%) followed by Skene gland cysts in 14%, Mullerian cysts in 7%, Gartner cysts in 3.5%, and dermoid inclusion cysts in 10.5%. MRI precisely diagnosed the various pathological entities and anatomical complex lesions prior to surgery. This was confirmed after surgery and pathology analysis. All patients were followed up with a mean duration of 35 months, without any evidence of recurrence. CONCLUSION: MRI as a standalone imaging technique is mandatory for diagnosis of all urethral and periurethral cystic lesions, as it offers the most accurate diagnostic modality for delineation of these lesions and hence aids in the preoperative surgical planning, aiming to avoid recurrence and improving surgical outcomes.

Role of magnetic resonance imaging in the management of male pelvic fracture urethral injury.

The management of male pelvic fracture urethral injury remains a urological challenge. Pelvic fracture urethral injury can be associated with sequelae, such as urethral gap, erectile dysfunction and urinary incontinence. Delayed anastomotic urethroplasty, the gold standard treatment for urethral gaps caused by pelvic fracture urethral injuries, is technically demanding, and reconstructive urologists should preoperatively obtain as much detailed anatomical information as possible. A combination of antegrade and retrograde urethrography is the fundamental preoperative evaluation, but it cannot accurately assess the urethral gap length, the degree of lateral prostatic displacement, the anatomical relationship of the urethra with its surrounding structures (such as the rectum and dorsal venous complex) or periurethral problems (such as minor fistulae or cavitation). To make up for these limitations of urethrography, magnetic resonance imaging has emerged as a non-invasive, multiplanar and high-resolution modality for the evaluation of pelvic fracture urethral injury. Magnetic resonance imaging has excellent soft-tissue contrast, and can clearly show the urethra and periurethral tissues without the effects of radiation, thus enabling clinicians to anticipate the required ancillary techniques for delayed anastomotic urethroplasty and to predict functional outcomes, such as erectile function and urinary continence, after delayed anastomotic urethroplasty. This review discusses the role of magnetic resonance imaging in the evaluation of pelvic fracture urethral injury and its impact on patient management.

Neonatal Para-urethral Cyst: A Report of Three Cases.

BACKGROUND: Para -urethral cysts are rare benign lesions, especially in newborns. They are often asymptomatic but can be present with obstructive sequels. CASES: We present the cases of 3 female newborn infants who were found to have a para-urethral cyst at birth with a characteristic finding of a displaced urethral opening. They were treated with the least invasive technique with total resolution on follow-up and good parental prospective. SUMMARY AND CONCLUSION: Para-urethral cysts are sparsely reported and diagnosis is based on physical examination, although imaging studies sometimes are needed. They are expected to resolve spontaneously; therefore, management aims to prevent obstructive consequences. However, treatment can be conservative or surgical according to the patient presentation. Further reports of this rare disease will improve management planning and outcomes.

Verumontanum Polyp in an Adult Man: Diagnosis by Ultrasonography.

The fibroepithelial polyp of the urethra is rare in adults. Hematuria and obstructive urinary symptoms are the most common findings. The investigation of these polyps usually includes imaging exams (voiding cystourethrography and ultrasonography) and urinary endoscopy. However, the diagnosis is primarily established by pathology. Ultrasonography can aid in diagnosis, as it can identify a polypoid lesion that can extend to the bladder neck, and cystourethroscopy allows the direct visualization of the lesion. We report this case of a polyp of the prostatic urethra in an adult male using prospective real-time sonographic diagnosis.

Adult residual rectourethral fistula and diverticulum presenting decades after imperforate anus repair: a case report.

BACKGROUND: This report describes a rare surgical case of an intraabdominal mass in a middle-aged patient 40 years after imperforate anus repair. CASE PRESENTATION: A 44-year-old Latino male with history of repaired anorectal malformation presented with recurrent urinary tract infections and rectal prolapse with bothersome bleeding and fecal incontinence. During his preoperative evaluation, he was initially diagnosed with a prostatic utricle cyst on the basis of magnetic resonance imaging findings, which demonstrated a cystic, thick-walled mass with low signal contents that extended inferiorly to insert into the distal prostatic urethra. However, at the time of surgical resection, the thick-walled structure contained an old, firm fecaloma. The final pathology report described findings consistent with colonic tissue, suggesting a retained remnant of the original fistula and diverticulum. CONCLUSIONS: Although rare, persistent rectourethral fistula tracts and rectal diverticula after imperforate anus repair can cause symptoms decades later, requiring surgical intervention. This is an important diagnostic consideration for any adult patient with history of imperforate anus.

Urethral duplication in a 1 year old: a rare case report.

An 8-month-old male child presented with the complaint of two separate urinary streams from the penis. The child had no complaints of incontinence or recurrent UTI (urinary tract infection). Initial diagnosis of urethrocutaneous fistula was made and proceeded to micturating cystourethrography (MCU) and found to be having a urethral duplication. The duplicated urethra was excised and accessory urethra closed. Postoperatively, the child was followed up for 1 year and had no complaints of recurrence or incontinence. Through this case report, we learn about different classification systems and types of urethral duplication and their associated anomalies, and mode of management, which is mainly surgical. Further, management should be individualised to each patient based on their complaints and intraoperative findings.

Bladder Agenesis and Bilateral Ectopic Ureters in an Infant Male With Cystic Renal Dysplasia, Imperforate Anus, and Penoscrotal Transposition.

Bladder agenesis is a rare congenital anomaly infrequently reported in the literature, with an incidence of 1/600,000 patients.1 Commonly associated with other fatal malformations, the condition is often incompatible with life.2 Prior reports estimate that over 90% of living children born with this malformation are female, owing to renal preservation resulting from low pressure drainage of urine into the vagina, uterus, and vestibule.3,4 Herein we report a rare case of an infant male born with penoscrotal transposition and end stage renal disease secondary to bilateral cystic renal dysplasia found to have concurrent bladder agenesis and bilateral ureteral ectopia.

Imaging spectrum of traumatic urinary bladder and urethral injuries.

Urinary bladder and urethral injuries usually occur as part of multiple injuries in polytrauma patients. These injuries are easily overlooked because the initial evaluation is focused on other life-threatening injuries such as traumatic brain injury, hemopneumothorax or hemoperitoneum. Although the urinary bladder and urethral injuries are not life-threatening, they pose the risk of long-term morbidity which can be burdensome. These complications include urinary incontinence, voiding dysfunction, urethrocutaneous fistula, urethral stricture and erectile dysfunction. Computed tomography (CT) findings of urinary bladder and urethral injuries are usually subtle. Retrograde fluoroscopic/CT cystography and urethrography remain the mainstay imaging techniques for complete evaluation, diagnosis, staging, and follow-up of these traumatic injuries. In this review, we discuss the pathophysiology and imaging spectrum of urinary bladder and urethral injuries with an emphasis on the classification schemes. Familiarity with the pelvic anatomy and the injury pattern leads to the prompt diagnosis, accurate classification and appropriate management, which have been associated with better prognosis.

Are anterior urethral valve and anterior urethral diverticulum two separate entities: A radiological and endoscopic review.

BACKGROUND: Anterior urethral valve (AUV) and anterior urethral diverticulum (AUD) are two rare causes of anterior urethral obstruction with variable presentation and anatomy. Their existence as the same or different entity is still debatable, and management has not yet been standardized. OBJECTIVE: This study is a retrospective review of cases diagnosed with anterior urethral obstruction and correlation of radiological and endoscopic anatomy of AUV and AUD. STUDY DESIGN: A retrospective review of cases diagnosed with AUV and AUD, between May 2013 and February 2020 is presented. The presentation, laboratory, radiological and endoscopic anatomy along with the management required was reviewed. A special emphasis has been given on the correlation of radiological and endoscopic anatomy and an attempt has been made to standardize the management. RESULTS: A total of 8 patients with age ranging from 2 months to 9 years were reviewed. Poor urinary stream and recurrent UTI was the commonest presentation. The anatomy of the anterior urethra on VCUG (voiding cystourethrogram) and Urethrocystoscopy was correlated. Two sets of patients were identified. In the first set, five cases on endoscopy had findings of the classical valve-like fold in the anterior urethra with immediate proximal dilation of the urethra giving the appearance of a 'pseudodiverticula' without any definite opening. In three of these cases, endoscopic findings correlated well with radiological findings of 'pseudodiverticula' in which dilated proximal urethra formed an obtuse angle with the ventral floor of the urethra. The other set of four patients had a 'true diverticula' on endoscopy with a well-defined mouth and prominent distal lip, correlating well with radiological findings of a 'true diverticula' forming an acute angle with the ventral floor of the urethra. One case on endoscopy had both an anterior urethral valve with a proximal 'pseudodiverticula and a large wide-mouthed bulbar 'true diverticula'. All the patients with classical valves were successfully treated using a resectoscope while two patients with 'true diverticula' were successfully managed by incising the distal lip. One of the patients previously managed for the posterior urethral valve (PUV) had both classical valves in the anterior urethra with proximal 'pseudodiverticula' and a bulbar 'true diverticula'. The AUV was ablated with a resectoscope while 'true diverticula' required diverticulectomy. All the patients after follow up of 3 months-8 years, were asymptomatic except the one with 'true diverticulum' who remained symptomatic after TUR (Trans-urethral resection) and required vesicostomy. DISCUSSION: AUV and AUD both can cause obstructive uropathy. The proximal dilatation related to AUV cannot be labeled as a 'true diverticula', which lacks a classical orifice. The distal obstructing lip of 'true diverticula' should not be confused with a classical mucosal valve-like fold seen in AUV. While AUV and small AUD can be treated with endoscopic ablation, large diverticula as a result of wide spongiosal defects require surgical excision. A good understanding of their radiological and endoscopic anatomy is required to differentiate them and decide for appropriate management. CONCLUSION: Based on our experience, AUV and AUD should be differentiated and should be considered as two separate entities.