The Urothelium: Life in a Liquid Environment.

The urothelium, which lines the renal pelvis, ureters, urinary bladder, and proximal urethra, forms a high-resistance but adaptable barrier that surveils its mechanochemical environment and communicates changes to underlying tissues including afferent nerve fibers and the smooth muscle. The goal of this review is to summarize new insights into urothelial biology and function that have occurred in the past decade. After familiarizing the reader with key aspects of urothelial histology, we describe new insights into urothelial development and regeneration. This is followed by an extended discussion of urothelial barrier function, including information about the roles of the glycocalyx, ion and water transport, tight junctions, and the cellular and tissue shape changes and other adaptations that accompany expansion and contraction of the lower urinary tract. We also explore evidence that the urothelium can alter the water and solute composition of urine during normal physiology and in response to overdistension. We complete the review by providing an overview of our current knowledge about the urothelial environment, discussing the sensor and transducer functions of the urothelium, exploring the role of circadian rhythms in urothelial gene expression, and describing novel research tools that are likely to further advance our understanding of urothelial biology.

Nitrergic inhibition of sympathetic arteriolar constrictions in the female rodent urethra.

During the urine storage phase, tonically contracting urethral musculature would have a higher energy consumption than bladder muscle that develops phasic contractions. However, ischaemic dysfunction is less prevalent in the urethra than in the bladder, suggesting that urethral vasculature has intrinsic properties ensuring an adequate blood supply. Diameter changes in rat or mouse urethral arterioles were measured using a video-tracking system. Intercellular Ca2+ dynamics in arteriolar smooth muscle (SMCs) and endothelial cells were visualised using NG2- and parvalbumin-GCaMP6 mice, respectively. Fluorescence immunohistochemistry was used to visualise the perivascular innervation. In rat urethral arterioles, sympathetic vasoconstrictions were predominantly suppressed by α,ß-methylene ATP (10 µM) but not prazosin (1 µM). Tadalafil (100 nM), a PDE5 inhibitor, diminished the vasoconstrictions in a manner reversed by N-ω-propyl-l-arginine hydrochloride (l-NPA, 1 µM), a neuronal NO synthesis (nNOS) inhibitor. Vesicular acetylcholine transporter immunoreactive perivascular nerve fibres co-expressing nNOS were intertwined with tyrosine hydroxylase immunoreactive sympathetic nerve fibres. In phenylephrine (1 µM) pre-constricted rat or mouse urethral arterioles, nerve-evoked vasodilatations or transient SMC Ca2+ reductions were largely diminished by l-nitroarginine (l-NA, 10 µM), a broad-spectrum NOS inhibitor, but not by l-NPA. The CGRP receptor antagonist BIBN-4096 (1 µM) shortened the vasodilatory responses, while atropine (1 µM) abolished the l-NA-resistant transient vasodilatory responses. Nerve-evoked endothelial Ca2+ transients were abolished by atropine plus guanethidine (10 µM), indicating its neurotransmitter origin and absence of non-adrenergic non-cholinergic endothelial NO release. In urethral arterioles, NO released from parasympathetic nerves counteracts sympathetic vasoconstrictions pre- and post-synaptically to restrict arteriolar contractility. KEY POINTS: Despite a higher energy consumption of the urethral musculature than the bladder detrusor muscle, ischaemic dysfunction of the urethra is less prevalent than that of the bladder. In the urethral arterioles, sympathetic vasoconstrictions are predominately mediated by ATP, not noradrenaline. NO released from parasympathetic nerves counteracts sympathetic vasoconstrictions by its pre-synaptic inhibition of sympathetic transmission as well as post-synaptic arteriolar smooth muscle relaxation. Acetylcholine released from parasympathetic nerves contributes to endothelium-dependent, transient vasodilatations, while CGRP released from sensory nerves prolongs NO-mediated vasodilatations. PDE5 inhibitors could be beneficial to maintain and/or improve urethral blood supply and in turn the volume and contractility of urethral musculature.

New uses for an old technique: live imaging on the slice organ culture to study reproductive processes†.

Reproductive processes are dynamic and involve extensive morphological remodeling and cell-cell interactions. Live imaging of organs enhances our understanding of how biological processes occur in real time. Slice culture is a type of organ culture where thick slices are collected from an organ and cultured for several days. Slice culture is a useful and easy-to-implement technique for live imaging of reproductive events at cellular resolution. Here we describe a pipeline of live imaging on slice culture to visualize the process of urethra closure in mouse embryonic penis as a proof of principle. In combination with genetic reporter mice, nuclear stains, and exposure experiments, we demonstrate the feasibility of slice culture on a reproductive organ. We also provide a step-by-step protocol and troubleshooting guide to facilitate the adoption of slice culture with live imaging in other reproductive organs. Lastly, we discuss potential utilities and experiments that could be implemented with slice culture in reproductive sciences.

Primary mucinous adenocarcinoma of the urethra: A clinicopathological analysis of 35 cases.

AIM: Primary mucinous adenocarcinoma of the urethra represents an extremely rare entity. We sought to characterise further these tumours' clinicopathological, immunohistochemical and molecular features. METHODS AND RESULTS: Thirty-five cases were identified, occurring in 18 males and 17 females. The mean age at diagnosis was 65 years (28-89 years). The main presentation symptoms were haematuria and urinary outlet obstruction. Microscopic analysis revealed that all 35 tumours have stromal dissection by mucin. Ten tumours showed villoglandular dysplasia, nine showed mucinous metaplasia, two showed adenocarcinoma in situ and four showed signet ring cell features. All tumours were immunopositive for CEA, while immunonegative for nuclear ß-catenin; 19 of 23 (83%) expressed high molecular weight cytokeratin; 19 of 33 (58%) CK7; 28 of 34 (82%) CK20; 32 of 35 (91%) CDX2; 22 of 27 (81%) cadherin-17 (CDH-17); 26 of 29 (90%) SATB2; and one of 31 (3%) GATA3. Mismatch repair gene products, including MLH1, PMS2, MSH2 and MSH6, were immunopositive, suggesting the MSI-low genotype of mucinous adenocarcinoma of the urethra. BRAF V600E and ALK rearrangements were not detected. During the mean follow-up of 20 months, nine patients either developed distant metastasis or succumbed to the illness. CONCLUSION: Our study, encompassing the most extensive series of 35 cases of primary mucinous adenocarcinoma of the urethra, provides crucial insights into its precise diagnosis, management and potential targeted treatments. We found a greater CDX2, SATB2 and CDH17 sensitivity in these urethral tumours for the first time, to our knowledge. We identified characteristics such as an MSI-low profile, non-V600E BRAF mutations and an absence of ALK rearrangements.

Anatomy of muscle connections in the male urethra and anorectal canal.

OBJECTIVES: To elucidate the male urethral muscular structure and its relationship with the anorectal canal muscles, as establishing an anatomical foundation for urethral function will contribute to the prevention, diagnosis, and treatment of urinary incontinence. METHODS: Eight male cadavers were used. Using a multifaceted approach, we performed macroscopic anatomical examination, histological analysis of wide-range serial sectioning and immunostaining, and three-dimensional (3D) reconstruction from histological sections. In the macroscopic anatomical examination, pelvic halves were meticulously dissected in layers from the medial aspect. In the histological analysis, the tissue, including the urethra and anorectal canal, was serially sectioned in the horizontal plane. The muscular structures were reconstructed and visualised in 3D. RESULTS: The membranous portion of the urethra had three muscle layers: the longitudinal and circular muscles (smooth muscle) and the external urethral sphincter (skeletal muscle). The circular muscle was connected posteriorly to the longitudinal rectal muscle. The external urethral sphincter had a horseshoe shape, with its posterior ends continuing to the external anal sphincter, forming a 3D ring-like sphincter. CONCLUSION: This study revealed skeletal and smooth muscle connections between the male urethra and anorectal canal, enabling urethral compression and closure. These anatomical muscle connections suggest a functional linkage between them.

Distribution of prostatic markers in glands of the female urethra and anterior vaginal wall-a rapid autopsy study.

BACKGROUND: There are varying reports of immunohistochemically detected prostatic marker protein distribution in glands associated with the female urethra that may be related to tissue integrity at the time of fixation. AIM: In this study we used tissue derived from rapid autopsies of female patients to determine the distribution of glandular structures expressing prostate-specific antigen (PSA) and prostate-specific acid phosphatase (PSAP) along the female urethra and in surrounding tissues, including the anterior vaginal wall (AVW). METHODS: Tissue blocks from 7 donors that contained the entire urethra and adjacent AVW were analyzed. These tissue samples were fixed within 4-12 hours of death and divided into 5-mm transverse slices that were paraffin embedded. Sections cut from each slice were immunolabeled for PSA or PSAP and a neighboring section was stained with hematoxylin and eosin. The sections were reviewed by light microscopy and analyzed using QuPath software. OBSERVATIONS: In tissue from all donors, glandular structures expressing PSA and/or PSAP were located within the wall of the urethra and were present along its whole length. RESULTS: In the proximal half of the urethra from all donors, small glands expressing PSAP, but not PSA, were observed adjacent to the and emptying into the lumen. In the distal half of the urethra from 5 of the 7 donors, tubuloacinar structures lined by a glandular epithelium expressed both PSA and PSAP. In addition, columnar cells at the surface of structures with a multilayered transitional epithelium in the distal half of the urethra from all donors expressed PSAP. No glands expressing PSA or PSAP were found in tissues surrounding the urethra, including the AVW. CLINICAL IMPLICATIONS: Greater understanding of the distribution of urethral glands expressing prostatic proteins in female patients is important because these glands are reported to contribute to the female sexual response and to urethral pathology, including urethral cysts, diverticula, and adenocarcinoma. STRENGTHS AND LIMITATIONS: Strengths of the present study include the use of rapid autopsy to minimize protein degradation and autolysis, and the preparation of large tissue sections to demonstrate precise anatomical relations within all the tissues surrounding the urethral lumen. Limitations include the sample size and that all donors had advanced malignancy and had undergone previous therapy which may have had unknown tissue effects. CONCLUSION: Proximal and distal glands expressing prostate-specific proteins were observed in tissue from all donors, and these glands were located only within the wall of the urethra.

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.

Membranous urethral length measurement on preoperative MRI to predict incontinence after radical prostatectomy: a literature review towards a proposal for measurement standardization.

OBJECTIVES: To investigate the membranous urethral length (MUL) measurement and its interobserver agreement, and propose literature-based recommendations to standardize MUL measurement for increasing interobserver agreement. MUL measurements based on prostate MRI scans, for urinary incontinence risk assessment before radical prostatectomy (RP), may influence treatment decision-making in men with localised prostate cancer. Before implementation in clinical practise, MRI-based MUL measurements need standardization to improve observer agreement. METHODS: Online libraries were searched up to August 5, 2022, on MUL measurements. Two reviewers performed article selection and critical appraisal. Papers reporting on preoperative MUL measurements and urinary continence correlation were selected. Extracted information included measuring procedures, MRI sequences, population mean/median values, and observer agreement. RESULTS: Fifty papers were included. Studies that specified the MRI sequence used T2-weighted images and used either coronal images (n = 13), sagittal images (n = 18), or both (n = 12) for MUL measurements. 'Prostatic apex' was the most common description of the proximal membranous urethra landmark and 'level/entry of the urethra into the penile bulb' was the most common description of the distal landmark. Population mean (median) MUL value range was 10.4-17.1 mm (7.3-17.3 mm), suggesting either population or measurement differences. Detailed measurement technique descriptions for reproducibility were lacking. Recommendations on MRI-based MUL measurement were formulated by using anatomical landmarks and detailed descriptions and illustrations. CONCLUSIONS: In order to improve on measurement variability, a literature-based measuring method of the MUL was proposed, supported by several illustrative case studies, in an attempt to standardize MRI-based MUL measurements for appropriate urinary incontinence risk preoperatively. CLINICAL RELEVANCE STATEMENT: Implementation of MUL measurements into clinical practise for personalized post-prostatectomy continence prediction is hampered by lack of standardization and suboptimal interobserver agreement. Our proposed standardized MUL measurement aims to facilitate standardization and to improve the interobserver agreement. KEY POINTS: • Variable approaches for membranous urethral length measurement are being used, without detailed description and with substantial differences in length of the membranous urethra, hampering standardization. • Limited interobserver agreement for membranous urethral length measurement was observed in several studies, while preoperative incontinence risk assessment necessitates high interobserver agreement. • Literature-based recommendations are proposed to standardize MRI-based membranous urethral length measurement for increasing interobserver agreement and improving preoperative incontinence risk assessment, using anatomical landmarks on sagittal T2-weighted images.

Is the time right for a new initiative in mathematical modeling of the lower urinary tract? ICI-RS 2023.

INTRODUCTION: A session at the 2023 International Consultation on Incontinence - Research Society (ICI-RS) held in Bristol, UK, focused on the question: Is the time right for a new initiative in mathematical modeling of the lower urinary tract (LUT)? The LUT is a complex system, comprising various synergetic components (i.e., bladder, urethra, neural control), each with its own dynamic functioning and high interindividual variability. This has led to a variety of different types of models for different purposes, each with advantages and disadvantages. METHODS: When addressing the LUT, the modeling approach should be selected and sized according to the specific purpose, the targeted level of detail, and the available computational resources. Four areas were selected as examples to discuss: utility of nomograms in clinical use, value of fluid mechanical modeling, applications of models to simplify urodynamics, and utility of statistical models. RESULTS: A brief literature review is provided along with discussion of the merits of different types of models for different applications. Remaining research questions are provided. CONCLUSIONS: Inadequacies in current (outdated) models of the LUT as well as recent advances in computing power (e.g., quantum computing) and methods (e.g., artificial intelligence/machine learning), would dictate that the answer is an emphatic "Yes, the time is right for a new initiative in mathematical modeling of the LUT."

Levator-urethra gap: is there a need for individualization of cut-offs?

OBJECTIVES: To determine whether height, weight and body mass index (BMI) are associated with the levator-urethra gap (LUG) measurement, and whether these factors confound the relationship between LUG and symptoms and signs of pelvic organ prolapse (POP). METHODS: This was a retrospective study of women seen at a tertiary urogynecology unit between January 2020 and December 2021. Postprocessing of saved ultrasound volume data was used to measure the LUG, blinded against all other data. This measurement was tested for its association with organ descent and hiatal area, and height, weight and BMI were investigated for any potential confounding effect. RESULTS: The 624 women seen during the inclusion period presented mostly with stress urinary incontinence (448/624 (72%)), urgency urinary incontinence (469/624 (75%)) and/or prolapse (338/624 (54%)). Mean age at assessment was 58 (range, 20-94) years, mean height was 163 (range, 142-182) cm, mean weight was 80 (range, 41-153) kg and mean BMI was 30 (range, 17-65) kg/m2. LUG measurements could be obtained in 613 women, resulting in 7356 (12 × 613) measurements. The average LUG in individual women measured 2.35 cm on the right and 2.32 cm on the left side (difference not significant), with a mean ± SD of 2.34 ± 0.63 cm overall. Mean LUG was associated with symptoms and signs of prolapse, both on clinical examination (POP quantification system) and on imaging, but not with height (P = 0.36), weight (P = 0.20) or BMI (P = 0.09). CONCLUSIONS: Levator-urethra gap measurements do not seem to be significantly associated with height, weight or BMI in our population, obviating the need for individualization of LUG. However, this does not exclude interethnic variability of this biometric measure. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Female Urethroplasty with a Buccal Mucosa Graft using a Supraurethral Approach.

INTRODUCTION AND HYPOTHESIS: In the setting of recurrent female urethral stricture, urethroplasty offer the best chance of cure. However, which approach (dorsal or ventral) and which tissue (buccal mucosa, vaginal graft, vaginal flap) remain areas of controversy. In this article and accompanying video, we describe female urethroplasty with a supraurethral approach using a buccal mucosa graft. METHODS: A stricture of 3 cm in length was observed in the mid urethra. A supraurethral semi-lunar incision was made and dissection was performed up to the stricture. A dorsal urethrotomy was performed and a 3 × 2 cm oral mucosal graft was harvested from the left cheek. The mucosal graft was anastomosed to both urethral edges with running sutures. The graft was fixed to the supraurethral tissue with quilting sutures. A urethral catheter and a suprapubic catheter were left in place for 3 weeks. RESULTS: Following removal of the catheters, the patient was able to void satisfactorily with no incontinence. No complications were observed in the urethral area or at the graft harvest site. CONCLUSIONS: Buccal mucosa graft urethroplasty with a supraurethral approach is a reliable method in the treatment of female urethral stricture.

Carcinoma in situ within the bladder trigone with an isolated metastasis to the prostate without involvement of prostatic urethra: a unique case report.

BACKGROUND: Carcinoma in situ of the bladder is a high-grade cancer that originates in the superficial layer of the bladder. It has the potential to invade nearby organs, and it can spread through blood and lymphatic circulation to distant parts of the body. CASE PRESENTATION: A 58-year-old non-smoker male presented with gross and microscopic hematuria. His family history included his father's recent bladder cancer. Initial investigations showed hematuria, inflammation, negative urine culture, digital rectal examination revealed an enlarged right lobe of the prostate, and an elevated Prostate-Specific Antigen level. Histopathological examination of samples taken from the bladder mucosa and the prostate confirmed urothelial carcinoma in situ in the bladder and prostate. Further evaluation revealed no other metastasis. The tumor was classified as T4aN0M0. The patient underwent radical cystoprostatectomy and histopathological examination showed that the tumor invading the muscularis propria of the bladder as well as the prostatic glands, but no malignancy was found in prostatic urethra and other areas. The patient was discharged three weeks post-operation and completed on adjuvant chemotherapy consisting of Gemcitabine, and Cisplatin to prevent of relapse. The patient is currently in a good healthy. CONCLUSION: The occurrence of bladder cancer metastasizing to the prostate without involving the prostatic urethra is uncommon and requires precise diagnostic techniques for accurate tumor classification. Early management is advised to enhance the prognosis for the patient.

Preservation of the native urethral plate and corpus spongiosum combined with buccal mucosa graft plus Orandi's penile skin flap as an alternative to staged urethroplasty for narrow penile strictures.

OBJECTIVE: In narrow anterior urethral strictures, the combined buccal mucosa graft (BMG) with pedicled penile skin flap (PSF) represents a well-known effective alternative to staged urethroplasty. We hypothesized that if the native urethral plate and adjacent corpus spongiosum were preserved, a narrower flap would be needed, and reinforced ventral stability could be achieved without compromising the surgical outcome. METHODS: Twelve patients with narrow penile urethral strictures underwent single-stage augmentation urethroplasty using a combined technique. A BMG was quilted to the corpora cavernosa in a dorsal onlay approach, and a longitudinal ventral PSF was transposed ventrally and sutured to the scarred native urethral mucosa on one side and to the BMG on the other side to form a neourethra of triangular form. The preserved corpus spongiosum was wrapped and fixed around the flap ventrally. RESULTS: The median age was 47 years (IQR 35-59), and the median stricture length was 5 cm (IQR 3, 8-7). The median surgical time was 205 min (IQR 172-236). The overall success rate (SR) was 91.7% without sacculation or diverticula formation after a median follow-up period of 38 months (IQR 33-40). Three transient fistulas healed through prolonged urinary diversion. Five patients (41.7%) reported postvoid dribbling following urethroplasty. CONCLUSION: Preservation of the native urethral plate is a valuable adjunct to the combination of graft and flap for single-stage augmentation urethroplasty for narrow urethral strictures, with satisfactory mid-term success and an acceptable complication rate.

Clinical observation of male bulbar urethral strictures resulting from straddle injuries associated with falling from heights and riding activities.

OBJECTIVES: To retrospectively investigate and analyze the characteristics of male bulbar urethral strictures or occlusions resulting from straddle injuries caused by falling from heights and riding activities. METHODS: The study included 56 patients with a history of straddle injury, who were divided into two groups: the falling group (n = 29) and the riding group (n = 27). All patients underwent urethroscopy and X-ray urethrography, followed by urethrotomy and anastomotic procedure. Both urethral and suprapubic catheters were retained for one month postoperatively. Subsequent follow-up assessments were conducted within one month to one year after surgery. RESULTS: The clinical data of two groups were analyzed. The average ages were 40.1 ± 11.2 (falling group, aged 18-59) and 26.8 ± 4.4 (riding group, aged 19-35), P < 0.05. In the falling group, 21 cases (72.4%) had offspring, while in the riding group, only 3 cases (11.1%) had offspring, P < 0.05. The stricture segments in the falling group were predominantly located in the proximal part of the bulbar region (89.7%), whereas in the riding group they mainly found in the distal part (96.3%), P < 0.05. In terms of urethrography results, the average lengths of stricture segments were measured as 17.6 ± 2.8 mm and 15.5 ± 4.6 mm respectively, P < 0.05. During surgery, the average lengths of stricture segments were recorded as 19.0 ± 2.5 mm and 17.4 ± 6.1 mm, P > 0.05. In the falling group, 20 cases (69.0%) involved bulbocavernosus muscle injury, P < 0.05. In the riding group, 5 cases (18.5%) involved corpus cavernosum injury, P < 0.05. After one month of the operation, all cases were able to pass through the 16Fr urethroscope without any apparent urethral strictures or complications observed in urethrography results. The maximum urinary flow rate for all cases exceeded 15 ml/s. Two months and one year after the operation, all cases experienced smooth urinary flow and ejaculation without any disorders reported. 3 cases (10.3%) in the falling group and 7 cases (25.9%) in the riding group complained of urethral stretching pain during erection, P > 0.05. CONCLUSIONS: Male bulbar urethral strictures or occlusions resulting from straddle injuries associated with falling from heights and riding activities exhibit distinct characteristics, necessitating the development of a comprehensive surgical plan tailored to the specific features of each condition and the diverse age groups affected.

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.

Diagnosis of traumatic urethral stricture in a canine patient with contrast-enhanced voiding urosonography : A case report.

A 5-year-old intact male mixed-breed dog presented with a 3-day history of stranguria and dysuria. Results of physical examination, plain radiographs, and ultrasonography were consistent with a traumatic urethral stricture in the prescrotal urethra just under the previous trauma region, resulting in partial obstruction of urine outflow. Contrast-enhanced voiding urosonography (CE-VUS) was performed, and a urethral stricture was confirmed. The dog underwent surgery. A scrotal urethrostomy was performed. After 3 days of hospitalization, the dog was discharged from the Clinic. Based on an extensive literature review, this is the first report using CE-VUS to evaluate urethral pathology in a canine patient.

Cloacal Exstrophy with Normal Penis and Urethra - A Rare Variant.

Classically, cloacal exstrophy presents with omphalocele, bladder exstrophy, imperforate anus, and spinal defects. We report a rare variant of cloacal exstrophy in a 6-day-old male with an intact lower abdominal wall, normal penis, and urethra. Only two such cases have been reported in the literature.

First in Human Subjects Testing of the UroMonitor: A Catheter-free Wireless Ambulatory Bladder Pressure Monitor.

PURPOSE: Urodynamics is the standard method of diagnosing bladder dysfunction, but involves catheters and retrograde bladder filling. With these artificial conditions, urodynamics cannot always reproduce patient complaints. We have developed a wireless, catheter-free intravesical pressure sensor, the UroMonitor, which enables catheter-free telemetric ambulatory bladder monitoring. The purpose of this study was twofold: to evaluate accuracy of UroMonitor pressure data, and assess safety and feasibility of use in humans. MATERIALS AND METHODS: Eleven adult female patients undergoing urodynamics for overactive bladder symptoms were enrolled. After baseline urodynamics, the UroMonitor was transurethrally inserted into the bladder and position was confirmed cystoscopically. A second urodynamics was then performed with the UroMonitor simultaneously transmitting bladder pressure. Following removal of urodynamics catheters, the UroMonitor transmitted bladder pressure during ambulation and voiding in private. Visual analogue pain scales (0-5) were used to assess patient discomfort. RESULTS: The UroMonitor did not significantly alter capacity, sensation, or flow during urodynamics. The UroMonitor was also easily inserted and removed in all subjects. The UroMonitor reproduced bladder pressure, capturing 98% (85/87) of voiding and nonvoiding urodynamic events. All subjects voided with only the UroMonitor in place with low post-void residual volume. Median ambulatory pain score with the UroMonitor was rated 0 (0-2). There were no post-procedural infections or changes to voiding behavior. CONCLUSIONS: The UroMonitor is the first device to enable catheter-free telemetric ambulatory bladder pressure monitoring in humans. The UroMonitor appears safe and well tolerated, does not impede lower urinary tract function, and can reliably identify bladder events compared to urodynamics.

Anatomic relationships of the clitoral body, bulbs of the vestibule, and urethra.

BACKGROUND: Although recent studies have enhanced our understanding of the anatomy of the clitoris and its somatic innervation, less emphasis has been placed on the anatomic relationships of the clitoris to its surrounding structures. OBJECTIVE: This study aimed to further characterize the gross and histologic relationships of the clitoris, vestibular bulbs, and urethra. STUDY DESIGN: Detailed dissections were performed in 30 unembalmed female cadavers. In 23 specimens, gross dissections were performed, and relationships of the clitoris, vestibular bulbs, and urethra were annotated. Histologic evaluation was performed in 7 specimens, in which tissues were harvested within 24 hours from death. Descriptive statistics were used for data analyses. RESULTS: The clitoral body consisted of 2 components, the proximal body and the distal body. The distal body was oriented ≤90° from the proximal body, forming an outer and inner angle at the inflection point. A "septumlike" arrangement of fibroconnective and vascular tissues was noted between the inner angle of the clitoral body and the urethra. Neurovascular bundles coursed laterally along the clitoral body and the surfaces of the crura and vestibular bulbs. The vestibular bulbs approached each other over the ventral surface of the urethra, at the commissure of the vestibular bulbs. Each bulb was separated by fibrous tissue and did not merge along the midline. The vestibular bulbs approximated the clitoral body, but the erectile tissue of the vestibular bulbs was separated from the corpora cavernosa of the clitoral body by the tunica albuginea. The erectile tissue of the vestibular bulbs abutted the ventrolateral walls of the urethra but was separated from the urethral mucosa by an indiscrete layer of erectilelike tissue with dense stroma. CONCLUSION: This study provided gross and histological confirmation of the relationships of the clitoris, vestibular bulbs, and urethra. Detailed knowledge of the anatomy of the clitoris is crucial for reducing surgical complications associated with periclitoral and distal urethral procedures, which may adversely affect sexual arousal and sexual function.

Determining the outcomes of urethral construction in phalloplasty.

OBJECTIVE: To evaluate the surgical and functional outcomes of urethral reconstruction associated with phalloplasty, depending on the surgical techniques and patient history. MATERIALS AND METHODS: We conducted a single-centre retrospective study including 89 patients who underwent phalloplasty with urethral reconstruction between 2007 and 2018. Patients included were trans-male patients undergoing gender-affirming surgery and cis-male patients undergoing penile reconstruction after trauma, congenital malformation, or cancer. Urethral reconstructions were performed by free flap or skin graft (total or thin). Secondary urethroplasty may include direct vision urethrotomy, excision-anastomosis, or augmentation urethroplasty (skin graft, buccal mucosa graft). Patient demographics, medical history, peri- and postoperative data were collected from patient files. Functional results were evaluated using individual questionnaires. RESULTS: The mean (±sd) follow-up duration was 5.5 (±3.7) years. No significant difference was found for total urethral complication rate (fistula and/or stricture) according to type of urethral construction (70.9% for free flap urethra vs 73.5% for skin graft urethra; P = 0.911), nor according to the patient's grounds for surgery (72.7% for cis-male vs 71.8% for trans-male patients; P = 1). A total of 36 patients (40.5%) answered the functional questionnaire, of whom 80.5% reported usually voiding while standing and 47.5% were comfortable with urinating in public. CONCLUSIONS: Urethral construction in phalloplasty is associated with a high complication and revision rate regardless of the type of urethral reconstruction. Voiding in a standing position is generally possible but should not conceal feeble functional results.