Genitourinary Fistula: 5 Years' Experience of Five Referral Centers in Iran.

INTRODUCTION AND HYPOTHESIS: Genitourinary fistula is a devastating ailment that has an impact on women's physical health, mental health, emotional health, and financial security. The management of genitourinary fistula depends on the type, size, and duration of fistula formation. The purpose of this study is to report the features of genitourinary fistula in Iranian women and our experience in the management of fistula. METHODS: Retrospective chart reviews of 283 patients were performed to determine the cause of the fistula, prior repairs, tissue interposition, and the success rate. The operation was considered successful if the patient did not have any urine leakage during the observation time. RESULTS: The mean (SD) age of women was 49.51 (19.39; range: 21-70) years, Of these, 137 (52.9%) had a history of previous genitourinary fistula surgery. The average fistula was 1.53 (0.041) cm in size. The median (interquartile range) operation lasted 70 (15) min. The success rate after fistula repair was 91.5%. The typical follow-up period lasted 13.26 (range: 1-88) months. Forty-three (15.2%) patients had a big fistula (>2.5 cm) and 4 patients (1.4%) had a history of pelvic radiation therapy, among other reasons for failure. After a second repair, all patients' initial failures were resolved. There were no significant complications, as classified by Clavien-Dindo class 2 or greater. Additionally, there were no bowel, ureteral, or nerve injuries. CONCLUSIONS: Our patients with genitourinary fistula had a successful outcome following repair techniques, without any significant morbidity or mortality.

Comparing Laparoscopic Sacrocolpopexy with Vaginal Sacrospinous Ligament Fixation in the Treatment of Vaginal Apical Prolapse; the First Randomized Clinical Trial: A pilot study.

PURPOSE: To compare two methods of laparoscopic sacrocolpopexy (LSCP) and sacrospinous ligament fixation (SSLF) in terms of efficacy and safety in the treatment of vaginal apical prolapse. MATERIALS AND METHODS: This prospective, randomized controlled clinical trial was conducted on 32 patients with symptomatic vaginal apical prolapse, referred to the female urology clinic of Kerman University, Iran, during 2018-2019. The patients were re-examined at 12 months after surgery. Objective success was recorded using Pelvic Organ Prolapse Quantification (POP-Q) classification as primary outcome. The subjective success of the methods was determined by the quality-of-life parameters, based on Pelvic Floor Impact Questionnaire (PFIQ-7), Pelvic Floor Distress Inventory (PFDI-20), and Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) scores as secondary outcomes. Moreover, complications were recorded in both groups. RESULTS: The amount of intraoperative bleeding was significantly higher in the SSLF group, compared to the LSCP group (P = 0.01). Persistent pain was observed in two (12%) patients in the LSCP group and five (31%) patients in the SSLF group (P = 0.2). The decrease in the total PFIQ-7 score was in favor of the LSCP group but not statistically significant (p = 0.06). The LSCP group showed bigger improvement in vaginal (p = 0.04) and bowel (p = 0.03) scores. The results of the PISQ-12 and PFDI-20 questionnaires as well as POP-Q examination were not different in two groups. CONCLUSION: Although the surgical methods of LSCP and SSLF can be equally effective in the treatment of apical prolapse, LSCP appears to be superior to SSLF regarding less bleeding.

Comparing Periurethral Injection of Autologous Muscle-Derived Stem Cell and Fibroblasts with Mid-Urethral Sling Surgery in the Treatment of Female Stress Urinary Incontinence: A Randomized Clinical Trial.

Objective: In this study, we analyzed the therapeutic effect of periurethral injection of autologous muscle-derived stem cell versus mid-urethral sling surgery at a 1-year follow-up. Method: This randomized controlled clinical trial was conducted on 30 women with stress urinary incontinence (SUI) who had not responded to conservative treatments, after registering the participants and obtaining informed consent. Patients were divided into two groups of 15 each treated with periurethral injection of muscle-derived stem cells (MDSCs) and mid-urethral sling surgery, respectively. Follow-ups were done at 1, 3, 6, and 12 months after the treatment using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UISF) and Incontinence Quality of Life Questionnaire (I-QOL) questionnaires, clinical examination, cough test, and 1-hour pad test. The results were analyzed within the groups and then compared between the two groups. Moreover, both groups were compared in terms of postoperative complications. Results: At the 1-year follow-up, in the stem cell group, 10 patients (66.6%) experienced improvements after the periurethral injection of stem cells; half of these patients (33.3%) reported a full recovery. In the mid-urethral sling group, 13 patients (93.3%) experienced improvement, and 12 patients (80%) reported a full recovery. The analysis of ICIQ-UISF and I-QOL questionnaires indicated that the responses in both groups were significant, but the response in the stem cell group was significantly lower compared with the standard surgery group. No considerable complications were observed in the two groups. Conclusion: Although the periurethral injection of MDSCs considerably improves the symptoms with minimum complications in women with SUI, its therapeutic response is significantly lower compared with mid-urethral sling surgery.

An Unusual Presentation of Giant Fibroepithelial Polyp of the Vagina.

Fibroepithelial polyps of the vagina (FEPV) are rare entities which normally manifest as one or more painless polyps sometimes with symptoms such as bleeding, vaginal discharge, and discomfort regarding the size of the mass. Despite their benign nature, they can be confused with other vaginal tumors due to their abnormal histology. In this report, we present a case of a 44-year-old woman with a giant pedunculated and symptomatic polyp of the vagina with anterior vaginal wall prolapse. The treatment method included a simple local excision of the polyp and anterior vaginal compartment repair. Histopathological examination revealed a polypoid lesion covered by squamous epithelium containing a central fibrovascular core without atypia. The patient experienced an uneventful postoperative recovery, with no complication, which implies that surgery is the most effective modality for managing such tumors.

The Therapeutic Effect of Intravesical Instillation of Platelet Rich Plasma on Recurrent Bacterial Cystitis in Women: A Randomized Clinical Trial.

PURPOSE: Recurrent bacterial cystitis is a common infection in women and there are concerns about its antibiotic therapy. Platelet rich plasma has antimicrobial and tissue repairing effects. We investigated the effect of platelet rich plasma as an intravesical therapy to prevent recurrence of bacterial cystitis. MATERIALS AND METHODS: Thirty women with a history of recurrent bacterial cystitis were randomly assigned into two groups: 1) platelet rich plasma and 2) control groups. The first group received 10 mL of platelet rich plasma with intravesical instillation plus 40 mL of normal saline. The control group only received 50 mL of normal saline. We did the instillation once a week for four weeks in both groups. We followed up the participants two and 12 months after the last instillation with a questionnaire (the international consultation on incontinence questionnaire in overactive bladder) and result of their urine culture. RESULTS: A significant decrease was observed in the number of bacterial cystitis recurrences in the platelet rich plasma group compared to the control group 12 months after the instillation (4 vs. 1, P = 0.004). Also, there was a significant improvement in the questionnaire's score two (3.6 ± 2.58 vs. 0.66 ± 1.63, P = 0.002) and 12 months (3.4 ± 2.77 vs. 0.006 ± 1.83, P < 0.001) after instillation in the platelet rich plasma group compared to control group. There was no adverse effect 12 months after instillation. CONCLUSION: Platelet rich plasma can significantly decrease the recurrence of bacterial cystitis up to a year after instillation without any side effect.

Minimally invasive open dismembered pyeloplasty technique: Miniature incision, muscle-splitting dissection, and nopelvis reduction in children.

OBJECTIVE: To report the outcomes and complications of open dismembered Anderson-Hynes pyeloplasty with miniature incision in treating children's ureteropelvic junction obstruction. METHODS: Between March 2007 and April 2011, 109 children with a mean age of 2 years and 8 months old with ureteropelvic junction obstruction underwent open dismembered pyeloplasty. Clinical manifestations, radiographic assessments, incision size, surgery time, hospital stay, and complication rate were recorded. All patients had a documented ureteropelvic junction obstruction (having T1/2 more than 20 min in diethylenetriaminepentaacetic acid [DTPA] scan) with symptomatic stenosis or decreased kidney function (differential function <40%). Pyeloplasty was done by a retroperitoneal flank approach with miniature incision without pelvis reduction. One surgeon did all the surgeries. Success rate and complications were assessed in a 3-year follow-up. RESULTS: Mean surgery time was 52 min (47-60 min). Incision size was 18-28 mm. Mean hospital stay was 3 days (2-8 days). The surgery was successful in 98.2% of patients with a mean follow-up time of 36 months (success was defined as disappearance of symptoms, if present, with improved ultrasound imaging results or Reno graphic parameters). The complication rate was 7.33%, including urinary leakage, double-J urethral stent dislocation and infection. CONCLUSION: Open dismembered pyeloplasty is a safe, technically feasible and effective therapy in treatment of children's ureteropelvic junction obstruction. It takes a short time to do, requires a small incision and has few complications and a short recovery period.

Amplatz versus Balloon for Tract Dilation in Ultrasonographically Guided Percutaneous Nephrolithotomy: A Randomized Clinical Trial.

PURPOSE: To compare balloon with Amplatz for tract dilation in totally ultrasonographically guided PCNL (UPCN). METHODS: We randomized 66 patients candidate for sonographically guided PCNL in the flank position in two study groups. In the first group, we used single step Amplatz dilation (AG) technique in which the 28- or 30-French Amplatz dilator is used for tract dilation. In the other group, we dilated the tract using balloon dilator (BG). We compared procedure time, success rate of dilation, and postoperative clinical outcomes and cost between two groups. RESULTS: The rate of short dilation was higher in the Amplatz group (57.6%) compared with Balloon group (36.4%) (P=0.08). When using Amplatz for lower pole access, short dilation occurred in 81% of cases compared with 44% in the BG (P=0.02). Overall operation was longer in the AG (80±21 versus 65±20 minutes P=0.02). Stone free rate was 87.9% in the AG compared with 72.7% in the BG (p=0.12). Mean cost of the surgery was 603±85 USD and 718±78 USD in the AG and BG, respectively (P=0.0001). Hemoglobin drop, transfusion rate, renal function alteration, duration of hospitalization, and complication rate based on Clavien classification were similar in both groups. CONCLUSIONS: AG showed a higher rate of short dilation compared with BG; consequently, overall operating time was significantly longer in the AG whereas BG was significantly more expensive than AG. Bleeding and other complications were similar in two groups. We observed an advantage for balloon dilation over Amplatz when approaching the lower pole calyxes.

An unusual cause of urinary incontinence: Urethral coitus in a case of Mayer-Rokitansky-Kuster-Hauser syndrome.

Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a rare anomaly in women and is characterized by congenital aplasia of the uterus and vagina, with normal development of secondary sexual characteristics and a normal karyotype. We report a case of a 38-year-old women with MRKH syndrome that had experienced urethral sex for many years. She presented with urinary incontinence and dyspareunia. The patient's secondary sexual characteristics were normal, and examination revealed a widely open incompetent megalourethra and an absent vagina. Laboratory studies confirmed a 46, XX karyotype. Imaging included ultrasonography and magnetic resonance imaging, which indicated bilateral normal ovaries and a rudimental bicornuate uterus. After confirming the diagnosis of MRKH, the patient underwent urethroplasty by urethral plication, antiincontinence surgery by autologous fascial sling of the bladder neck, and the creation of a neo-vagina using a urethral flap. After 3 months, voiding cystourethrography and uroflowmetry confirmed normal voiding. There were no postoperative symptoms of urinary incontinence, and the patient was completely satisfied.

Simultaneous treatment of anterior vaginal wall prolapse and stress urinary incontinence by using transobturator four arms polypropylene mesh.

PURPOSE: To evaluate the medium-term efficacy and safety of transobturator four-arm polypropylene mesh in the treatment of high-stage anterior vaginal wall prolapse and concomitant stress urinary incontinence (SUI). MATERIALS AND METHODS: Between September 2010 and August 2013, a prospective single-center trial was performed to evaluate women with stage≥3 anterior vaginal wall prolapse with or without SUI who presented to Labbafinejad Hospital, Teheran, Iran, and underwent anterior vaginal wall repair with polypropylene mesh. Pre- and postoperative evaluation included history; physical examination using the Pelvic Organ Prolapse Quantification system and cough stress test, both before and after reduction of prolapsed structures; Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ); urinalysis and culture; and a postvoid residual assessment. Complications were reported at a mean of 2 years of follow-up. RESULTS: A total of 71 patients underwent cystocele repair with the transobturator four-arm polypropylene mesh. Seven of the patients were lost to follow-up. There were no perioperative complications. The anatomical success rate was 87.5%. The subjective success rate was 92.1%. The PFDI and PFIQ were significantly improved after surgery (p<0.001). Among those with the simultaneous complaint of SUI, 82% were cured without any additional procedure. Three patients (4.6%) experienced vaginal mesh extrusion. Two patients (3.1%) reported worsening of dyspareunia after surgery. CONCLUSIONS: The four arms polypropylene mesh is an effective device for simultaneous correction of anterior vaginal wall prolapse and SUI with a low complication rate at a medium-term follow-up. The majority of the subgroup with concomitant SUI were cured without a second simultaneous procedure.

Paraurethral cyst in adult women: experience with 85 cases.

PURPOSE: To present the clinical experience in the management of Skene's duct cysts (paraurethral cysts) in women. MATERIALS AND METHODS: A retrospective chart review of patients who have underwent surgical treatment for paraurethral cyst between 2002 and 2012 was performed. A total of 85 women were diagnosed with paraurethral cyst over a 10-year period. The paraurethral cysts were detected at vaginal examination. Evaluations consisted of urine analysis and culture and urinary tract ultrasound. The first 20 cases underwent cystourethroscopy as well. All patients underwent surgical incision, drainage and marsupialization of the cyst. They were followed for evidence of any complications and recurrence. RESULTS: The mean follow up time was 5.5 years. Totally, 83 patients (97.6%) were cured. There were two cases of recurrence which were treated with second surgical attempt. CONCLUSION: Most paraurethral cysts in women may be diagnosed by history and physical examination alone. Simple incision and marsupialization of the female paraurethral cyst was effective in more than 97% of our patients, without recurrence.

Intraprostatic botulinum toxin type A injection for the treatment of benign prostatic hyperplasia: Initial experience with Dysport.

OBJECTIVE: To evaluate the effect of intraprostatic botulinum toxin type A (BoNTA, Dysport) injection on lower urinary tract symptoms, prostate-specific antigen (PSA), prostate volume (PV), peak urine flow rate (Q(max)) and postvoiding residue (PVR), and to evaluate the role of PV in the treatment outcome. MATERIAL AND METHODS: Seventy-two men with PSA < 4 ng/ml, International Prostate Symptom Score (IPSS) > or = 8, Q(max) < 12 ml/s and PV < 60 ml were enrolled. A total of 300-600 U Dysport was injected transperineally under transrectal ultrasound guidance. Initial IPSS, quality of life (QoL) score, Q(max) and PVR were compared with their measures at 1, 6 and 12 months after the injection. Initial PSA and PV were compared with their values after 6 months. Parameters were also compared between patients with PV < or = 30 ml and those with PV > 30 ml. RESULTS: The mean age of participants was 63.5 years. At follow-up sessions, IPSS and QoL score were significantly decreased (p < 0.001). PVR reduced significantly and Q(max) increased considerably (p < 0.001). PSA and PV substantially decreased after 6 months (p < 0.001). No serious complications were reported. Similar to patients with larger prostates, IPSS and QoL score decreased statistically significantly after 12 months in those with PV < or = 30 ml; however, changes in PV, PSA, PVR and Q(max) did not persist during 12 months' follow-up. CONCLUSIONS: The procedure is safe and efficacious and the results are comparable to previous experiences with Botox. It seems that the toxin efficacy depends directly on PV in prostates < 60 ml.