Canadian Urological Association guideline on male urethral stricture.

Urethral stricture is fundamentally a fibrosis of the urethral epithelial and associated corpus spongiosum, which in turn, causes obstruction of the urethral lumen. Patients with urethral stricture most commonly present with lower urinary tract symptoms, urinary retention or urinary tract infection but may also experience a broad spectrum of other signs and symptoms, including genitourinary pain, hematuria, abscess, ejaculatory dysfunction, or renal failure. When urethral stricture is initially suspected based on clinical assessment, cystoscopy is suggested as the modality that most accurately establishes the diagnosis. This recommendation is based on several factors, including the accuracy of cystoscopy, as well as its wide availability, lesser overall cost, and comfort of urologists with this technique. When recurrent urethral stricture is suspected, we suggest performing retrograde urethrography to further stage the length and location of the stricture or referring the patient to a physician with expertise in reconstructive urology. Ultimately, the treatment decision depends on several factors, including the type and acuity of patient symptoms, the presence of complications, prior interventions, and the overall impact of the urethral stricture on the patient's quality of life. Endoscopic treatment, either as dilation or internal urethrotomy, is suggested rather than urethroplasty for the initial treatment of urethral stricture. This recommendation applies to men with undifferentiated urethral stricture and does not apply to trauma-related urethral injuries, penile urethral strictures (hypospadias, lichen sclerosus), or suspected urethral malignancy. In the setting of recurrent urethral stricture, urethroplasty is suggested rather than repeat endoscopic management but this may vary depending on patient preference and impact of the symptoms on the patient.The purpose of this guideline is to provide a practical summary outlining the diagnosis and treatment of urethral stricture in the Canadian setting.

Placenta percreta into the urinary bladder: the importance of the urologist.

The incidence of placenta accreta spectrum is on the rise. The most serious entity within this spectrum is percreta: extension beyond the uterus. The bladder is most commonly involved in these cases and is especially relevant for the urologist. Important sequelae include hemorrhage, massive transfusion, maternal mortality and urinary tract injury. Approaching this disorder as well as associated urinary tract involvement in a standardized and multi-disciplinary fashion significantly improves outcomes and reduces morbidity. Herein, we present a case of complete placenta percreta involving the bladder that was successfully managed with minimal obstetrical and genitourinary morbidity.

Male Urethral Stricture: American Urological Association Guideline.

PURPOSE: The purpose of this Guideline is to provide a clinical framework for the diagnosis and treatment of male urethral stricture. MATERIALS AND METHODS: A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1990 to 12/1/2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional guidance is provided as Clinical Principles and Expert Opinion when insufficient evidence existed. RESULTS: The Panel identified the most common scenarios seen in clinical practice related to the treatment of urethral strictures. Guideline statements were developed to aid the clinician in optimal evaluation, treatment, and follow-up of patients presenting with urethral strictures. CONCLUSIONS: Successful treatment of male urethral stricture requires selection of the appropriate endoscopic or surgical procedure based on anatomic location, length of stricture, and prior interventions. Routine use of imaging to assess stricture characteristics will be required to apply evidence based recommendations, which must be applied with consideration of patient preferences and personal goals. As scientific knowledge relevant to urethral stricture evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

SIU/ICUD Consultation on Urethral Strictures: Pelvic fracture urethral injuries.

The posterior urethra pierces the perineal diaphragm in close relationship to the pubic arc elements of the bony pelvis to which it is tethered by attachments to the puboprostatic ligaments and the perineal membrane. Because of these relationships, it is not surprising that fracture disruptions of the pelvic ring can be associated with injuries to the urethra at this level. Although the relationship between pelvic fracture and posterior urethral injury has been recognized for >1 century, considerable controversy exists on almost any aspect of these injuries, from the anatomy and classification of the injuries to the strategies for acute management, reconstruction, and treatment of complications, to mention just a few. What it is not controversial and well known is that these injuries can result in significant morbidity in the long run--mainly strictures, erectile dysfunction, and urinary incontinence--which can cause lifelong disability. It also well known that, just as in many other areas of trauma, the severity and duration of the complications can be reduced considerably if the injury is diagnosed and treated promptly and efficiently. This chapter summarizes the most relevant published evidence about the management of pelvic fracture urethral injuries. This comprehensive review, performed by an international panel of experts, will provide valuable information and recommendations to help urologists worldwide improve the treatment and outcomes of their injured patients.

The newly graduated Canadian urologist: Over-trained and underemployed?

INTRODUCTION: There are two prevailing perceptions among urology residents (1) fellowship training is becoming a requirement after residency, and (2) there are few job opportunities after graduation. In this study, we examine postgraduate training patterns and employment choices of urology residents. METHODS: All Canadian urology program directors provided a summary of fellowship training and employment of Canadian residents graduating between 1998 and 2009. Logistic regression models were used to detect linear trends. RESULTS: In total, 258 Canadian urology residents graduated over the study period, with a median of 22 (interquartile range 21-22) graduating per year. Of these, 72% completed a fellowship. Of these fellowships, 62% included protected research time. The most common subspecialty area was minimally invasive surgery (MIS)/endourology (39% of fellowships). There was a significant increase in fellowship training over time (p < 0.0001); this was mostly due to an increase in MIS/endourology fellowships. The number of urologists obtaining graduate degrees after medical school has increased significantly over the study period. Almost all graduates are employed. Of the employed graduates in total, 34% are academic urologists. Among all graduates, 50% are practicing within 100 km of their residency site, 16% are practicing in the United States and 22% are in rural practice. There has been no significant change over time in the proportion of residents practicing within 100 km of their training program, practicing rurally, leaving their province of training, practicing in the United States, or choosing academic practice. CONCLUSIONS: Fellowship training, especially in MIS/endourology, has become significantly more common. Graduate degrees are more frequently being obtained. We did not find evidence that there has been a significant change in a urology resident's ultimate ability to obtain employment upon graduation.

The augmented nontransected anastomotic urethroplasty for the treatment of bulbar urethral strictures.

OBJECTIVE: The augmented anastomotic urethroplasty (AAU) combines resection of a urethral stricture and an onlay graft. The augmented nontransected anastomotic urethroplasty (ANTA) is a modification of the AAU and involves complete stricture excision without transecting the spongiosum. MATERIALS AND METHODS: This is a retrospective cohort study comparing ANTA with dorsal onlay buccal grafting (DOBG) for bulbar urethral strictures. Medical records between 2005 and 2010 were reviewed. A cross-sectional questionnaire was used to assess long-term outcomes. Medians and interquartile ranges are reported. RESULTS: Forty-four men (23 DOBG, 21 ANTA) with a median follow-up of 2.3 years (range 1.2-3.8) were identified. There were no significant differences between ANTA patients and DOBG patients in terms of age, previous treatment, stricture location, or postoperative follow-up. There was no significant difference between groups in the use of bilateral buccal grafts (P = .416); median buccal length harvested was significantly less in the ANTA group (4.5 cm [range 4.0-5.0]) vs the DOBG group (5.0 cm [range 5.0-8.0], P = .047). Response rate to the cross-sectional survey was 59%. Five patients reported postoperative donor site complications, and there were no significant differences between the ANTA and DOBG groups. Overall success was 93% and not statistically different between groups (log rank test, P = .548). One ANTA patient and 2 DOBG patients required posturethroplasty treatment. CONCLUSIONS: The ANTA has results similar to DOBG and appears to be a viable option in the treatment of bulbar urethral strictures. This technique allows the surgeon to avoid urethral transection, to reconfigure the width of the urethral plate, and to use a smaller buccal graft.

Retrograde urethrocystography impairs computed tomography diagnosis of pelvic arterial hemorrhage in the presence of a lower urologic tract injury.

BACKGROUND: There is controversy about the appropriate sequence of urologic investigation in patients with pelvic fracture. Use of retrograde urethrography or cystography may interfere with regular pelvic CT scanning for arterial extravasation. STUDY DESIGN: We performed a retrospective study at a regional trauma center in Toronto, Canada. Included were adult blunt trauma patients with pelvic fractures and concomitant bladder or urethral disruption who underwent initial pelvic CT before operation or hospital admission. Exposure of interest was whether retrograde urethrography (RUG) and cystography were performed before pelvic CT scanning. Main outcomes measures were indeterminate or false negative initial CT examinations for pelvic arterial extravasation. RESULTS: Sixty blunt trauma patients had a pelvic fracture and either a urethral or bladder rupture. Forty-nine of these patients underwent initial CT scanning. Of these 49 patients, 23 had RUG or conventional cystography performed before pelvic CT scanning; 26 had cystography after regular CT examination. Performing cystography before CT was associated with considerably more indeterminate scans (9 patients) and false negatives (2 patients) for pelvic arterial extravasation (11 of 23 versus 0 of 26, p < 0.001) compared with performing urologic investigation after CT. In the presence of pelvic arterial hemorrhage, indeterminate or false negative CT scans for arterial extravasation were associated with a trend toward longer mean times to embolization compared with positive scans (p=0.1). CONCLUSIONS: Extravasating contrast from lower urologic injuries can interfere with the CT assessment for pelvic arterial extravasation, delaying angiographic embolization.