British Association of Urological Surgeons Consensus statements on the management of ketamine uropathy.

OBJECTIVES: To provide guidance in the form of consensus statement in the management of ketamine uropathy. METHODS: A literature review of ketamine uropathy was performed. The consensus method was of a modified nominal group technique and has been use in the previous British Association of Urological Surgeons (BAUS) consensus documents and was led by the Female, Neurological and Urodynamic Urology Section of the BAUS. RESULTS: A number of consensus statements detailing the assessment and management of urological complications relate to the recreational use of ketamine (ketamine uropathy) in both elective and emergency urology settings. CONCLUSION: Comprehensive management pathway for ketamine-related urinary tract dysfunction and uropathy has been detailed.

Sacral Tarlov cysts: Neurophysiology abnormalities and correlation with pelvic sensory and visceral symptoms.

BACKGROUND AND PURPOSE: Recent studies suggest a possible association between Tarlov cysts (TCs), usually considered as incidental radiological findings, and neurological symptoms such as pain, numbness and urogenital complaints. The aim was to explore the relationship between TCs and sacral nerve root functions using pelvic neurophysiology tests, and to correlate changes with clinical symptoms and magnetic resonance imaging (MRI) findings. METHODS: Consecutive patients with sacral TCs, referred for pelvic neurophysiology testing and presenting with at least one symptom related to the pelvic area, participated in a cross-sectional review of symptoms using validated questionnaires. Findings of pelvic neurophysiology (pudendal sensory evoked potentials, sacral dermatomal sensory evoked potentials, external anal sphincter electromyography) and urodynamics testing were collected retrospectively. The relationship between neurophysiology, MRI findings and patients' symptoms was assessed using Fisher and ANOVA tests. RESULTS: Sixty-five females were included (mean age 51.2 ± 12.1 years). The commonest symptom was pain (92%). Urinary (91%), bowel (71%) and sexual (80%) symptoms were also frequently reported. Thirty-seven patients (57%) had abnormal neurophysiology findings reflecting sacral root dysfunction. No association was seen between MRI findings (size, location of the cysts, severity of compression) and neurophysiology. A negative association was observed between neurophysiology abnormalities and occurrence of urgency urinary incontinence (p = 0.03), detrusor overactivity (p < 0.01) and stress urinary incontinence (p = 0.04); however, there was no association with voiding difficulties. CONCLUSIONS: Contrary to current understanding, TCs are associated with injury to the sacral somatic innervation in the majority of patients with presumed symptomatic cysts. However, urinary incontinence is unlikely to be related to TC-induced nerve damage.

Botulinum toxin A injection to the external urethral sphincter for voiding dysfunction in females: A tertiary center experience.

AIM: The aim of this study is to examine the functional outcomes of ona-botulinum toxin A (BTX-A) injection into the external urethral sphincter (EUS) for female patients with nonneurogenic nonrelaxing sphincter as the underlying cause of voiding dysfunction (VD). METHOD: A retrospective analysis was performed for all the patients with the urodynamic findings of higher than expected maximum urethral closure pressure (MUCP) who received their first injection during the study period. All patients were evaluated with preoperative videourodynamic study and urethral pressure profilometry and received 100 U of EUS BTX-A. Patients aged less than 18 years and those with neurogenic bladder were excluded. All patients were followed up with the free flow, postvoid residuals (PVR), and patient global impression of improvement (PGI-I) scale at 6 weeks and then at 3 monthly intervals. RESULT: We identified 35 female patients with a mean age of 37.5 ± 15 years (range 18-72 years) with a mean follow-up of 20 months. More than 50% of patients had a history of prior surgical intervention and 28 (80%) patients were catheter dependent, a suprapubic catheterization, or clean intermittent self-catheterization. Mean MUCP was 97.1 ± 22 cm of water. After treatment with BTX-A, 21 (60%) patients were able to void per urethral (p = 0.02). The mean maximum flow rate (Qmax) improved from 8.8 to 11 mls/s and the mean PVR decreased from 200 to 149 mls (p < 0.05). On multivariate analysis, we identified high preoperative PVR, high preoperative actual MUCP, and previous surgical intervention (urethral dilatation, sacral neuromodulation, and pelvic surgery) as predictors of successful voiding restoration. The mean duration of response was 4.7 months, 46% of patients requested repeat injection, and 29% were established on maintenance injections. On the 5-point PGI-I score, 13 (37%), 12 (34%), and 10 (29%) patients reported good, some, and no improvement, respectively. Quality of life was also improved in 60% of patients. Two patients had transient stress urinary incontinence (for <6 weeks) and there were no significant long-lasting adverse events. CONCLUSION: EUS BTX-A is a valid treatment option for VD considering therapeutic options are limited. The patient must be made aware of the need for repeat treatments.

Functional outcomes of vaginal surgery for urethral extrusion of mid-urethral tape in women.

INTRODUCTION AND HYPOTHESIS: We aim to determine the presentation of and immediate and longer-term outcomes of vaginal surgical excision of urethral extrusion of mid-urethral tape (MUT). METHODS: We performed a retrospective analysis of all patients with urethral extrusion of MUT having vaginal surgical excision between 2007 and 2018. The MUT was removed either partially (via vaginal approach) or completely (via combined vaginal and laparoscopic approach). Functional outcomes and any re-interventions are described. RESULTS: Thirty-four patients of median age 53 (range 34-82) years were identified. Preoperative symptomatic recurrent/persistent urinary incontinence was present in 29/34(85%) with 24/34(71%) women having recurrent/persistent stress urinary incontinence (SUI) or stress predominant mixed urinary incontinence (s-MUI) on urodynamics. Vaginal surgical excision was performed alone in 33/34(97%) women and in combination with laparoscopic removal of abdominopelvic MUT in 1/34(3%) woman. In the longer term vaginal/urethral pain resolved or improved in all 15/15(100%) patients presenting with this complaint whilst patient reported poor flow resolved in 8/9 (89%) women. Twenty-eight of 34 women (82%) had persistent/recurrent SUI or s-MUI following MUT excision. Twenty-four of 34 women (71%) had further SUI surgery with cure or improvement of SUI in 20/24 (83%) patients. CONCLUSIONS: The outcome of vaginal surgical excision of the MUT was cure or improvement of pain in 100% and resolution of poor flow in 89% women. Recurrent/persistent SUI or s-MUI was present in 82% following removal as compared to 71% women prior to removal. Of the 71% of women electing to have further surgery for recurrent/persistent SUI/s-MUI, 83% were dry or improved afterwards.

Seizing the opportunity to improve patient care: pelvic floor services in 2021 and beyond.

Patients requiring pelvic floor and functional urological, gynaecological and coloproctological surgery were viewed as a low priority even before COVID-19. A consensus report outlines recommendations to improve care and encourage clinicians to help bring about positive changes for patients with pelvic floor problems.

Intravesical onabotulinumtoxinA injections in patients on antiplatelet and anticoagulation therapy.

AIMS: To determine the bleeding risk in patients taking anticoagulants (AC) and antiplatelets (AP) before onabotulinumtoxinA (BoNT-A) injections and improve peri-operative decision making and counseling. METHODS: We performed a retrospective review of patients having intravesical BoNT-A in three teaching hospitals from January 2016 to July 2018. Demographic data, indication for intravesical BoNT-A injection, and side-effects of significant bleeding requiring intervention were recorded. RESULTS: Five hundred and thirty-two patients had intravesical BoNT-A injections during this time. Sixty-three patients of mean age 69 years (range 19-89) had a total of 114 separate rounds of BoNT-A injections whilst on treatment dose AC/AP therapy. Of the 63, there were 33 males, with 46 having idiopatic detrusor overactivity and 17 with neurogenic detrusor overactivity. Each patient had between 1 and 7 repeat injections during the studied period. AC/AP use across the 114 episodes included; aspirin 44, clopidogrel 37, warfarin 19, and NOAC (novel/non-vitamin K oral anticoagulant) 14. Patients on warfarin who had point of care testing all had international normalized ratio less than 3. BoNT-A dose varied from 100U to 300U-modal dosage was 200U.1/114(0.88%) injection episodes resulted in postinjection hematuria requiring overnight admission. This resolved spontaneously, with an overnight catheter. This patient was on rivaroxaban and had 300U of BoNT-A injected through 20 sites, on a background of previous prostate radiotherapy and self-catheterization. CONCLUSIONS: Continuation of AP/AC therapy during intravesical BoNT-A injection treatment appears to be safe-with a 0.88% rate of spontaneously resolving hematuria.

A comparison of flow rate curve shape and video-urodynamic findings in women with lower urinary tract symptoms: can flow rate curve shape predict female bladder outflow obstruction or detrusor underactivity?

PURPOSE: To establish the correlation between flow rate curve shape and video-urodynamic findings in women with lower urinary tract symptoms (LUTS). METHODS: A retrospective review of consecutive women with LUTS who performed a free flow study immediately before undergoing video-urodynamic investigations over a 28-month period. Flow rate curve shape and video-urodynamic parameters were analysed. Free flow curves were defined into five categories: bell-shaped, prolonged, fluctuating, intermittent or plateau. Women who voided less than 150 ml on the free flow study were excluded from the analysis. RESULTS: A total of 250 women with LUTS, with a mean age 48 years (range 18-83), were included. Bell-shaped tracings excluded obstruction in 89%. Prolonged flow rate curves diagnosed obstruction in 62% and detrusor underactivity in 8%. Fluctuating and intermittent flow rate curves were associated with urodynamic obstruction in 37 and 39%, respectively, and detrusor underactivity in 25 and 29%, respectively. A plateau flow rate curve was indicative of urodynamic obstruction in all three cases observed. CONCLUSION: Flow rate curve patterns can be suggestive of urodynamic diagnoses. Women without a prolonged void and bell-shaped traces had normal voiding urodynamics in 76% of cases, and the majority could be managed without invasive investigations. Patients with fluctuating and intermittent flow rate curves demonstrate a spectrum of urodynamic diagnoses with a third of cases having obstruction and a third of cases having detrusor underactivity. Plateau flow rate curve patterns are associated with urethral obstruction.

A clinico-neurophysiological study of urogenital dysfunction in MOG-antibody transverse myelitis.

OBJECTIVE: To assess the clinical, urodynamic, and neurophysiologic features of patients with persisting bladder, bowel, and sexual dysfunction after transverse myelitis in myelin oligodendrocyte glycoprotein antibody (MOG-Ab) disease. METHODS: Patients with a history of MOG-Ab disease-related transverse myelitis seen prospectively in a tertiary center uro-neurology service between 2017 and 2019 were included. They received cross-sectional clinical assessment; completed standardized questionnaires on bladder, bowel, and sexual symptoms; and underwent urodynamic and pelvic neurophysiologic investigations. RESULTS: Twelve patients (9 male) were included with a total of 17 episodes of transverse myelitis. Mean age at first attack was 26 (SD 9) years, and median follow-up duration was 50 (interquartile range 32-87) months. Acute urinary retention requiring bladder catheterization occurred in 14 episodes and was the first symptom in 10 episodes. Patients with lesions affecting the conus medullaris required catheterization for significantly longer durations than those without a conus lesion (median difference 15.5 days, p = 0.007). At follow-up, all patients had recovered full ambulatory function, but persisting bladder and bowel dysfunction moderately or severely affected quality of life in 55% and 36%, respectively, and 82% had sexual dysfunction. Pelvic neurophysiology demonstrated abnormal residual conus function in 6 patients. Urodynamic findings predominantly showed detrusor overactivity and/or detrusor-sphincter dyssynergia, indicative of a supraconal pattern of lower urinary tract dysfunction. CONCLUSIONS: Persisting urogenital and bowel dysfunction is common despite motor recovery. Although a proportion of patients had neurophysiologic evidence of residual conus abnormalities at follow-up, predominant urodyamic findings suggest that ongoing lower urinary tract dysfunction results from supraconal injury.

The efficacy of onabotulinumtoxinA in patients with previous failed augmentation cystoplasty: Cohort series and literature review.

AIMS: To investigate the role of onabotulinumtoxinA (BTX-A) injections in patients with failed augmentation cystoplasty for neuropathic or idiopathic detrusor overactivity (NDO or IDO). METHODS: A retrospective review of all cystoplasty patients who underwent onabotulinumtoxinA injection at a tertiary center between 2008 and 2019 was performed. Details including indications and time from cystoplasty, video-urodynamic parameters, onabotulinumtoxinA dose, and clinical outcomes were analyzed. Telephone interview was performed for patients that requested repeat onabotulinumtoxinA injections. The interview included a modified PGIC7 and UDI6 questionnaires. A positive clinical response was considered improvement of overactive symptoms sufficient to merit repeat onabotulinumtoxinA injection and a modified PGIC7 of four or above. RESULTS: Thirty patients were identified (11 men and 19 women). The indications for augmentation were IDO (n = 18) or NDO (n = 12). Mean age at the time of cystoplasty was 42 years (range, 10-61). Interval between cystoplasty and initial onabotulinumtoxinA was 98 months (range, 3-271). Video-urodynamics before onabotulinumtoxinA revealed low compliance in 13 patients, DO in 22 patients, and combined low compliance/DO in 10. The median maximum cystometric bladder capacity was 338 mL (range, 77-570 mL). Thirteen patients responded to onabotulinumtoxinA injections. Higher peak DO pressure was associated with a significantly higher chance that the patient would experience benefit from the injections P = .026). The patients that responded to onabotulinumtoxin A underwent a total of 115 procedures (mean, 8.8 injections) over a mean 88 months (range, 20-157 months). CONCLUSIONS: Forty-three percent of patients responded well to intra-detrusor onabotulinumtoxinA injections. This avoided the need for more invasive surgery and had a positive impact on their quality of life.

Treatment validation of the Solomon-Greenwell nomogram for female bladder outlet obstruction.

AIM: Bladder outflow in women (bladder outlet obstruction [BOO]) has no well-accepted defining diagnostic criteria. Various nomograms exist based on flow rates, pressure-flow data, and fluoroscopy. We have prospectively evaluated the Solomon-Greenwell bladder outflow obstruction nomogram (SG BOO nomogram) as a measurement of BOO resolution following targeted surgical intervention. METHODS: The routine posttreatment urodynamics of 21 unselected women with an original urodynamic diagnosis of BOO on fluoroscopy and the SG BOO nomogram (BOO boundary defined as Qmax > 2.2 Pdet.Qmax + 5) were reviewed. All women had symptomatic BOO secondary to anterior pelvic organ prolapse (aPOP), urethrovaginal fistula (UVF), previous stress urinary incontinence (SUI) surgery, urethral stricture (US), or urethral diverticulum (U Div). Following treatment, all presenting symptoms resolved and simple urodynamics were performed as part of routine follow-up. RESULTS: The urodynamic findings preoperatively and postoperatively showed statistically significant changes posttreatment in mean flow rate which increased from 9.38 to 14.71 mL/s, mean Pdet.Qmax which decreased from 38 to 18.38 cmH2 O, and mean SG BOO nomogram probability (PBOO) which reduced from PBOO = 0.68 to 0.08. Mean SG BOO nomogram PBOO was significantly reduced posttreatment in all individual categories except UVF where a nonsignificant reduction from PBOO = 0.55 to 0.05 occurred. CONCLUSIONS: All urodynamic parameters significantly improve in women who become asymptomatic following surgical treatment of BOO. This improvement is best demonstrated by the change in probability of BOO according to the Solomon-Greenwell nomogram. These findings underline the validity of the Solomon-Greenwell female BOO nomogram for diagnosing and monitoring BOO in women.

Surgical outcomes of vesicovaginal fistulae in patients with previous pelvic radiotherapy.

INTRODUCTION AND HYPOTHESIS: Vesicovaginal fistulae (VVF) repair success rates for simple surgical fistulae are high, but constitute a significantly greater challenge when occurring in a radiotherapy field. We aim to evaluate the causes, assessment, closure rates and functional outcomes of VVF surgery in patients with previous radiotherapy. METHODS: Data on all VVF repairs were collected prospectively. A retrospective review of outcomes in those with VVF performed between 2009 and 2018 was carried out. Details including time from radiotherapy, pre-operative assessments, approach to surgery and functional outcome were analysed. RESULTS: Twenty women with VVFs were identified. The mean age was 59 (range 25-88) years. Primary malignancy was cervical in 16 women, with the remaining 4 women having ovarian, urethral, endometrial and rectal cancer respectively. All women had external beam radiotherapy with 6 (30%) undergoing boosted brachytherapy. Mean interval between radiotherapy and fistula repair was 19 (range 0-40) years. Fistulae arose spontaneously in 14 patients, whereas 6 occurred following a further surgical intervention.Closure was attempted vaginally in 7 women and abdominally in 1, whereas 12 had a primary diversion owing to significant bladder contracture and ureteric involvement. The closure rate in those attempted was 62.5%, 40% in those with spontaneous fistulae compared with 100% for post-surgical fistulae, but only 20% for the total cohort. CONCLUSIONS: Closure of VVF is a significant challenge, with an initial success rate of 20% and an overall success rate of only 25%. Seventy percent required primary or secondary urinary diversion. Vaginal surgery was utilised in the majority to try to avoid a hostile pelvis, but the surgical approach should be tailored to individual circumstances.

Female Urology and Urogynecology: The Outcome of Patients Participating in Live Surgical Broadcasts.

INTRODUCTION: The aims of this study were to assess the complications and short- and long-term outcomes of patients involved in live surgical broadcasts (LSBs) of female urology and urogynecological surgery and compare the surgical success with operations performed outside this setting by the same surgeons. METHODS: We reviewed our prospectively collected database of all patients who had taken part in LSBs between 2008 and 2015 for the annual female urology and urogynecology course. Data on intraoperative and 30- and 90-day complications and primary outcomes from surgery were collected. Procedure-specific success rates were determined and compared with the center's previously published success rate for these procedures. RESULTS: Overall, 53 females with a median age of 50 years (range, 23-77 years) underwent 62 procedures during these LSBs. There were no intraoperative complications. There was 1 Clavien-Dindo grade II complication within 30 days of surgery. Within 90 days of surgery, there was 1 Clavien-Dindo grade III complication, which occurred in a patient having removal of anterior pelvic organ prolapse mesh for urethral erosion and simultaneous colposuspension. The majority of operations, 57 (92%) of 62, achieved their intended primary outcome. CONCLUSIONS: With careful planning, LSB can offer a safe way of sharing current operative techniques and decision making with similar 30- and 90-day complication rates to standard practices and comparable functional outcomes to standard practice.

Treatment of Urinary Urgency Incontinence Using a Rechargeable SNM System: 6-Month Results of the ARTISAN-SNM Study.

PURPOSE: Sacral neuromodulation is a guideline recommended treatment of urinary dysfunction and fecal incontinence in patients in whom conservative treatments have failed. Historically sacral neuromodulation has been delivered using a nonrechargeable device with an average life span of 4.4 years. Surgery is required to replace the implanted neurostimulator due to battery depletion. Implantation of a long-lived implanted neurostimulator can eliminate the need for replacement surgeries, potentially reducing patient surgical risks and health care costs. The Axonics r-SNM System™ is a miniaturized, rechargeable sacral neuromodulation system designed to deliver therapy for at least 15 years. The ARTISAN-SNM (Axonics® Sacral Neuromodulation System for Urinary Urgency Incontinence Treatment) study is a pivotal study using rechargeable sacral neuromodulation therapy to treat urinary urgency incontinence. Six-month results are presented. MATERIALS AND METHODS: A total of 129 eligible patients with urinary urgency incontinence were treated. All participants were implanted with a tined lead and the rechargeable sacral neuromodulation system in a nonstaged procedure. Efficacy data were collected using a 3-day bladder diary, the validated ICIQ-OABqol (International Consultation on Incontinence Questionnaire Overactive Bladder quality of life) questionnaire and a participant satisfaction questionnaire. Therapy responders were identified as participants with a 50% or greater reduction in urinary urgency incontinence episodes compared to baseline. We performed an as-treated analysis in all implanted participants. RESULTS: At 6 months 90% of participants were therapy responders. The mean ± SE number of urinary urgency incontinence episodes per day was reduced from 5.6 ± 0.3 at baseline to 1.3 ± 0.2. Participants experienced a clinically meaningful 34-point improvement on the ICIQ-OABqol questionnaire. There were no serious device related adverse events. CONCLUSIONS: The Axonics r-SNM System is safe and effective with 90% of participants experiencing clinically and statistically significant improvements in urinary urgency incontinence symptoms.

The cost effectiveness of vaginal versus abdominal repair of vesicovaginal fistulae.

INTRODUCTION AND HYPOTHESIS: The objective was to assess the comparative provider costs of vaginal and open abdominal repair of vesicovaginal fistula (VVF) and to determine the most cost-effective means of managing VVF. METHODS: A prospectively acquired database of all women undergoing VVF repair by a single surgeon between 2007 and 2015 was retrospectively reviewed to determine operating time, perioperative complications, inpatient stay and 30-day readmissions. The success and cost of the VVF repair were identified. Statistical analysis was by unpaired t test, Chi-squared test and Mann-Whitney U test. RESULTS: Forty-seven consecutive women of mean age 51 years (range 21-88) undergoing a first attempt at VVF repair at our institution were included; 32(68%) had vaginal repair with Martius fat pad interposition and 15 (32%) had open abdominal repair with omental interposition. There were no perioperative complications or 30-day readmissions in either group. Mean operative time was longer for open abdominal (223.4 min) than vaginal repair (196.9 min). Median inpatient stay was longer for an open abdominal (8 days) than for a vaginal approach (4 days). Successful anatomical closure was achieved in 91% of vaginal and 86% of open abdominal repairs at first attempt, and in 100% after second repair, where required. Mean/median costs for an abdominal repair were significantly higher, at £4,608.69/£4,169.20 than for vaginal repair at £3,381.50/£3,009.24 (P<0.05). CONCLUSIONS: Vesicovaginal fistulae were successfully repaired in 89% of cases at first attempt. The success rate did not differ between approaches. Vaginal repair is significantly more cost-effective than abdominal repair owing to the shorter operative time and length of stay.

The incidence and outcomes of urodynamic stress urinary incontinence in female patients with urethral diverticulum.

AIMS: To assess the incidence and management of urodynamic stress urinary incontinence (USUI) in women undergoing transvaginal excision of a urethral diverticulum (UD) at our institution. METHODS: A prospective database, capturing patients undergoing urethral diverticulectomy over a 9-year period (May 2007 to August 2016), was reviewed focusing on USUI and subsequent management. RESULTS: One hundred patients underwent UD excision (with modified Martius labial fat-pad flap interposition). Preoperative magnetic resonance imaging data, available in 90 patients, demonstrated that 80% had complex diverticula. Complete urodynamic data were available for 93 patients. Preoperatively, 27 patients (29%) had USUI of which 16 patients resolved with either UD excision alone (n = 8) or 3 months of pelvic floor muscle therapy (PFMT) (n = 8). All 11 with persistent postoperative USUI had video urodynamics (VUDs) confirming Blaivas type 3 USUI. Six patients had a rectus fascial pubovaginal sling (RFPVS) with success in five (83.3%) while five had a mid-urethral obturator tape (MUT-O) with 100% success. Sixteen patients developed de novo stress urinary incontinence (SUI) postoperatively, with resolution after PFMT in 12 (75%). VUDS identified USUI (Blaivas type 3) in two (of the remaining four) patients, managed successfully with MUT-O (n = 1) and RFPVS (n = 1). CONCLUSION: Preoperative USUI is present in 29% with UD. Postoperatively, 35.5% (n = 33) have pre-existing (19) or de novo (14) SUI, of which 60.6% (n = 20) resolves after 12 months of conservative management. Surgery for USUI is required in 13 (13.9%), with cure in 92.3%. This supports our practice to excise UD primarily and delay USUI surgery, therefore, avoiding overtreatment for the majority.

Urethral diverticula in women are associated with increased urethra-sphincter complex volumes: A potential role for high-tone nonrelaxing sphincter in their etiology?

AIMS: Functional obstruction secondary to a high-tone nonrelaxing sphincter (HTNRS) may lead to the formation of a proximal-to-mid-urethral diverticulum (pmUD) in patients without a history of anatomical obstruction, vaginal delivery, vaginal and/or urethral surgery, or periurethral gland infection, that is, a functional pmUD (fpmUD). We used measurements of the urethra-sphincter complex volume (USCv) as a proxy for the maximal urethral closure pressure to evaluate this potential etiological factor. METHODS: We compared 17 consecutive women with fpmUD (mean age ± SD of 49.4 ± 13.2 years) with a control group consisting of 24 age-matched women (mean age: 50.8 ± 11.2 years) with no previous urological symptoms having MRI for posthysterectomy vesicovaginal fistula, and in all 71 women (mean age: 48.1 ± 11.6 years) with classical urethral diverticulum (cpmUD) referred in the same time period. The urethra-sphincter complex was measured using T2-weighted MRI and OsiriX© was then used to determine the USCv. RESULTS: The mean USCv of the fpmUD group was 10.01 ± 6.97 cm3 . The mean USCv of the cpmUD was 5.19 ± 1.19 cm 3 and for the control group was 3.92 ± 1.60 cm 3 . There was a high statistically significant (P = .01) difference between the USCv in the fpmUD group and the USCv of both the cpmUD and the control groups. CONCLUSIONS: Women with fpmUD demonstrated USCv that were significantly higher than those in women with cpmUD and the control group. These findings suggest that high pressure in the proximal urethra during voiding secondary to a HTNRS may contribute to the formation of urethral diverticula.

Incidence, type and management of ureteric injury associated with vesicovaginal fistulas: Report of a series from a specialized center.

OBJECTIVES: To report a large series of vesicovaginal fistula, and to assess the incidence of ureteric injury in association with vesicovaginal fistula. METHODS: We retrospectively reviewed a prospective database of patients with vesicovaginal fistula referred to our center between 2004 and 2016. Data on patient demographics, fistula etiology, mode of repair, and any associated ureteric injury and its treatment were noted. RESULTS: Overall, 116 patients (median age 49 years, range 23-88 years) were referred for management of vesicovaginal fistula during the study period. Four of these patients (3.4%) had associated ureteric injury, one of whom had bilateral injury. Ureteric obstruction alone was noted in two patients, ureterovaginal fistula alone in one patient, and bilateral ureteric obstruction and ureterovaginal fistula in one patient. All ureteric injuries were managed with simultaneous reimplantation into the bladder at the time of vesicovaginal fistula repair. Five patients had post-radiotherapy vesicovaginal fistula, and the remainder were post-surgical. Three patients with post-radiotherapy vesicovaginal fistula proceeded to primary diversion. CONCLUSIONS: Ureteric injury is far less common than previously reported, occurring in <5% of patients presenting with vesicovaginal fistula. It can be successfully managed, and it remains the major indication for abdominal repair of vesicovaginal fistula.

Diagnosis and surgical outcomes of ectopic ureters in adults: A case series and literature review.

OBJECTIVES: To evaluate functional outcomes of surgery in patients with ectopic ureters diagnosed in adulthood; to review the world literature. PATIENTS AND METHODS: Patients were referred over 10 years. Data including surgical history, presenting symptoms, diagnostic modalities, interventions and functional outcomes were collected; and the world literature reviewed. RESULTS: 9 women and 1 man had a mean age of 37 (range 20-58). All women were referred with lifelong leakage. The man was referred with storage LUTS. Three women had heminephrectomy/nephrectomy with the distal ureter left in-situ prior to referral. MRI was the predominant diagnostic tool but often took senior review to confirm the diagnosis. Excision of the ectopic ureter was performed with bladder neck reconstruction in 6 women, with concomitant rectus fascial sling in one patient. 4 of 6 (67%) women were cured of their stress incontinence with the bladder neck reconstruction alone, whilst two required further intervention. Three women had nephroureterectomy alone as primary treatment of which two were cured. The single male had heminephrectomy and excision of seminal vesicle. CONCLUSIONS: Ectopic ureter is a rare diagnosis in adults but should be considered in patients who describe lifelong incontinence. Fine slice MRI is the imaging of choice. Excision of the ureter with bladder neck reconstruction alone was successful in two-thirds of patients, whilst further stress urinary incontinence surgery was required in one-third. Malignancy in ureteric remnants is described in 8% of the world literature. Patients should be counselled of this risk if the ureter is left in-situ.

Outcomes of reconstructive urinary tract surgery after pelvic radiotherapy.

Background: Pelvic radiotherapy causes tissue atrophy and fibrosis, leading to urinary tract dysfunction. Tissue ischaemia poses a significant surgical challenge. This study examined the urological sequelae of radiotherapy, types of reconstructive urological surgery (RUS) required and functional outcomes. Methods: A retrospective review was performed of all radiotherapy patients who underwent RUS at a tertiary centre between 2007-2017. Details including time from radiotherapy, pre-operative assessments, type of surgery performed and functional outcome were analysed. Results: Fifty-four patients were identified. The primary malignancy was cervical (32), colorectal (9) and other urogenital/metastatic origins in the remaining cases. Mean time between radiation and RUS was 13 years. Sixty-nine reconstructive surgeries were performed. Twenty-two patients had fistulae, but only 27% were closed and 73% ended with urinary diversion. Eighteen had ureteric strictures, with 56% having associated bladder dysfunction. Twelve (67%) patients had RUS, of whom 83% required bowel interposition, and 33% primary diversion. Nine of 24 patients with contracted bladders were reconstructed and eight remain functionally continent. Renal function stabilised or improved in 87%. Nine patients (17%) had Clavien 3 or 4 complications. Conclusions: A variety of complex, major RUS were required. In 61%, urinary diversion was necessary, with radiotherapy fistulae being a particular challenge and closed in only a third. In total, 37% of patients were reconstructed achieving functional continence and restoration of upper-tract drainage with renal function preservation. This surgery was at a cost of a re-intervention rate of 28% and significant morbidity in 17%. RUS in the radiotherapy field should be performed in centres with experience.