Ultrasonographic features of female urethral caruncle: a retrospective study of 20 patients.

Female urethral caruncle is the most common urethral mass in postmenopausal women, yet there is a lack of studies on its imaging. The aim of this study was to provide a summary of the clinical and ultrasound features as well as the precise location of female urethral caruncle. This study reviewed the clinical and ultrasonographic records of 20 consecutive women with pathologically confirmed urethral caruncle. Data on patient demographics, symptoms, and transperineal and transrectal ultrasound imaging features, including location, shape, margin, size, blood flow, and inner echo of the caruncle, were extracted. Each patient presented with only one mass at the urethral meatus. Most caruncles were located on the posterior lip (75%) of the urethra, presenting as oval (80%), mixed-echoic (50%), or hypo-echoic (40%) nodules with abundant linear (40%) or dendritic (60%) blood flow. The average distance between the bladder neck and the cranial end of the masses was 28 mm. Hyper-echogenic spots, cystic echo areas, and macrocalcifications were detected in thirteen caruncles (70%). This study shows that transperineal combined with transrectal ultrasound can be used to assess female urethral caruncle, and its relative location to the urethra can be accurately described, which is helpful for surgeons making preoperative localization and conversations.

Human umbilical cord allograft associated with higher pediatric urethrocutaneous fistula repair success rates.

BACKGROUND: Urethrocutaneous fistula (UCF) formation is a known complication following hypospadias repair, affecting between 5 and 70% of cases. Moreover, approximately 30% of patients experience refistulization after UCF repair. The use of extracellular matrices, such as AmnioCord, a dehydrated human umbilical cord allograft manufactured by MiMedx®, may mitigate high rates of refistulization. OBJECTIVE: To determine whether the use of AmnioCord during UCF repair is associated with reduced incidence of subsequent UCFs among pediatric patients. DESIGN, SETTING, AND PARTICIPANTS: Electronic medical records were retrospectively reviewed among 60 patients who underwent at least one UCF repair at a pediatric hospital in a large urban setting in the U.S. between January 2012-June 2018. Patients were followed through January 2024. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Adjusted generalized estimating equation regression models were used to assess the association between AmnioCord use and rates of refistulization, while controlling for confounding variables. RESULTS: The number of fistula presentations per patient ranged from one to four; 53.3% had one fistula, 30.0% had two, and 16.6% had three or more. Overall fistula repair success rate was 56.8% but significantly differed by AmnioCord use in adjusted modelling; 69.4% of cases that received AmnioCord were successfully repaired, compared to 47.2% of cases that did not receive AmnioCord. In adjusted models, patients who received AmnioCord had 2.66 times greater odds of surgical success than patients who did not receive AmnioCord (95% CI:1.13-6.24; p = 0.02). CONCLUSIONS: This study demonstrates a positive association between AmnioCord use and successful UCF closure among pediatric patients.

Case Report: Urethral Diverticulum after Tubularised Incised Plate Repair of Distal Hypospadias: An Uncommon Complication.

Introduction: A urethral diverticulum can be defined as a pocket that forms from the lining of the urethra and protrudes into the surrounding tissue, a condition which causes voiding dysfunction and may result as a rare complication of hypospadias repair surgery. Case report: We report the case of a 2-year-old child who presented to us in 2019 complaining of a thin forceful stream, ballooning of the ventral aspect of the penis while voiding, and post-void dribbling. He has a history of undergoing a tubularised incised plate urethroplasty for distal penile hypospadias at 18-months-old. Ultrasound showed increased post-void residual volume and cystourethroscopy confirmed a urethral diverticulum extending from the subcorona to the base of the penis. The patient underwent partial excision of diverticulum, urethroplasty, and meatoplasty. He was followed-up 3 months later with complete resolution of his symptoms and a normal urinary stream with no urethral ballooning or dribbling. Conclusion: Urethral diverticulum may present as a complication post hypospadias repair. Although it is rare, we believe that it is important for the patient's parents to understand the possibility and know of the signs and symptoms in addition to attending regular outpatient clinic appointments in order to facilitate early management if needed. Furthermore, it is highly important for physicians to assess newborns for hypospadias before carrying out circumcision as it is a contraindication for the procedure.

Ectopic Prostatic Tissue in Female Urethral Diverticulum.

BACKGROUND: Ectopic prostatic tissue in female patients is rare. It is theorized that the presence of prostatic tissue in female patients is likely a Wolffian remnant or transformation of hormonally mediated tissue of the uterus, cervix, Skene's gland, and, rarely, periurethral tissue. Due to the increase in the use of testosterone and gender-affirming therapies, it is important to understand the role of testosterone in mediating the presence of ectopic prostatic tissue. CASE: We present a case of ectopic prostatic tissue in a urethral diverticulum in a female patient with exposure to testosterone hormone therapy and review the literature on this finding. CONCLUSION: Although rare, ectopic prostatic tissue should be considered in the differential diagnosis of anterior vaginal cysts, especially in the setting of testosterone supplementation.

Stone-induced urethral fistula treatment with microfragmented adipose tissue containing mesenchymal stem cells: a case report from veterinary medicine with potential application in humans.

We report on a case of a two-year-old male dog, breed chow-chow, who suffered from urethral fistula as a result of ureterolithiasis. The urethral defect was identified intraoperatively with methylene blue. An autologous regenerative approach was combined with surgical closure of the defect, due to the well-known healing issues of the urethral wall in such conditions. A part of abdominal fat tissue was dissected to produce microfragmented adipose tissue containing mesenchymal stem cells, which was combined with platelet-rich plasma. The final product was applied in the area around the urethral defect closure. One month after the procedure, healing was confirmed with positive-contrast cystography. This therapeutic approach yielded success, and the follow-up period of one year was uneventful. The observed positive outcome of this approach in the canine model may be considered as a starting point for investigating the translational potential of the treatment in human medicine.

Evaluation of postoperative complications of hypospadias using high-frequency ultrasound imaging.

PURPOSE: Various complications following hypospadias surgery present distinct manifestations when examined with ultrasound. Utilizing high-frequency ultrasound, clinicians can promptly identify these complications and initiate appropriate treatment. The aim of this study is to catalogue the ultrasonographic presentations of various postoperative complications following hypospadias surgery, thereby providing a reference for ultrasonographic diagnosis. METHODS: Ultrasonic images of post-hypospadias surgery from October 1, 2015, to June 30, 2023, recorded at the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences, serve as the basis for this investigation. Drawing on patient clinical diagnoses, this study compiles and selects representative ultrasound images of diverse complications. RESULTS: The study encompassed a total of 121 subjects; 26 demonstrated urethral stricture on ultrasonic images, two presented local urethral dilation, six showed intraurethral hair-like structures, 17 revealed intraurethral septum, two exhibited intraurethral fold, one had urethral calculus, one displayed urethral calcification, 12 indicated intraurethral urine accumulation, and two showed urethral diverticulum. CONCLUSION: Ultrasound examination is helpful for postoperative diagnosis following hypospadias, detecting complications such as urethral stricture, urethral hair growth, and urethral diverticulum, which can help doctors choose appropriate clinical treatment strategies.

Surgical Approach to Urethral Diverticulum and Urethrovaginal Fistula With Mesh Erosion.

INTRODUCTION AND HYPOTHESIS: This video illustrates a rare surgical case involving a urethral diverticulum, urethrovaginal fistula, and mesh erosion. METHODS: We present a 58-year-old patient attending a tertiary care center with a suspected urethrovaginal fistula. Her concerns included stress urinary incontinence (SUI), recurrent urinary tract infection, and vaginal pain. The surgical history was notable for the placement of two different mesh slings during the same procedure to treat SUI. Preoperative evaluation and findings are illustrated in detail. The video uses a high-definition surgical camera to emphasize the initial intraoperative evaluation with localization of the fistula and diverticulum. We then demonstrate the approach to the dissection with the goal of ensuring complete resection of the diverticulum, fistula, and mesh, while preserving healthy tissue for subsequent closure. The utilization of unique and specialized tools for each portion of the procedure is also illustrated. A layered vaginal closure, including a Martius flap, is created to prevent recurrence. RESULTS: The surgery was accomplished without complications. CONCLUSIONS: To our knowledge, concomitant findings of a urethral diverticulum, urethrovaginal fistula, and mesh erosion are unique in the literature. We postulate that this triad could have resulted from the mesh burden in this particular patient.

Placement of an artificial urethral sphincter in 8 male dogs with urethral diverticulum.

BACKGROUND: Urethral diverticulum (UD) is a poorly defined anomaly consisting of an outpouching of the urethra. Management without surgical resection is not previously reported in dogs. HYPOTHESIS/OBJECTIVES: Report the outcome of male dogs presented for urinary incontinence with UD treated with an artificial urethral sphincter (AUS). ANIMALS: Eight client-owned dogs with UD treated with an AUS. METHODS: Multicenter retrospective study. Medical records from male dogs with urinary incontinence were reviewed. INCLUSION CRITERIA:  diagnosis of a UD by retrograde cystourethrography, cystoscopy, abdominal ultrasonography or contrast computed tomodensitometry (CT) or a combination of these modalities, AUS placement, and at least 1 follow-up. Urinary continence score (UCS) was attributed retrospectively. RESULTS: Median UCS at presentation was 1/5. A contrast cystourethrogram was diagnostic in 8/8 dogs. All diverticula were saccular, and 7/8 were within the prostatic urethra and 1/8 extended up to the membranous urethra. A congenital origin was suspected in 7 dogs and acquired in 1. Concurrent anomalies included renal dysplasia or chronic pyelonephritis (n = 4), bilateral cryptorchidism (n = 3), and pelvic urinary bladder (n = 3). All dogs were poorly/moderately responsive to phenylpropanolamine. Artificial urethral sphincter placement resulted in improvement in continence in all dogs with a median UCS of 4/5 (5/5 in 2/8 dogs, 4/5 in 5/8 dogs, 3/5 in 1/8 dogs). CONCLUSION: Urethral diverticulum should be considered in male dogs with persistent urinary incontinence not responding to medical management. Artificial urethral sphincter placement is an effective therapeutic option that improved continence scores in all dogs.

Urethral Outcomes of the Labia Minora Ring Flap for Metoidioplasty and Phalloplasty.

OBJECTIVE: To determine urethral outcomes of single-stage metoidioplasty and radial forearm free flap (RFFF) phalloplasty using the labia minora ring flap for urethral lengthening (UL). METHODS: A retrospective review was performed of patients undergoing single-stage metoidioplasty and RFFF phalloplasty utilizing the labia minora ring flap technique. The ring flap consists of endodermal labia minora tissue ventral to the clitoris and surrounding the vaginal introitus. During metoidioplasty, the ring flap accounts for the entirety of UL. During RFFF phalloplasty, the ring flap becomes the pars fixa (PF) urethra. The primary outcomes measured were rates of fistula, stricture, and surgical revision. RESULTS: Between November 2017 and August 2023, 311 patients underwent metoidioplasty or RFFF phalloplasty (mean follow-up 37 months). Of the 69 metoidioplasties, urethrocutaneous fistulas developed in 11 patients (16%); strictures occurred in 4 (6%). Of the 242 phalloplasty patients, there were 71 fistulas (29%), 56 of which resolved spontaneously. Strictures developed in 44 patients (18%). Twenty-five patients (10%) developed both a stricture and fistula. Surgical repair was required in 8/69 (12%) metoidioplasty patients and in 46/242 (19%) RFFF phalloplasty patients for an overall revision rate of 17%. CONCLUSION: UL during metoidioplasty or RFFF phalloplasty can be accomplished in a single stage using the labia minora ring flap with comparable surgical revision rates to previously described techniques. This approach can also be applied to other phalloplasty techniques. Many fistulas of the PF urethra resolve spontaneously. Higher urethral revision rates were seen in phalloplasty compared to metoidioplasty.

Reducing fistula rate in hypospadias repair: A comparative study between standard tubularized incised plate repair and incorporation of a layer of spongiosum tissue.

INTRODUCTION: The most prevalent complication in hypospadias repair is fistula formation. Adhering to the principle of providing urethroplasty coverage to mitigate fistula occurrence, we implemented a modification by integrating a spongiosum layer between the urethroplasty and the dartos flap. Our hypothesis posited that this approach would result in a reduced fistula formation rate. METHODS: This study is a comparative analysis involving patients under 18 years of age who underwent primary hypospadias repair. The cases were allocated into two groups. In the study group, in addition to performing tubularized incised plate (TIP) repair, a spongiosum layer harvested from both sides of the urethra was used to cover the urethroplasty (modification of the Y-to-I urethroplasty). The control group underwent a standard TIP repair. The primary outcome was to assess urethrocutaneous fistula formation. Secondary outcomes included evaluating the development of meatal stenosis and glans dehiscence, along with assessing cosmetic results by the Hypospadias Objective Penile Evaluation (HOPE) score. RESULTS: Overall, 154 hypospadias cases were included in the study. Eighty-seven patients (56%) were allocated to the study group, and 67 (44%) were allocated to the control group. Urethrocutaneous fistula developed in 3 (3.4%) and 11 (16.4%) patients in the study and control group, respectively (p = 0.006). Glans dehiscence occurred in 2 (2.3%) patients in the study group and 4 (6%) patients in the control group (p = 0.198). Meatal stenosis was observed in 4 (4.6%) patients in the study group and 5 (7.5%) patients in the control (p = 0.452). The mean HOPE score was 59 in both groups (p = 0.36). DISCUSSION: This study details our encounters with the novel modification and compares the results with standard TIP. Our data suggest that adding a layer of spongiosum tissue over the urethroplasty reduces the complication of urethrocutaneous fistula without increasing the occurrence of dehiscence, significant meatal stenosis, or compromising cosmetic outcomes. CONCLUSION: We advocate for implementing the described surgical modification as a viable option for hypospadias repair.

Eighteen years of experience in laparoscopic implantation of artificial urinary sphincter in women with intrinsic sphincter deficiency.

INTRODUCTION AND OBJECTIVES: Artificial urinary sphincter (AUS) is a treatment option for women with stress urinary incontinence (SUI) after failure of previous surgery or as a primary procedure in severe intrinsic sphincter deficiency (ISD). The aim of the study was to assess the long-term efficacy and risk factors for surgical revision and definitive explantation of AUS laparoscopic implantation in female patients. METHODS: A retrospective review of all women submitted to AUS implantation between April 2005 and March 2023 was conducted. The AUS was implanted via transperitoneal laparoscopic approach, by two experienced surgeons. The primary endpoint was postoperative continence. Continence was defined as no leakage and no pad usage or leakage and/or pad usage with no impact on social life and failure as leakage and/or pad usage impacting social life. As secondary outcomes, clinical predictive factors for AUS revision and definitive explantation were evaluated. RESULTS: In the last 18 years, females with a mean age of 68±12 years-old were submitted to laparoscopic implantation of AUS. Early overall complication rate was 16%, but only one case was Clavien-Dindo ≥3. After a median follow-up of 67 months, 22.2% of the patients needed a device revision, the majority due to mechanical device dysfunction. AUS definitive explantation was performed in 16%, mainly due to urethral/vaginal erosion (9.9%) and infection (6.2%). Patients with age ≥70 years and follow-up ≥10 years significantly predisposed for device revision. At the time of the last follow-up, 72% of the patients were keeping the urinary continency. CONCLUSIONS: Laparoscopic AUS implantation in females is an effective treatment for SUI due to ISD. Meanwhile, adequate patient selection, multidisciplinary evaluation and careful expectation management are essential to achieving good results, concerning their significant complication rate.

Timing of male urethral injury treatment in patients with polytrauma: A retrospective study.

INTRODUCTION: Male urethral injuries are uncommon, and the ideal timing of the definitive treatment remains controversial. This study aimed to compare the outcomes of early and delayed interventions (1 month or more after the injury) for male urethral injuries. PATIENT AND METHODS: We conducted a retrospective review of the medical records of 67 male patients with urethral injuries treated at our institution between 2011 and 2020. We examined patient age, injury severity score (ISS), abbreviated injury scale, mechanism, location and severity of injury, presence of pelvic fractures, surgical interventions, timing of treatment, and complications. We analysed factors associated with urinary complications based on the location of urethral injury. Additionally, we performed a subset analysis of patients with severe injuries (ISS≥16) to assess the impact of delayed surgery. RESULTS: Overall, 47 %, 37 %, and 27 % of patients in the delayed treatment group (N = 30) had urethral stricture (US), erectile dysfunction (ED), and/or urinary incontinence (UI). These rates were greater than the 22 % US, 3 % ED, and 11 % UI rates in the early treatment group (N = 37). The subgroup analysis revealed that patients with anterior urethral injury (AUI) who underwent delayed treatment (N = 18) tended to be more severely injured (ISS, 19 vs 9, p = 0.003) and exhibited higher rates of US (44% vs 21 %, p = 0.193) and ED (39% vs 0 %, p = 0.002) than those who received early treatment (N = 24). In the case of posterior urethral injury (PUI), the delayed treatment group (N = 13) had higher rates of US (50% vs 23 %, p = 0.326), ED (33% vs 8 %, p = 0.272), and UI (42% vs 0 %, p = 0.030) than the early treatment group. Regarding study limitations, more than 45 % of the enrolled patients were severely injured (ISS≥16), which may have potentially influenced the timing of urethral injury repair. CONCLUSIONS: The treatment of male urethral injuries may be delayed due to concurrent polytrauma and other associated injuries. However, delayed treatment is associated with higher rates of urinary complications. Early treatment of urethral injuries may be beneficial to male patients with urethral trauma, even in cases of severe injury.

Comparison of postoperative urinary complications in laparoscopic-assisted anorectoplasty versus posterior sagittal anorectoplasty for anorectal malformation with rectourethral fistula.

BACKGROUND: Long-term urinary outcomes after anorectal malformation (ARM) repair are affected by surgical approach and sacral anomalies. This study aimed to compare laparoscopic-assisted anorectoplasty (LAARP) and posterior sagittal anorectoplasty (PSARP) in terms of urinary complications. METHODS: Between 2001 and 2022, 45 patients were treated with LAARP or PSARP. The rectourethral fistula and inflow angle between the fistula and rectum was confirmed by preoperative colonography. The incidence of urinary complications and treatment were compared between the two groups. RESULTS: Four patients (14%) had remnant fistula and five patients (17%) had neurogenic bladder dysfunction in LAARP group, while three patients (18%) had urethral injury in PSARP group. All patients with remnant fistula were asymptomatic and followed without treatment. The incidence of remnant fistula improved between earlier decade and later decade. In all cases with urethral injury, suture repair was performed and no postoperative leakage was noted. All five patients with neurogenic bladder dysfunction had spine abnormalities that required clean intermittent catheterization (CIC) and two were free from CIC finally. CONCLUSIONS: It is important to check inflow angle preoperatively to prevent remnant fistula. For PSARP, meticulous dissection is required when separating fistula from urethra because they create common wall. The most contributing factor to neurogenic bladder is sacral anomalies. Preoperative evaluation and postoperative urinary drainage are important.

Correlation between congenital pelvic floor muscle development assessed by magnetic resonance imaging and postoperative defecation.

OBJECTIVE: Children with congenital anorectal malformation (CAM) experience challenges with defecation. This study aims to assess defecation in preschool-age children with CAM and to evaluate the correlation between pelvic floor muscle developed assessed by magnetic resonance imaging (MRI) and postoperative defecation. METHODS: We collected clinical data and MRI results from 89 male children with CAM. The bowel function scores for children with Perineal (cutaneous) fistula, Rectourethral fistula(Prostatic or Bulbar), and Rectovesical fistula were computed. MRI scans were subjected to image analysis of the striated muscle complex (SMC). The association between pelvic floor muscle score and bowel function score was examined using the Cochran-Armitage Trend Test. RESULTS: We observed that 77.4% of the SMC scores by MRI for Perineal fistula were good. The Rectourethral fistula SMC score was 40.6% for moderate and 59.4% for poor. The SMC score for Rectovesical fistula was 100% for moderate. Furthermore, 77.4% of patients with Perineal fistula had bowel function scores (BFS) ≥ 17 points. Among those with Rectourethral fistula and Rectovesical fistula, 12.5% and 0 had BFS ≥ 17 points, respectively. An analysis of muscle development and bowel function in patients with Rectovesical fistula, Rectourethral fistula, and Perineal fistula revealed a correlation between SMC development and BFS. Subgroup analysis showed that the Perineal fistula had statistical significance; however, the Rectourethral fistula and Rectovesical fistula were not statistically significant. CONCLUSION: A correlation exists between pelvic floor muscle development and postoperative defecation in children with Perineal fistula.

Genitourinary Fistula: epidemiology, changing trends in etiology and management: A tertiary care institute's perspective.

INTRODUCTION: Urogenital fistula is a physically, socially and psychologically devastating condition for the patient. In developed countries, these fistulae are typically related to gynecological surgery, pelvic pathology like malignancy or post radiation therapy. In contrast, classical teaching is that urogenital fistulae in the developing countries like India are usually associated with prolonged labor and obstetric complications. This retrospective study conducted at a tertiary care health Institute shows a paradigm shift in epidemiology, etiology and management of genitourinary fistulae in India in recent times. METHODS: This retrospective study included patients undergoing surgical repair for various genitourinary fistulae at our institute from 2016 to 2022. Epidemiology, etiology, site, size and number of fistulae, clinical presentation, and management records of these patients were recorded and reviewed retrospectively. RESULTS: In our study, the mean age of the patients was 38.4 ± 10.2 years. Vesicovaginal Fistula (VVF) was found to be most common fistula in the study population (87.5%) followed by vesicouterine (7.1%) and urethrovaginal fistula (5.4%). The causes of genitourinary fistula were iatrogenic (73.2%), carcinoma of cervix (16.1%), obstructed prolonged labor (7.1%), and genitourinary tuberculosis (3.57%). Among the 48 vesicovaginal fistulas that underwent surgery, 45.8% were treated using a transvaginal approach, 29.2% were managed through a laparoscopic transabdominal repair, and 25% were addressed using a robotic approach. Recurrence occurred in 7.1% of the operated patients. CONCLUSION: Enhanced healthcare services in the country have contributed to a decrease in the incidence of obstructed labor, subsequently reducing related injuries. Iatrogenic injuries resulting from gynecological surgeries and carcinoma cervix have given rise to more complex fistulas, necessitating the implementation of advanced treatment strategies.

Mid-term results of ReMEEX sling system in female stress urinary incontinence with various indications and feasibility of readjustment.

PURPOSE: To examine efficacy and safety of ReMEEX implantation in patients with female stress urinary incontinence (SUI) associated with detrusor underactivity (DU), recurrence, or intrinsic sphincter deficiency (ISD). MATERIALS AND METHODS: Retrospective cohort study included 303 females who underwent ReMEEX system (March 2008 to May 2021). Patients were stratified into three groups by purpose of surgery (SUI with DU, reoperation, and SUI with ISD) and evaluated with following criteria: cure (absence of subjective complaint of leakage and objective leakage in the stress test), improvement (rare leakage subjectively, but satisfaction regardless of stress test), and failure. Primary outcome was success rate of surgery assessed through patient interviews and a stress test. Surgical outcomes and complications were evaluated. RESULTS: Mean follow-up was 34.4 months (range, 6.0-145.0 months). At the final follow-up visit, 42.9% and 49.2% of patients were cured and improved. Twenty-one point five percent required tension readjustment (mean number, 1.2). The total complication rate was 19.5% (none for grade ≥4). Preoperative Qmax was significantly higher in the ISD group (p<0.001) and preoperative total International Prostate Symptom Score (IPSS) score was significantly higher in the DU group (p=0.044). Moreover, at postoperative 1 year, both total IPSS score and IPSS quality of life score were significantly higher in the DU group (both p=0.001). CONCLUSIONS: The success rate of ReMEEX system was 92.1% at mean follow-up of 34.4 months in female SUI with DU, reoperation, or ISD. It also enabled postoperative readjustment of sling tension, as needed, up to 130 months after surgery.

Modified PATIO technique for urethrocutaneous fistula after hypospadias repair: Experience from a tertiary referral hospital.

INTRODUCTION: Urethrocutaneous fistula (UCF) is a common complication after hypospadias repair with an incidence of 5-10%. Several techniques are described for its repair: small UCFs are frequently corrected by isolation, excision, and closure with apposition of a protective second layer. In 2008 Malone described the PATIO technique: the fistula tract is turned inside out in the urethral lumen preventing contact with passing urine without direct urethral sutures. OBJECTIVE: Aim of our study is to present our outcomes using a modified version of the PATIO technique, with a more reproducible isolation of the tract and without its fixation at the urethral meatus. STUDY DESIGN: We retrospectively reviewed all cases of UCFs corrected with a modified PATIO technique at our center between 2016 and 2020. Data collected from electronical clinical notes were age at UCF closure, location of UCF, presence of meatal stenosis and clinical outcomes. Data are presented as median and IQR. RESULTS: In the study period we performed 425 urethroplasties for distal and mid penile hypospadias. The incidence of UCFs was 7% (30/425) and 25 patients underwent UCF correction with modified PATIO. Median age at repair was 4.5 years (IQR: 2.5-6.2). At a median follow-up of 3 years (IQR: 2-4) recurrence was observed in 5 cases out of 24 with one patient who was lost at follow-up (20.8%). One case was corrected successfully with re-do modified PATIO technique, while 4 are awaiting repair. One cases was lost at follow-up. UFC-recurrence was homogeneously distributed along the study period. DISCUSSION: Risk factors for UCF recurrence are mostly the type of hypospadias, neo-urethral length, and quality of the urethral plate. Among the many existing techniques, we propose a modified version of Malone's PATIO repair. We believe that the use of four stay-suture to isolate the fistula allows a well-defined dissection of the tract along its surface, compared to the use of a single stay-suture. In our experience, there is no need to keep and fix the traction on the fistula tract to the urethral meatus, probably reflecting the efficacy of the fistula closure during the introflection, which is then maintained without traction. Limitations to our study include the retrospective nature of the review, the small sample size of the cohort and the absence of control groups. CONCLUSIONS: Our results appear consistent with literature regarding the efficacy of PATIO principles in treating UCF. Modified PATIO seem to be particularly reproducible, showing encouraging results.

Intrinsic ureteric obstruction secondary to endometriosis: a rare clinical entity causing obstructive uropathy and renal failure.

Ureteral endometriosis is rare and can be a silent clinical entity, which can potentially lead to serious complications such as obstructive uropathy, sepsis and renal failure. A high clinical suspicion is required especially in childbearing age groups due to non-specific presentation such as renal colic, recurrent urinary tract infection (UTI), renal failure or asymptomatic hydronephrosis.A woman in her 40s presented with febrile UTI and flank pain. She reportedly suffered from recurrent UTIs in the past. Initial workup revealed an infected, obstructed left renal collecting system with gross hydronephrosis and hydroureter to the distal ureter on a significant gynaecological background of severe endometriosis requiring hysterectomy in the past.CT showed chronic obstructive changes and soft tissue nodules within the renal pelvis with no radio-opaque stones. She underwent emergent ureteric stent insertion. Functional imaging demonstrated only 1% contribution of the left kidney with a preserved estimated glomerular filtration rate of 65 mL/min/1.73 m2Endoscopic evaluation of ureters found extensive soft tissue lesions throughout the dilated left collecting system with biopsy-confirmed endometriosis. Subsequently, she underwent laparoscopic nephroureterectomy due to extensive ureteric involvement and chronically obstructed non-functioning kidney. Histopathology demonstrated completely obstructing ureteral endometriosis.Ureteric obstruction secondary to endometriosis can be due to extrinsic or intrinsic disease. In addition to initial assessment with CT urogram MRI may be helpful to evaluate soft tissue thickening. Endoscopic assessment with ureteroscopy and biopsy is required for tissue diagnosis. Surgery is often the treatment of choice, ranging from ureteroureterostomy, ureteroneocystostomy or nephroureterectomy in severe cases.Ureteral endometriosis is a rare clinical entity, clinicians should remain vigilant about common presentations of this rare entity, early diagnosis and prompt treatment is crucial to prevent progression to renal failure.

Long-term Outcomes With Macroplastique in Women With Stress Urinary Incontinence Secondary to Intrinsic Sphincter Deficiency.

OBJECTIVE: To evaluate the long-term outcomes of polydimethylsiloxane (Macroplastique (MPQ)) in women with stress urinary incontinence (SUI) secondary to intrinsic sphincter deficiency (ISD) using validated questionnaires. METHODS: Following IRB approval, charts of non-neurogenic women with SUI secondary to ISD who underwent MPQ injection were reviewed from a prospectively maintained database. ISD was defined as positive stress test with a well-supported urethra and low Valsalva leak point pressure when available. Excluded were women with follow-up <5years. Baseline data included validated questionnaire scores (UDI-6 question 3 (0-3), VAS Quality of Life, Incontinence Impact Questionnaire (IIQ-7)) and urodynamic study findings. Patients were followed with same questionnaires and three-dimensional ultrasound evaluating volume/configuration of MPQ. All three-dimensional ultrasound measurements were performed by the same imaging team blinded to clinical outcomes. Outcomes were evaluated in four groups based on prior SUI treatment. Success was defined as UDI-6 question 3 score of 0-1 and not requiring additional anti-incontinence therapy at the last visit after the last MPQ injection. RESULTS: From April 2011-December 2016, 106 patients (median age 67) met study criteria. Median follow-up time was 7.4years. Median MPQ injected was 5 mL. Overall success was 43%, with 54% successful after one injection and 46% requiring ≥2 injections. Across all groups, patients had improvement in Quality of Life and IIQ-7 Question 7 (frustration). Among the failure group, 17% opted for a secondary autologous sling procedure. CONCLUSION: MPQ demonstrated long-term favorable outcomes in a subset of women with SUI secondary to ISD.

Confronting urethrorrhagia after Otis urethrotomy: a case report.

BACKGROUND: Otis urethrotomy can sometimes lead to troublesome bleeding after seemingly uneventful procedures. This case report highlights one such case which went unnoticed initially; the bleeding was erroneously ascribed to the prostate, thereby falsely indicting the "decoy" prostate. CASE PRESENTATION: A 78-year-old Asian gentleman was referred to our hospital with complaint of intractable bleeding after undergoing laser enucleation of prostate at another institute, wherein he further underwent unsuccessful bilateral angioembolization of pudendal arteries. On endoscopy (for hemostasis), we found a spurting vessel in the navicular fossa, which was effectively controlled. CONCLUSIONS: This case report highlights the importance of performing prompt endoscopy in case of uncontrolled bleeding after prostate endoscopic surgery.