Application of Urethral Contrast Computed Tomography Three-Dimensional Imaging in the Postoperative Assessment of Prostate Hyperplasia.

This study assesses the morphological effectiveness of benign prostatic hyperplasia (BPH) surgery using multislice spiral computed tomography three-dimensional imaging (CT3D) with urethral contrast. Twenty-five male patients with BPH and bladder outlet obstruction (BOO) who underwent bipolar transurethral resection of the prostate were selected. Preoperative and postoperative CT3D indicators of retrograde and voiding cystourethrography, including bladder neck diameter, length of the posterior urethra, and degree of prostate protrusion into the bladder and upper and lower diameter of the prostate were used to assess bladder neck and posterior urethra morphology and BOO severity. In addition, preoperative and postoperative International Prostate Symptom Scores and maximum urine flow rates were compared. Postoperative CT3D was used to evaluate changes following obstruction relief postsurgery. Preoperative CT3D indicated significant BOO, whereas postoperative imaging showed improved patency but with irregular posterior urethral lumens and varying degrees of residual glandular tissue. Comparative analysis of preoperative and postoperative bladder outlet metrics revealed significant changes (p < .05). Urethral contrast CT3D effectively visualizes the prostate, bladder neck, and prostatic urethra. It quantifies changes in the urethral lumen postsurgery, correlating the extent of posterior urethral lumen spaciousness with urinary flow rates.

Design, Development, and Validation of a First, Low-cost, Three-dimensional (3D) Printed Optical Urethrotomy Simulation Model.

OBJECTIVE: To develop and validate a low-cost, portable, and reusable simulation model for optical internal urethrotomy (OIU) training. METHODS: A 3D-printed low-cost simulation model for OIU was designed locally and the final model was evaluated by trainees and trainers at the urology boot camps (UK, Belgium, Portugal, Poland). Participants were asked to complete a questionnaire, using a 6-item 5-point Likert Scale, to assess the model's anatomic realism. RESULTS: A total of 27 trainees and 9 trainers evaluated the model. The model's anatomy and color were rated as the most realistic features, with 88.9% and 11.1% of respondents rating them as good and excellent, respectively. There were no significant differences between consultants and trainees in their assessment of any of the simulation properties of the OIU model. CONCLUSION: Our study introduces an innovative, lifelike, and cost-effective simulation model for OIU training. Our model provides a realistic simulation of OIU. We feel that our low-cost and reusable model fills the gap in simulation-based training for young trainees in urology.

Urethral Bulking With Polyacrylamide Hydrogel Compared With Other Treatments for Stress Urinary Incontinence: A Cost-Effectiveness Analysis.

Our objective was to perform a cost-effectiveness analysis comparing polyacrylamide hydrogel urethral bulking with other surgical and nonsurgical treatments for stress urinary incontinence (SUI). We created a cost-effectiveness analysis using TreeAge Pro, modeling eight SUI treatments. Treatment with midurethral sling (MUS) had the highest effectiveness (1.86 quality-adjusted life-years [QALYs]), followed by polyacrylamide hydrogel (1.82 QALYs), with a difference (Δ 0.02/year) less than the minimally important difference for utilities of 0.03 annually. When the proportion of polyacrylamide hydrogel urethral bulking procedures performed in the office setting is greater than 58%, polyacrylamide hydrogel is a cost-effective treatment for SUI, along with pessary, pelvic floor physical therapy, and MUS. Although MUS is more effective and, therefore, the preferred SUI treatment, polyacrylamide hydrogel is a reasonable alternative depending on patient preferences and treatment goals.

Advancing Intraoperative Assessment of Urethral Stricture Anatomic Variation: A Prospective Proof-of-Concept Study.

INTRODUCTION: Urethral strictures, particularly those refractory to endoscopic interventions, are commonly treated through open urethroplasty. However, predicting recurrence in homogeneous patient populations remains challenging. METHODS: To address this, we developed an intraoperative urethral stricture assessment tool aiming to identify comprehensive risk predictors. The assessment includes detailed parameters on stricture location, length, urethral bed width, spongiosum thickness, obliteration grade, and spongiofibrosis extension. The tool was prospectively implemented in 106 men with anterior one-stage augmentation urethroplasty from April 2020 to October 2021. RESULTS: An intraoperative granular assessment of intricate stricture characteristics is feasible. Comparative analyses revealed significant differences between bulbar and penile strictures. Bulbar strictures exhibited wider urethral beds and thicker spongiosum compared to penile strictures (all p < 0.001). The assessment showed marked variations in the degree of obliteration and spongiofibrosis extension. CONCLUSION: Our tool aligns with efforts to standardize urethral surgery, providing insights into subtle disease intricacies and enabling comparisons between institutions. Notably, intraoperative assessment may surpass the limitations of preoperative imaging, emphasizing the necessity of intraoperative evaluation. While limitations include a single-institution study and limited sample size, future research aims to refine this tool and determine its impact on treatment strategies, potentially improving long-term outcomes for urethral strictures.

Semiquantitative Tissue Perfusion Assessment Using Indocyanine Green in Complex Open Urethral Reconstruction.

OBJECTIVE: Current assessment of critical tissue in genitourinary reconstruction, including graft beds and tissue flaps, primarily relies upon qualitative visual and tactile assessment by experienced surgeons. Here we explore the feasibility of using intravenous indocyanine green (ICG) for semiquantitative assessment of perfusion in complex open urethral reconstruction. METHODS: A standardized protocol for intravenous use of ICG and near-infrared fluorescence was established. Black and white mode was used for qualitative assessment of perfusion based on signal brightness. Quantitative perfusion mode was used to assess relative perfusion to tissue of interest compared to a control area with similar tissue type outside of the studied area. Real-time perfusion was visualized as percentage of perfusion relative to control. RESULTS: In case 1, the graft bed was assessed during dorsal onlay graft substitution urethroplasty. Perfusion to graft bed was compared to that of erectile bodies proximally. A proposed perfusion cutoff of 60% was noted to correlate with clinical judgment of graft bed quality. In case 2, tissue perfusion of Blandy flap in perineal urethrostomy was assessed before and after mobilization. A cutoff of 40% was proposed based on existing flap-based reconstruction literature with the goal to tailor flap and ultimately avoid tissue ischemia and necrosis. In case 3, in a complex staged substitution urethroplasty after hypospadias repair, the use of ICG facilitated a limited excision and shorter graft inlay in this staged reconstruction. CONCLUSION: The application of near-infrared fluorescence tools in open genitourinary reconstruction has the potential to advance quantitative assessment of graft, flaps, and other critical tissue planes, and help establish meaningful perfusion threshold and correlate with clinical outcomes.

Assessment of clinical prognosis improvement in children with concomitant anterior and posterior urethral valves: A case series report.

BACKGROUND: Concomitant anterior urethral valves (AUVs) and posterior urethral valves (PUVs) is an extremely rare congenital urologic anomaly, which may be easily overlooked in the clinic. OBJECTIVE: This study assessed the prognosis of children with concomitant PUVs and AUVs. METHODS: The clinical data of inpatients with concomitant AUVs and PUVs in our hospital were collected from January 1983 to June 2022. The clinical manifestations, auxiliary inspection, and treatment were described in detail. RESULTS: In total, 6 cases of concomitant AUVs and PUVs in boys were found in our hospital, with ages ranging from 3 months to 9 years; the main clinical manifestation was abnormal urination. Four patients exhibited concomitant AUVs and PUVs preoperatively and underwent simultaneous anterior and posterior urethral valvotomy. Follow-up studies showed that 3 patients' clinical symptoms substantially improved with well-maintained renal function. One patient died of renal failure. In the other 2 patients, PUVs were initially identified and excised, but their clinical symptoms did not show substantial improvement. Following voiding cystourethrography (VCUG), the AUVs were found and obstructions were then completely relieved. However, 2 patients died of renal failure. CONCLUSIONS: If urinary symptoms cannot be substantially relieved after posterior urethral valvotomy, VCUG and cystoscopy should be repeated to shorten the interval between anterior and posterior urethral valvotomies to improve patient prognosis.

External validation and reliability assessment of posterior urethral morphology on initial voiding cystourethrogram as a predictor for infants with posterior urethral valves.

INTRODUCTION: The morphology of the bladder and posterior urethra on initial voiding cystourethrogram (VCUG) in posterior urethral valve (PUV) has been proposed as a meaningful early metric for short- and long-term kidney outcomes. Here, we seek to externally validate the proposed association and assess the reliability of PUV morphology characteristics. MATERIALS AND METHODS: We reviewed our institutional database for patients managed for PUV between 2000 and 2022 and included those treated with primary ablation with at least 1 year of follow-up for kidney function. Each VCUG was evaluated by three independent raters for the height-width ratio of the bladder (HW-B), height-width ratio of the posterior urethra (HW-PU), and posterior-anterior urethral ratio (PA-UR), and trabeculation (none, fine, or coarse). We assessed the reliability in these with intra-class coefficient and Fleiss kappa for continuous and categorical data, respectively. We performed univariate analysis with nadir creatinine and five-year follow-up glomerular filtration rate (GFR). RESULTS: In total, 98 patients met inclusion criteria. The median age at diagnosis and ablation was 10 and 21 days, respectively. Patients with nadir creatinine <0.8 mg/dL had higher follow-up GFR (101 vs. 20 ml/min/1.73 m2, p = 0.04), and lower risk of CKD (odds ratio 14.7, p = 0.002). The median value for HW-B was 1.4, median HW-PU was 2.1, and median PA-U was 4.7, There was significant inter-class agreement between all three measures of 0.80, 0.51, and 0.70 (p < 0.001). The inter-rater agreement for bladder trabeculation was fair (Fleiss K = 0.40, p < 0.001). There was no statistically significant correlation between HW-B, HW-PU, PU-A with nadir creatinine (p = 0.07, 0.33, 0.91) or 5-year GFR (0.27, 0.45, 0.62), respectively. DISCUSSION: There is significant interest in determining prognostic factors and metrics in PUV. The morphological characteristics on VCUG are reliable and is available information for all boys diagnosed with PUV, resulting in an attractive metric. While we do not demonstrate correlation with kidney outcomes, VCUG features warrant further attention as prognostic factors in PUV. CONCLUSIONS: PUV morphology on initial VCUG is a reliable metric of lower urinary tract deformity but is not associated with 5-year kidney outcomes.

Unaided visual assessment of ventral curvature during hypospadias repair is inferior to objective measurement using app goniometry.

OBJECTIVE: Failure to perform artificial erection or objectively assess ventral curvature (VC) during primary hypospadias repair is an important reason for residual/ recurrent chordee. The present study compares the accuracy of unaided visual inspection (UVI) with objective VC assessment using smartphone application (app) goniometry. METHODS: All patients who underwent primary hypospadias repair between January 2021 and September 2022 were included. Assistant surgeons were asked to grade the degree of VC on UVI (after degloving and an artificial erection test) into: none, mild (<30 degree), severe(>30 degree). Lateral profile photograph was taken and angle measurement was performed on an android mobile application (Angulus). Correlation was performed with both methods of assessment. RESULTS: During this period a total of 210 patients were analyzed; VC was noted in 40/138 (29%) cases of distal and in 62/72 (86%) cases of proximal hypospadias. Erroneous visual inspection was noted in 41/210 (20%; 95% CI 14-25%) on UVI (15 erroneously marked none while 26 marked mild). Among those found to have chordee, UVI assessed 39/82 (47%) as severe while app goniometry assessed 65/97 (67%) as severe. There was significant relative risk of labelling severe chordee as a mild one by UVI: 1.4 (95%CI 1-1.8; p=0.01). CONCLUSIONS: UVI was erroneous in 20% of cases. UVI was less accurate in differentiating severe chordee from mild one. In 60% patients UVI alone could have led to erroneous VC assessment and thus wrong selection of technique. Further studies are required to validate our findings and standardize VC measurement using an app goniometry.

Mechanical and morphological characterisation of porcine urethras for the assessment of paediatric urinary catheter safety.

Paediatric urinary catheters are often necessary in critical care settings or to address congenital anomalies affecting the urogenital system. Iatrogenic injuries can occur during the placement of such catheters, highlighting the need for a safety device that can function in paediatric settings. Despite successful efforts to develop devices that improve the safety of adult urinary catheters, no such devices are available for use with paediatric catheters. This study investigates the potential for utilising a pressure-controlled safety mechanism to limit the trauma experienced by paediatric patients during inadvertent inflation of a urinary catheter anchoring balloon in the urethra. Firstly, we establish a paediatric model of the human urethra using porcine tissue by characterising the mechanical and morphological properties of porcine tissue at increasing postnatal timepoints (8, 12, 16 and 30 weeks). We identified that porcine urethras harvested from pigs at postnatal week 8 and 12 exhibit morphological properties (diameter and thickness) that are statistically distinct from adult porcine urethras (postnatal week 30). We therefore utilise urethra tissue from postnatal week 8 and 12 pigs as a model to evaluate a pressure-controlled approach to paediatric urinary catheter balloon inflation intended to limit tissue trauma during inadvertent inflation in the urethra. Our results show that limiting catheter system pressure to 150 kPa avoided trauma in all tissue samples. Conversely, all of the tissue samples that underwent traditional uncontrolled urinary catheter inflation experienced complete rupture. The findings of this study pave the way for the development of a safety device for use with paediatric catheters, thereby alleviating the burden of catastrophic trauma and life changing injuries in children due to a preventable iatrogenic urogenital event.

What is the angle of a banana? The difficulty in reliable assessment of hypospadias chordee.

INTRODUCTION: The degree of chordee associated with hypospadias impacts operative management. Unfortunately, poor inter-observer reliability in assessing chordee by multiple methods in vitro has been demonstrated. This variability may be related to the fact that chordee is not a discrete angle, but rather an arc-like curvature similar to that of a banana. On an attempt to improve this variability, we assessed the inter-rater reliability of a novel method of chordee measurement and compared it to measurements with a goniometer both in vitro and in vivo. MATERIALS AND METHODS: In vitro assessment of curvature was performed using 5 bananas. In vivo chordee measurement was performed during 43 hypospadias repairs. On in vitro and in vivo cases, chordee was assessed independently by faculty and resident physicians. Angle assessment was performed in a standard manner with a goniometer and with a smartphone app using ruler measurements of the length and width of the arc (Summary Figure). The proximal and distal aspect of the arc to be measured was marked on the bananas, whereas the penile measurements were taken from the penoscrotal to the sub-coronal junctions. RESULTS: In vitro banana assessment demonstrated strong intra- and inter-rater reliability for length (0.89 and 0.88, respectively) and width measurements (0.97 and 0.96). The calculated angle demonstrated an intra- and inter-rater reliability of 0.67 and 0.67. The banana goniometer/protractor measurements were weak with an intra-rater and inter-rater reliability of 0.33 and 0.21. With hypospadias chordee, the inter-rater reliability was strong for length and width measurements (0.95 and 0.94) and 0.48 for calculated angle. The inter-rater reliability of the goniometer angle was 0.96. Further assessment of inter-rater goniometer reliability was performed relative to degree of chordee as characterized by faculty. The inter-rater reliability for ≤15°, 16-30, and ≥30° was 0.68 (n = 20), 0.34 (n = 14), and 0.90 (n = 9), respectively. When the goniometer angle was classified as ≤15, 16-30, or ≥30° by one physician, it was classified outside of this range by the other physician 23%, 47%, and 25% of the time, respectively. DISCUSSION: Our data demonstrate significant limitations of the goniometer for assessing chordee in vitro and in vivo. We were unable to demonstrate significant improvement in chordee assessment using arc length and width measurements to calculate radians. CONCLUSIONS: Reliable and precise techniques for measuring hypospadias chordee remain elusive and draw into question the validity and usability of management algorithms employing discrete values.

[Anthropometric assessment on prepubertal boys with hypospadias: a multicenter case series].

Objective: Anthropometric variants in prepubertal boys with hypospadias were assigned and assessed to illustrate anatomical malformation. Methods: A total of 516 prepubertal (Tanner grade Ⅰ) boys with hypospadias who were admitted to three medical centers between March 2021 and December 2021 and met the selection criteria for primary surgery were selected. The age of the boys ranged from 10 to 111 months, with an average of 32.6 months. Hypospadias were classified according to the location of the urethral defect, 47 cases (9.11%) of the distal type (the urethral defect is in the coronal groove or beyond), 208 cases (40.31%) of the middle type (the urethral defect is in the penis body), and 261 cases (50.58%) of the proximal type (the urethral defect is at the junction or proximal side of the penis and scrotum). The following indexes were measured: penis length before and immediately after operation, reconstructed urethral length, and total urethral length. Morphological indicators of the glans area, including preoperative height and width of glans, AB, BC, AE, AD, effective AD, CC, BB, the urethral plate width of the coronal sulcus, and postoperative height and width of glans, AB, BE, and AD. In which point A is the distal endpoint of navicular groove, point B is the protuberance lateral to the navicular groove, point C is the ventrolateral protuberance of the glans corona, point D is the dorsal midline point of the glans corona, and point E is the ventral midline point of the coronal sulcus. The foreskin morphological indicators, including the foreskin width, inner foreskin length, and outer foreskin length. The scrotal morphological indicators, including the left, right, and front penile to scrotum distance. The anogenital distances, including anoscrotal distance 1 (ASD1), ASD2, anogenital distance 1 (AGD1), and AGD2. Results: The penis length of the distal, middle, and proximal types decreased successively before operation, the reconstructed urethral length increased successively and the total urethral length decreased successively, these differences were all significant ( P<0.05). The height and width of the glans of the distal, middle, and proximal types significantly decreased successively ( P<0.05), but the height/width of the glans was generally close; AB value, AD value, and effective AD value significantly decreased successively ( P<0.05); there was no significant difference in BB value, urethral plate width of the coronary sulcus, and (AB+BC)/AD value between the groups ( P>0.05). There was no significant difference in the width of glans between the groups after operation ( P>0.05); AB value and AB/BE value increased successively, and AD value decreased successively, these differences were all significant ( P<0.05). The inner foreskin length in the 3 groups significantly decreased successively ( P<0.05), while the outer foreskin length had no significant difference ( P>0.05). The left penile to scrotum distance of middle, distal, and proximal types significantly increased successively ( P<0.05). ASD1, AGD1, and AGD2 significantly decreased from distal type to proximal type successively ( P<0.05). The other indicators' differences were significant only between some groups ( P<0.05). Conclusion: The anatomic abnormalities of hypospadias can be described by anthropometric indicators, which can be used as the basis for further standardized surgical guidance.

3D CT Urethrography With Cinematic Rendering (3DUG): A New Modality for Evaluation of Complex Urethral Anatomy and Assessment of the Postoperative Phalloplasty Urethra.

OBJECTIVE: To develop an imaging modality for the postoperative phalloplasty urethra. Despite high urologic complication rates after masculinizing genital surgery, existing methods for postsurgical evaluation after phalloplasty have drawbacks. Fluoroscopic studies like the retrograde urethrogram have limitations like user-dependence and need for meticulous positioning but also are inadequate for the evaluation of the anatomically complex postphalloplasty urethra. We developed a novel protocol utilizing CT urethrography with 3D reconstruction using cinematic rendering (3DUG) for neo-urethral imaging. MATERIALS AND METHODS: Patients who underwent 3DUG after either phalloplasty, metoidioplasty, or prior to revision surgery were included. Low-dose imaging protocols were used to avoid any increases in radiation exposure. The first iteration of our protocol utilized retrograde contrast administration via the penile urethra, whereas the second iteration of our protocol utilized an antegrade technique with contrast instillation via the suprapubic catheter and a voiding scan. Imaging was initially obtained according to symptoms and then per protocol at 3 weeks after urethral lengthening. RESULTS: Twenty-six patients were included in the series. Among postoperative phalloplasty patients imaged for symptoms, contrast extravasation/fistula was identified in 5 (63%), vaginal remnant in 3 (38%), and stricture in 2 (25%) compared to 5 (45%), 1 (9%), and zero respectively for patients imaged routinely. When intervention was required, operative findings correlated to anatomy on imaging. CONCLUSION: We present a new protocol for the use of 3D CT urethrography with cinematic rendering for neo-urethral reconstruction. This technique has the potential to improve surgical planning and surveillance of urologic complications in postphalloplasty patients.

Prospective Assessment of Genital Pain in Patients With Urethral Stricture: Incidence, Associations, and Impact of Urethroplasty.

OBJECTIVE: To assess the incidence of genital pain in patients with urethral stricture and examine the impact of urethroplasty. Genital pain is a common and challenging urological condition and potentially associated with urethral stricture. METHODS: From 2011-2019, patients were offered enrollment in a prospective single-center study assessing patient-reported genital pain pre- and 6-months posturethroplasty. Genital pain was assessed with the question, "Do you experience genital (scrotum or penis) pain?" answered on a five-point scale ["Never" (1), "Occasionally" (2), "Sometimes" (3), "Most of the Time" (4) or "All of the Time" (5)]. Responses of 3, 4, or 5 were considered clinically significant. Wilcoxon signed-rank test was used to compare pre- and postoperative states and logistic regression was used to evaluate the association between genital pain and clinical variables. RESULTS: Of the 387 patients completing enrollment, 36.4% (141/387) reported genital pain preoperatively. Patients with panurethral stricture reported higher rates (57.1%) of pain (Odds Ratio 2.93, 95%CI 1.32-6.50; P = .008). Posturethroplasty, pain scores improved with an incidence of 14.2% (P < .0001). In patients reporting preoperative pain, 88.7% (125/141) experienced improvement, 8.5% were unchanged and 2.8% reported worsening pain. On logistic regression, patients with penile strictures (O.R. 0.24, 95%CI 0.06-0.91; P = .04), hypospadias (O.R. 0.14, 95%CI 0.02-0.88; P = .04), and staged reconstruction (O.R. 0.22, 95%CI 0.05-0.90; P = .04) were less likely to report improvement. CONCLUSION: Genital pain is common in patients with urethral stricture and improves in the majority of patients undergoing urethroplasty but less so in patients with penile strictures, hypospadias and staged reconstruction.

An assessment of urethral radiation exposure in the treatment of endometrial and rectal cancers.

INTRODUCTION AND HYPOTHESIS: Female survivors of endometrial and rectal cancers have increased risk of urinary incontinence. Survivors with prior radiation therapy are counseled against mesh incontinence surgery. We hypothesize that urethral radiation dose varies based on modality which may influence surgical risks. We aimed to demonstrate urethral radiation dose differences between vaginal brachytherapy (VBT) and external beam radiation therapy (EBRT). METHODS: This is a retrospective cohort study of women exposed to VBT for endometrial cancer and EBRT for rectal cancer. The urethra was contoured on CT imaging to calculate radiation doses in centigray (cGy). The primary outcome was the percent of treatment radiation dose estimated to be received by the urethra based on the volume dose to 0.2 cc of urethra. Secondary outcomes were point doses to the bladder neck, mid-urethra, and total mean urethral dose. Descriptive statistics described demographic characteristics. Bivariate analyses compared urethral radiation dose based on radiation modality. RESULTS: Between 2014-2017, 32 women treated were included: 18 with VBT and 14 with EBRT. Mean ± SD urethral volume doses were lower in VBT (1266 cGy ± 533, 42.2% of prescribed treatment dose) compared to EBRT (5051 cGy ± 192, 100.2% of prescribed treatment dose), p < 0.0001. VBT also had significantly lower mean total urethral dose and point doses to bladder neck and mid- urethra compared to EBRT (p < 0.0001). CONCLUSIONS: The female urethra is exposed to significantly less radiation in VBT compared to EBRT. These data highlight that modality of pelvic radiation should be considered in treatment counseling on urinary incontinence in women.

Assessment of the Anastomosis after Radical Prostatectomy: A Review of Available Diagnostic Methods.

INTRODUCTION: After radical prostatectomy, many institutions perform cystography to exclude vesicourethral anastomotic leakage before removing a urethral catheter. We reviewed diagnostic methods to exclude leakage compared to the reference standard cystography. METHODS: We performed systematic literature review to summarize the published options and outcomes for assessment of vesicourethral anastomotic leakage after radical prostatectomy. RESULTS: Of 2,137 publications, 45 full-text manuscripts underwent full-text screening, of which 9 studies contributing 919 patients were included. Seven studies described ultrasound-guided assessment (four transrectal, two transabdominal, one transperineal). Two further studies described the use of computerized tomography. Ultrasound-guided assessment of the anastomosis after radical prostatectomy shows promising agreement with cystography. Computerized tomography-aided assessment of vesicourethral anastomosis detects more leakages; however, clinical consequences are not defined. CONCLUSION: Further studies are warranted to (1) identify men at risk of anastomotic leakage who should undergo assessment before trial without a catheter and (2) provide prospective comparisons of different ultrasound-guided approaches.