Long-term follow-up suggests high satisfaction rates for bulbomembranous radiation-induced urethral stenoses treated with anastomotic urethroplasty.

PURPOSE: To analyze patients who underwent anastomotic urethroplasty for radiationinduced bulbomembranous urethral stricture/stenosis (RIS) due to prostate cancer treatment with up to 19 years of follow-up and assess long-term patient reported outcomes (PROMs). Long-term follow-up with the inclusion of urethroplasty specific PROMs is lacking in the available research. METHODS: Patients who underwent anastomotic urethroplasty for RIS were identified from 2002 to 2020. Inclusion criteria included completion of 4-month post-operative cystoscopy and PROMs including IPSS, SHIM, MSHQ-EF, 6Q-LUTS, and global satisfaction queries at 4 months. PROMs were assessed annually thereafter, and cystoscopy was performed for adverse change in PROMs or worsening uroflow/PVR parameters. PROMs were compared at pre-op, post-op, and most recent follow-up. RESULTS: 23 patients met inclusion criteria. Short-term anatomic success was 95.7%. At a mean follow-up of 73.1 months (9.1-228.9), one late recurrence occurred for an overall success of 91.3%. Significant and sustained objective improvement was identified in voiding scores, quality of life, and urethroplasty specific PROMs. Satisfaction was 91.3% despite sexual side effects, and 95.7% of patients stated they would have surgery again knowing their outcome at a mean of over 6 years' follow up. CONCLUSIONS: RIS are challenging problems, but durable symptomatic relief is achievable in well-selected patients. Patients with bulbomembranous RIS should be appropriately counseled regarding the risk of urinary incontinence and sexual side effects after anastomotic urethroplasty. However, long-term success is high, and overall QoL will have sustained subjective improvement in most cases.

Retrograde urethrography in children: a decade of experience at a children's hospital.

BACKGROUND: Retrograde urethrography (RUG) is a radiologic procedure that optimizes imaging evaluation of the urethra, particularly in settings of difficulty with micturition or urethral injury. OBJECTIVE: To review our experience with RUG at a large pediatric radiology practice. MATERIALS AND METHODS: We conducted a retrospective review of medical records and fluoroscopic images of RUGs performed from January 2010 to December 2020. RESULTS: We identified 180 RUG exams (median frequency 17 exams per year), all in male children (median age 13 years). The most common indications were stricture (42%; n=76), postsurgical evaluation (34%; n=62) and trauma (16%; n=29). The most commonly used catheter was Foley (40%; n=72), with a median catheter size of 5 French (Fr) for infants younger than 1 year, 7 Fr for children ages 1-5 years and 8 Fr for children older than 5 years. About a third of the children (57; 32%) had combined voiding cystourethrography (VCUG)-RUG exams. Water-soluble contrast agent, either 17% or 43% Cysto-Conray, was used. Most RUG exams were normal (46%; n=83). The most common urethral pathology was stricture (30%; n=54), commonly involving a bulbar urethra (n=26). Urethral trauma was seen in 11 children (6%), 10 bulbar and 1 membranous. Most children with stricture were surgically treated (n=40; 74%), whereas most children with trauma were conservatively treated (n=8; 73%). The remaining diagnoses included diverticula, polyps, valves, fistulas and duplications, constituting <17% of our sample; most of these were surgically treated. Four exams (2%) were non-diagnostic. RUG showed 89% sensitivity and 97% specificity compared to cystourethroscopy/VCUG findings. Technical difficulties occurred in 14 (8%) children (e.g., pain or inappropriate catheter seal). CONCLUSION: Our experience indicates that when catheterization techniques are properly tailored, RUG provides a useful and successful radiologic method of evaluating the pediatric male urethra.

Retrograde urethrogram - a novel approach to diagnosing a posterior urethral polyp in a neonate.

We present a case of antenatally detected fetal megacystis caused by an obstructing posterior urethral polyp. Antenatal and postnatal ultrasounds showed bladder wall thickening and bilateral hydroureteronephrosis, most marked antenatally. A working diagnosis of posterior urethral valves was therefore made. However, further postnatal assessment with a micturating cystourethrogram (MCUG) combined with a retrograde urethrogram identified a pedunculated urethral polyp as the cause. The addition of a retrograde urethrogram as an adjunct to the MCUG in the diagnosis of posterior urethral polyp has not previously been reported, and in this case provided diagnostic confidence of this rare condition, allowing for definitive surgical planning.

Identifying urethral strictures using machine learning: a proof-of-concept evaluation of convolutional neural network model.

INTRODUCTION: To evaluate urethral strictures and to determine appropriate surgical reconstructive options, retrograde urethrograms (RUG) are used. Herein, we develop a convolutional neural network (CNN)-based machine learning algorithm to characterize RUG images between those with urethral strictures and those without urethral strictures. METHODS: Following approval from institutional REB from participating institutions (The Hospital for Sick Children [Toronto, Canada], St. Luke's Medical Centre [Quezon City, Philippines], East Virginia Medical School [Norfolk, United States of America]), retrograde urethrogram images were collected and anonymized. Additional RUG images were downloaded online using web scraping method through Selenium and Python 3.8.2. A CNN with three convolutional layers and three pooling layers were built (Fig. 1). Data augmentation was applied with zoom, contrast, horizontal flip, and translation. The data were split into 90% training and 10% testing set. The model was trained with one hundred epochs. RESULTS: A total of 242 RUG images were identified. 196 were identified as strictures and 46 as normal. Following training, our model achieved accuracy of up to 92.2% with its training data set in characterizing RUG images to stricture and normal images. The validation accuracy using our testing set images showed that it was able to characterize 88.5% of the images correctly. CONCLUSION: It is feasible to use a machine learning algorithm to accurately differentiate between a stricture and normal RUG. Further development of the model with additional RUGs may allow characterization of stricture location and length to suggest optimal operative approach for repair.

Urethro-venous fistula following straddle injury: A case report and image series.

We present a case of a 49-year-old man with an acute traumatic urethral injury after a fall onto a fence post. Retrograde contrast study showed a contrast leak and suspicion of a traumatic urethro-venous fistula. We successfully placed a urethral indwelling catheter (IDC) in the operating room and follow-up urethrocystoscopy showed healing of the injury. The patient remained asymptomatic during further follow-up visits.

Multiple vas deferens with polyorchidism and many congenital malformations in a symptomatic 11-year-old male patient: a rare case report.

BACKGROUND: Ductus deferens may manifest in a variety of anomalies such as its absence, duplication, ectopy, or diverticulum. Ectopic seminal tract opening has two main types, ectopic ejaculatory duct opening, and ectopic vas deferens opening. Generally, ductus deferens anomalies affect approximately 0.05% of the population. Patients may be asymptomatic or complaining of urinary tract infections and/or epididymitis. Most of these cases are associated with renal dysplasia. To confirm the diagnosis Cystourethroscopy catheterization and retrograde urethrogram should be performed, but the definitive diagnosis is done by vasography. The definitive treatment is complete surgical resection of the pathological urogenital connection. This case is commonly discovered while exploring other findings such as testicular torsion and inguinal hernia. CASE PRESENTATION: We report a rare case of an 11-year-old male who presented with gross hematuria and numerous congenital malformations including a left polydactyly clubfoot, polyorchidism, with several surgical procedures, and left kidney dysgenesis. Surgery was performed for a left inguinal hernia, during which a third undescended testicle was discovered incidentally and was eradicated. A retrograde urethrogram was performed to establish the diagnosis. A fistula- that is connected with the left ureter- was resected. The histopathologic findings confirmed the diagnosis of true duplication of the Vas deferens, with communication between the ureter and the vas deferens. By follow-up, the kidney function tests were within normal limits. CONCLUSIONS: This case report aims to highlight the early diagnosis and management of the duplicated vas deferens and the associated congenital malformations to improve the prognosis and kidney function and to avoid long-term complications.

A comparison of urethral catheterization duration - three weeks versus two weeks after bulbar urethroplasty.

OBJECTIVE: To determine the incidence of bacteriuria, urinary tract infections (UTI), and significant extravasation of contrast on initial postoperative pericatheter retrograde urethrogram (pcRUG) after bulbar urethroplasty in relation to duration of urethral catheterization (DUC) of three weeks versus two weeks after surgery. METHODS: Retrospective chart review of 100 bulbar urethroplasty patients between January 2015 and November 2015 were compared with 50 prospective bulbar urethroplasty patients from June 2017 to February 2018 operated at the same university hospital. All patients in the retrospective cohort had catheter removal three weeks after surgery, while patients in the prospective cohort had catheter removal two weeks after surgery. Patient groups were compared using t-test and Fischer's exact test. RESULTS: There was a higher incidence of UTI in patients with a DUC of three weeks after open urethroplasty compared to patients with two weeks DUC (p = 0.03). Occurrence of extravasation on initial pcRUG or asymptomatic bacteruria did not differ between the two groups. CONCLUSION: The findings in this study suggest that a DUC of two weeks may be more favorable compared to a DUC of three weeks.

Comparative study between Amplatz renal dilator vs visual internal urethrotomy (cold knife) for the treatment of male urethral stricture.

AIM: The study aimed to assess and compare urethral stricture (US) management outcomes, efficiency, and complications, treated by either Amplatz renal dilator or visual internal urethrotomy (VIU). PATIENTS AND METHODS: This prospective comparative study was carried out on 88 male patients with stricture urethra. All patients have performed a physical examination, ascending and micturition urethrography, urodynamic, and pelvic ultrasound. The patients were randomized divided into group 1 (Amplatz group) 44 patients treated with Amplatz dilator, and group 2 (VIU group) 44 patients treated with a cold knife. Patients were followed up at 15 days,3,6, and 12 months after the procedure. RESULT: The mean age was 41.2 (22-73) years. The mean stricture length in group 1 and group 2 was 1.01 ± 0.40 and 1.04 ± 0.30, respectively (p = 0.421). The average IPSS score at baseline for group 1 and group 2 was 21.2 and 21.9 points, respectively. During the 12 months follow-up, IPSS improved, with average scores of 16.1 and 17.3 for group 1 and group 2, respectively (p > 0.05). The mean values of (Q max) between group 1 and group 2 at baseline, day 15, day 90 and 180 days showed no significant difference but at 12 months, (Q max) showed a higher significant difference in group 1 than group 2 (p = 0.003). The post-void residual (PVR) displayed a significant decline in both groups from baseline. After 1 year, PVR showed that group 2 was a little higher than group 1 (no significance) compared to baseline The procedures were found effective without recurrence in all patients (both groups) during the 12 months (Q max > 15m/s). However, group 2 reported (11.4%) intra-operative bleeding, and (6.8%) extravasations. CONCLUSION: The guided urethral dilation and internal urethrotomy are safe, short time procedures, and offer satisfactory results with the advance to VIUD in Qmax at 12 months. No recurrence was documented in both groups after 12 months. VIU reported 18% intraoperative complication.

A case of nontraumatic urethral rupture possibly induced by prostatic abscess.

We herein report a rare case of nontraumatic urethral rupture. The patient presented with oliguria, perineal pain and anorexia, and a 3 cm fistula was located in the perineum. Computed tomography revealed a retroperitoneal abscess invading the urethra, and a retrograde urethrogram revealed the rupture of the membranous urethra. He had no history of perineum trauma or transurethral procedures. Although he underwent a suprapubic cystostomy and conservative therapy by antibiotics, he eventually died.

Fracture With Urethral Injury: Evaluation by Retrograde Urethrogram.

Penile fracture is a rare condition. It primarily involves the rupture of the corpus cavernosum during erection, which may also affect the corpus spongiosum and urethra. We describe the case of a 35-year-old man who presented with acute penile pain, penile swelling, and a hematuria after a blunt trauma during sexual intercourse. The emergency retrograde urethrogram revealed a rare condition, extravasation of the opaque material from the penile urethra into the cavernous structure. The partial rupture of the corpus cavernosum with urethral disruption was repaired surgically. At the 3-month postoperative follow-up control, no complications were reported by the patient who has had both normal erectile and voiding functions. In cases of penile fracture with suspected urethral injury, retrograde urethrogram can be used for definitive diagnosis.

Looking beyond oral mucosa: Initial results of everted saphenous vein graft urethroplasty (eSVGU) in long anterior urethral strictures.

OBJECTIVE: To prospectively evaluate the feasibility and initial results of an everted saphenous vein graft (eSVG) as a dorsolateral onlay, in patients with long anterior urethral strictures and/or chronic tobacco users. PATIENTS AND METHODS: In all, 20 patients with long anterior urethral strictures (>7 cm) and/or chronic tobacco exposed oral mucosa were included in the study. The harvested SVG was hydro-distended, detubularised, and everted. Substitution urethroplasty using an eSVG was performed using a dorsolateral onlay technique. Symptoms were assessed using the International Prostate Symptom Score (IPSS) and uroflowmetry at 1, 3 and 6 months; and voiding and retrograde urethrograms, and urethroscopy were done at 3 months. Failure was defined as failure to void, need for interventions in form of direct-vision internal urethrotomy or endodilatation. RESULTS: Three patients were excluded because they underwent a staged urethroplasty. In all, 17 patients underwent eSVG substitution urethroplasty. The mean (SD, range) follow-up of our patients was 17.64 (5.23, 10-26) months. The mean (SD, range) length of the strictured segment was 14 (2.5, 10-18) cm and the length of the harvested SVG was 16.3 (2.7, 12-20) cm. The mean (SD) IPSS at 1, 3 and 6 months after catheter removal was 10 (2.8), 10 (3.4) and 10 (1.4) and the quality-of-life score was 1.76 (0.5), 2.05 (1.0) and 2.05 (1.0), respectively. Postoperatively, endodilatation was required in two patients. Complete failure occurred in one patient. CONCLUSIONS: An eSVG, as a dorsolateral onlay graft, is a promising and prudent option for long anterior urethral strictures, especially in patients with poor oral hygiene and chronic tobacco use.

Male urethral diverticulum uncommon entity: Our experience.

Out pouching of the urethral wall could be congenital or acquired. Male urethral diverticulum (UD) is a rare entity. We present 2 cases of acquired and 1 case of congenital male UD. Case 1A: 40 year male presented with SPC and dribbling urine. Clinically he had hard perineal swelling. RGU revealed large diverticulum in proximal bulbar, irregular narrow distal urethra and stricture just beyond diverticulum. Managed with perineal exploration, stone removal, diverticulum repair and urethroplasty using excess diverticular wall. Case 2A: 30 year male with obstructive lower urinary tract symptoms (LUTS). Retrograde urethrogram (RGU) revealed bulbar urethral diverticulum akin to anterior urethral valve, managed endoscopically. 1 year follow up urine stream satisfactory. Case 3A: 27 year male previously operated large proximal bulbar urethral stone with incontinence. RGU large proximal bulbar UD with wide open sphincter. Treated with excision of excess diverticular wall and penile clamp with pelvic exercises for incontinence. Congenital UD develops due to imperfect closure of urethral fold, Acquired UDs occurs secondary to stricture, infection, trauma, long standing impacted urethral stones or scrotal / skin flap urethroplasties. RGU and MCU are the best diagnostic technique to confirm and characterize the UD. Urethral diverticulectomy with urethral reconstruction is the recommended treatment for UD. UD is a rare entity. Especially in males, congenital are even more rare. Management should be individualized. Surgery can involve innovation and/or surgical modifications. We used excess diverticular flap for stricture urethroplasty in one case.

Use of Silodosin to Visualize the Posterior Urethra in Pelvic Floor Urethral Distraction Defect Patients.

BACKGROUND: Retrograde urethrogram and voiding cystourethrogram are used to define length and location of urethral stricture prior to surgery. We used a single dose of silodosin prior to VCUG to relax the bladder neck and achieve visualization of posterior urethra. OBJECTIVES: To evaluate the efficacy of silodosin in visualization of posterior urethra during VCUG, and to compare the findings with a control group. PATIENTS AND METHODS: Patients were divided into two groups A and B containing 20 and 15 patients, respectively. Patients in group A were given a single dose of silodosin prior to radiological studies. RESULTS: In group A 19 out of 20 patients were able to achieve satisfactory bladder neck opening while in group B 10 out of 15 patients were able to achieve bladder neck opening. CONCLUSIONS: Silodosin use prior to VCUG confers a statistically significant increase in bladder neck opening and visualization of posterior urethra.

Evaluation of healing at urethral anastomotic site by pericatheter retrograde urethrogram in patients with urethral stricture.

INTRODUCTION: Stricture urethra has been always a surgical challenge. Different opinions regarding time require healing at anastomotic site after urethroplasty, so various strategies are there regarding time for post-operative catheter removal. In this study, healing was assessed by pericatheter retrograde urethrogram (PUG) before the catheter removal. MATERIALS AND METHODS: Prospective study was conducted from January 2006 to December 2009. Twenty eight cases of short-segment urethral stricture (<2 cm) who underwent urethroplasty were included and divided into two groups depending upon etiology; post-traumatic group (road traffic accident/straddle type injury) and iatrogenic stricture group (due to prolong catheterization/after cystoscopy/Faulty Foleys balloon placement). Post-operative PUG was done on 14(th) post-operative day in all patients for healing assessment. Extravasation of dye on PUG was taken as anastomotic leak. If the patient had not showed extravasation, the catheter was removed. Otherwise it was kept further for next one week and again PUG was done for healing assessment. RESULTS: Extravasation of dye was noted in 4 patients (33%) of iatrogenic group and 14 patients (87.5%) of the post-traumatic group on 14(th) post-operative day PUG. (P ≤ 0.05). The decision to remove catheter was depended upon PUG finding and it was safe, no complication was developed in any patient. CONCLUSION: Iatrogenic strictures have better healing than post-traumatic stricture in the post-operative period. PUG is a safe and simple procedure and can guide about safe removal of catheter in the post-operative period.