Robotic sacrocolpopexy with medial umbilical ligament autologous graft to treat neovaginal prolapse in a transgender woman.

Vaginoplasty is commonly performed to treat gender dysphoria in transgender women. Neovaginal prolapse is a late complication of vaginoplasty, and there is minimal literature regarding its surgical management. We report a case of robotic sacrocolpopexy using medial umbilical ligament autologous graft to treat neovaginal prolapse in a transgender woman, which is a novel technique that has not been previously described. The procedure resulted in a good postoperative outcome for the patient. The innovative use of medial umbilical ligament autologous graft enabled the patient to benefit from a fully minimally invasive procedure whilst avoiding the risks associated with synthetic mesh.

COmparing Urolift and Standard Transurethral resection of prostate Ahead of Radiotherapy in men with urinary symptoms secondary to prostate enlargement in Southwest London and North Cumbria (CO-STAR): a study protocol for a randomised feasibility study.

INTRODUCTION: Patients undergoing prostate radiotherapy with an enlarged prostate can have short-term and long-term urinary complications. Currently, transurethral resection of the prostate (TURP) is the mainstay surgical intervention for men with urinary symptoms due to an enlarged prostate prior to radiotherapy. UroLift (NeoTract, Pleasanton, CA, USA) is a recent minimally invasive alternative, widely used in benign disease but is untested in men with prostate cancer. METHODS AND ANALYSIS: A multicentre, two-arm study designed in collaboration with a Patient Reference Group to assess the feasibility of randomising men with prostate cancer and coexisting urinary symptoms due to prostate enlargement to TURP or UroLift ahead of radiotherapy. 45 patients will be enrolled and randomised (1:1) using a computer-generated programme to TURP or UroLift. Recruitment and retention will be assessed over a 12 month period. Information on clinical outcomes, adverse events and costs will be collected. Clinical outcomes and patient reported outcome measures will be measured at baseline, 6 weeks postintervention and 3 months following radiotherapy. A further 12 in-depth interviews will be conducted with a subset of patients to assess acceptability using the Theoretical Framework of Acceptability. Descriptive analysis on all outcomes will be performed using Stata (StataCorp V.2021). ETHICS AND DISSEMINATION: The trial has been approved by the Research Ethics Committee (REC) NHS Health Research Authority (HRA) and Health and Care Research Wales (HCRW). The results will be published in peer-reviewed journals, presented at national meetings and disseminated to patients via social media, charity and hospital websites. TRIAL REGISTRATION NUMBER: NCT05840549.

Predictors for adverse events following intravesical botulinum toxin injections in men.

INTRODUCTION: Intravesical botulinum toxin A (BTX-A) has been long established as treatment for overactive bladder and neurogenic bladder dysfunction. However, most published data are reported among a female cohort. Adverse events such as intermittent self-catheterization (ISC) and urinary tract infections (UTIs) play a large role in discontinuation of therapy. There is currently limited information regarding predictive factors to appropriately counsel male patients. MATERIALS AND METHODS: We retrospectively collected data on male patients undergoing their first intravesical BTX-A therapy from January 2016 to July 2021 in two high-volume centers. Data included demographics, past medical and surgical history, and urodynamic parameters. Patients were excluded if they had a long-term catheter or ISC before initiation of therapy. RESULTS: A total of 69 men were included in the study with a median age of 66 years. There were 18 patients with neurogenic bladder dysfunction. Thirty men had urge incontinence secondary to radical prostatectomy or bladder outflow surgery. Overall rates of ISC were 43.5%. Predictors for ISC included a baseline postvoid residual (PVR) ≥ 50 mL (odds ratio [OR]: 4.2, 95% confidence interval [CI]: 1.36-13.03, p = 0.01), BTX-A dose >100 units (OR: 4.2, 95% CI: 1.36-13.0, p = 0.01). Stress urinary incontinence was protective against ISC (OR: 0.20, 95% CI: 0.04-1.00, p = 0.049) as well as history of prostatectomy/bladder outflow obstruction (BOO) surgery (OR: 0.16, 95% CI: 0.05-0.47, p < 0.001). A multivariable logistic regression model with these factors yielded a c-statistic of 0.80 (optimism-adjusted = 0.75). An enlarged prostate was the only predictor for UTI among our male cohort (OR: 8.0, 95% CI: 2.03-31.5, p = 0.003). CONCLUSIONS: This is the first study assessing risk factors of adverse events among men following BTX-A injection. High PVR and BTX-A dose of >100U were predictors of requiring ISC after BTX-A. Stress incontinence, previous radical prostatectomy, and BOO surgery were all protective against needing ISC post-BTX-A. An enlarged prostate was associated with development of UTI. These factors can be used to assist in counseling male patients regarding their risk of ISC and UTI.

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.

Prevalence of chronic pain following suburethral mesh sling implantation for post-prostatectomy incontinence.

PURPOSE: To evaluate postoperative pain and complications following AdVance™/AdVance™ XP male sling implantation. MATERIALS AND METHODS: A multi-center retrospective medical notes review of patients implanted for bothersome post-prostatectomy incontinence was conducted. All patients were telephoned to provide further information on pain or further complications related to their surgery. Statistical evaluation utilized logistical regression analysis. Additionally, a literature review was conducted reviewing pain outcomes following AdVance™/AdVance™ XP implantation. RESULTS: One-hundred and twenty-seven men were reviewed over an 8-year period. The mean age was 70 years, with mean follow up 52 months. Of those with mild stress urinary incontinence, 45 (79%) had a successful outcome compared to 42 (72%) in the moderate group. Twenty-nine (23%) men reported postoperative pain, with a mean maximal pain score of 6 (range: 0-10). The majority of pain resolved within 4 weeks (19/29 men). A further seven patients resolved by 3 months. Only three men (2.3%) had chronic pain greater than 3 months, which all resolved by 1 year. Men less than 65 years were more likely to suffer pain (p = 0.009). Acute urinary retention occurred in 23 (18%) men and correlated significantly with postoperative pain (p = 0.04). Overactive bladder symptoms, severity of incontinence or radiotherapy were not correlated with postoperative pain. In our cohort, there were no extrusions, divisions, or explantations. CONCLUSION: Approximately a quarter of men experience pain in the early postoperative period. However, the severity and rates of chronic pain (>3 months) are low (2.3%) but all settle within a year.

Is pre-operative urodynamic bladder function the true predictor of outcome of male sling for post prostatectomy incontinence?

PURPOSE: To investigate pre-operative urodynamic parameters in male sling patients to ascertain whether this might better predict surgical outcomes and facilitate patient selection. METHODS: We performed a retrospective, case notes and video-urodynamics, review of men who underwent AdVanceXP male sling in three London hospitals between 2012 and 2019. Urodynamics were performed in all centres, while retrograde leak point pressure (RLPP) was performed in one centre. RESULTS: Successful outcome was seen in 99/130 (76%) of men who required one pad or less per day. The dry rate was 51%. Pad usage was linked to worse surgical outcomes, mean 2.6 (range 1-6.5) for success vs 3.6 (range 1-10) although the ranges were wide (p = 0.002). 24 h pad weight also reached statistical significance (p = 0.05), with a mean of 181 g for success group versus 475 g for the non-successful group. The incidence of DO in the non-successful group was significantly higher than in successful group (55% versus 29%, p = 0.0009). Bladder capacity less than 250 ml was also associated with worse outcomes (p = 0.003). Reduced compliance was not correlated with outcomes (31% for success groups vs 45% for non-successful group, p = 0.15). Preoperative RLPP was performed in 60/130 patients but did not independently reach statistical significance (p = 0.25). CONCLUSION: Urodynamic parameters related to bladder function-detrusor overactivity and reduced maximum cystometric capacity predict male sling outcomes and may help in patient selection for male sling (or sphincter) surgery; whereas urodynamic parameters of sphincter incompetency (RLPP) were not predictive. Further larger scale studies are required to confirm these findings.

Outcomes following percutaneous tibial nerve stimulation (PTNS) treatment for neurogenic and idiopathic overactive bladder.

PURPOSE: Percutaneous tibial nerve stimulation is a minimally invasive neuromodulation technique for treating overactive bladder symptoms. The aim of this study was to assess safety, efficacy and impact on quality of life of percutaneous tibial nerve stimulation in neurological patients reporting overactive bladder symptoms. METHODS: In this retrospective evaluation over 18 months at a tertiary healthcare centre, patients finding first-line treatments for overactive bladder ineffective or intolerable underwent a standard 12-week course of percutaneous tibial nerve stimulation (Urgent PC, Uroplasty). Symptoms were evaluated using standardised International Consultation on Incontinence Questionnaires and bladder diaries. RESULTS: Of 74 patients (52 women, 22 men, mean age 56 years), 49 (66.2%) patients had neurological disorder [19 (25.7%) multiple sclerosis and 30 (40.5%) other neurological conditions] and 25 (33.8%) idiopathic overactive bladder. Overall for the entire cohort significant improvements were recorded after 12 weeks in the following domains: 24-h frequency on bladder diary - 1.67 (- 3.0, 0.33) (p = 0.002), number of incontinent episodes on bladder diary - 0.0 (- 1, 0) (p = 0.01), incontinence severity on bladder diary 0 (- 0.33, 0) (p = 0.007), OAB symptoms - 3 (- 11.5, 5) (p = 0.01), and quality of life - 16 (- 57, 6.5) (p = 0.004). There were no significant differences in outcomes between patients with idiopathic and neurogenic overactive bladder. CONCLUSIONS: Percutaneous tibial nerve stimulation appears to be a possible promising alternative for patients with neurological disorder reporting overactive bladder symptoms who find first-line treatments either ineffective or intolerable. However, a properly designed study is required to address safety and efficacy.

The MIC-KEY button vesicostomy: a superior alternative for suprapubic drainage?

OBJECTIVES: To evaluate the MIC-KEY button vesicostomy as an alternative to indwelling suprapubic catheters (SPCs) for bladder drainage in adults. PATIENTS AND METHODS: Phase II pilot study prospectively evaluating patients with indwelling SPCs that were converted to MIC-KEY buttons, or cystoscopic-guided de novo insertion, between November 2014 and February 2019. In all, 15 patients (14 female, one male) had indwelling SPCs that had conversion or attempted conversion to MIC-KEY button, and one (male) had a cystoscopic-guided de novo insertion with a history of previous suprapubic catheterisation. The mean (range) age was 44.2 (13-73) years. Catheter-related quality-of-life (C-IQoL) questionnaire data were collected at baseline and 3 months. RESULTS: Two patients had attempted conversion but were abandoned perioperatively due to sizing issues and insertion difficulties, respectively. Three patients were subsequently converted back to a SPC; due to button sizing (18 days), leaking (3 months), and recurrent infection (13 months). The remaining 11 patients have remained well with continued drainage via the MIC-KEY button; mean (range) duration since conversion was 34.2 (5-105) months. The C-IQoL score improved 3 months after insertion, from 50.0 to 75.4. Changes were performed dependent on patient's personalised management, typically every 3 months, under local or general anaesthetic. CONCLUSION: The MIC-KEY button is a safe alternative to SPC drainage in adults in the short- to medium-term, in a selected cohort.

The use of urethral bulking injections in post-prostatectomy stress urinary incontinence: A narrative review of the literature.

AIMS: Post-prostatectomy stress urinary incontinence (PPI) is a common condition with significant impact on patient quality of life. With rising numbers of prostatectomies performed, recognition of incontinence during survivorship care is growing. With increasing hesitance of the use of suburethral mesh in females, urethral bulking injections in this patient population as a minimally invasive alternative to surgery are evaluated. This review aims to evaluate the existing evidence base for urethral bulking therapy in PPI and provide a summary of its efficacy, durability, and side-effect profile. METHODS: A literature search of Medline/Pubmed and Cochrane databases was conducted to identify publications reporting the clinical outcomes of urethral bulking injections in patients with PPI, up to and including October 1st, 2018. Case reports, letters and reviews were excluded. RESULTS: We identified 25 studies that fit our inclusion criteria, comprised of one RCT, two large retrospective cohort studies, and 22 case series. The success rates reported varying widely from 13%-100% with reports of symptomatic control deterioration. Complication rates remain low. This review highlighted a poor performance using the more historic bulking agents (BA), and the lack of strong evidence with the more novel BA in PPI and discussed challenges regarding optimal patient selection and techniques. CONCLUSIONS: There exists poor clinical evidence base concerning the use of urethral bulking in PPI with few high-level studies and a significant lack of consistency between studies. Further study in this area is required to evaluate the role of BA in this patient population.

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.

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.

The autologous rectus fascia sheath sacrocolpopexy and sacrohysteropexy, a mesh free alternative in patients with recurrent uterine and vault prolapse: A contemporary series and literature review.

INTRODUCTION: About 40% of women suffer pelvic organ prolapse (POP) in a lifetime. The current standard intervention for vault prolapse is a mesh sacrocolpopexy or sacrohysteropexy. However, patients and surgeons are increasingly hesitant to use mesh given recent the UK and Food and Drug Administration warnings and litigation. A possible alternative is to use autologous tissue to support the vault, as a mesh-free solution. We report the outcomes from an initial series of autologous rectus fascia sheath (RFS) sacrocolpopexy and sacrohysteropexy in patients with complex pelvic floor dysfunction. PATIENTS AND METHODS: All patients had previous, multiple urological/gynecological surgery and declined standard mesh repairs. All had preoperative videourodynamics and defecating magnetic resonance imaging evaluation. The autologous POP repair was performed using 10-18 cm of rectus sheath with a similar technique to that employing mesh to support the anterior-posterior vaginal walls or encircle the cervix and secured to the sacral promontory. RESULTS: Seven patients with a mean age of 52 (33-64) years underwent autologous RFS POP repair between 2014 and 2017. Mean follow-up is 16 (range 2-33) months. All patients have durable result at last follow-up. No significant complications are reported. CONCLUSIONS: This is the first report of patients with complex pelvic floor dysfunction and apical POP being managed with autologous RFS sacrocolpopexy/sacrohysteropexy, and only the second report of a free graft being utilized with success. Autologous RFS sacrocolpopexy/sacrohysteropexy avoids the 10%-15% risks of mesh-related complications. Further studies of long-term durability are needed.

Correlation of MRI features of urethral diverticulum and pre- and post-operative stress urinary incontinence.

AIMS: The complexity of urethral diverticulectomy depends on location, size, and degree of circumferential involvement. MRI features were examined to predict functional outcome after surgery for urethral diverticulum (UD). METHODS: A prospectively acquired database was of all patients who have had surgical excision of UD at a tertiary center since 2004 was reviewed. Particular focus was pre- and post-operative urodynamically proven stress urinary incontinence (USUI), and pre-operative MRI features. MRI parameters included diverticular volume, degree of circumferential involvement around the urethra, distance of the Os of UD to bladder neck and urethral length. Students t-test and Mann-Whitney U-test were used to compare rates of de novo USUI. RESULTS: There were 100 patients (mean age 45.8 yrs), who had excision of UD since 2004, with a minimum follow-up of 10 months (range 10-112 months). Full MRI data was available for 83 patients. Fourteen were of simple configuration (16.8%), 32 were horseshoe (38.6%), and 37 (44.6%) were circumferential. Twenty-five (25%) patients had pre-operative USUI, while 12 (12%) patients developed de novo USUI post-excision. While, the majority of patients with de novo USUI (67%) had >270° circumferential involvement of urethra, the pre-operative diverticular volume did not predict the likelihood of USUI developing (P = 0.3). A shorter urethral length was associated with pre-operative USUI. CONCLUSIONS: 25% of all patients had pre-op USUI, and diverticular volume and urethral length was significantly smaller in this group. The majority of patients with de novo USUI had complex diverticula configuration with higher baseline circumferential angle around urethra, with 67% of angle's between 270 and 360°.

Feasibility of using a novel non-invasive ambulatory tibial nerve stimulation device for the home-based treatment of overactive bladder symptoms.

BACKGROUND: To evaluate safety, acceptability and pilot efficacy of transcutaneous low-frequency tibial nerve stimulation (TNS) using a novel device as home-based neuromodulation. METHODS: In this single-centre pilot study, 48 patients with overactive bladder (OAB) (24 with neurogenic and 24 with idiopathic OAB) were randomized to use a self-applicating ambulatory skin-adhering device stimulating transcutaneously the tibial nerve at 1 Hz for 30 minutes, either once daily or once weekly, for 12 weeks. Changes in OAB symptoms and QoL were measured at baseline, weeks 4, 8, and 12 using validated scoring instruments (ICIQ-OAB and ICIQ-LUTSqol), 3-day bladder diary and a Global Response Assessment (GRA) at week 12. RESULTS: Thirty-four patients completed the study (idiopathic n=15, neurogenic n=19). No significant adverse effects were noted. Patients found the device acceptable. Eighteen patients (53%) reported a moderate or marked improvement in symptoms from the GRA. Between baseline and week-12, ICIQ-OAB part A sub-scores improved from mean (SD) 9.3 (2.5) to 7.5 (3.1), and from 9.1 (1.9) to 5.9 (1.7) in the daily and the weekly arms, respectively. ICIQ-LUTSqol part A sub-scores improved from mean (SD) 51 (12.8) to 44.2 (13.1) and 44.9 (9.0) to 35.9 (8.8) in the daily and the weekly arms, respectively. Bladder diary mean 24-hour frequency episodes improved from 11.5 to 8.8 at week 12 for both arms. CONCLUSIONS: This novel ambulatory transcutaneous TNS (TTNS) device is safe and acceptable for use in patients reporting OAB symptoms as a form of home-based neuromodulation. A larger study however is required to confirm clinical efficacy.

Radiation Exposure during Ureterorenoscopy and Laser Lithotripsy: An Analysis of Stone Characteristics.

INTRODUCTION AND OBJECTIVES: Stone formers often have a chronic exposure to significant quantities of ionising radiation from radiological investigations and interventions. Predicting radiation exposure would allow the clinician to quantify expected cumulative radiation and find strategies to minimise exposure. We evaluated radiation exposure during ureteroscopy and laser lithotripsy (URS + LL) for a single stone episode and correlated the results to stone characteristics. METHOD: Data was collected retrospectively for all patients undergoing URS + LL in our institution over a 1 year period. Patients with multiple stones, staghorn stones or incomplete stone clearance were excluded to simplify the analysis. Patient characteristics, fluoroscopy data and stone characteristics were recorded. RESULTS: We included 302 consecutive patients in the study. The majority of stones were located in the renal calyces/pelvis (54%) with the rest located in the upper (18%), middle (13%) and lower ureter (15%). Mean stone diameter was 9.9 mm (range 4-30 mm). Mean radiation exposure time during URS + LL was 44 s (range 12-119 s) with a mean total radiation exposure of 7.5 milligray (mGy; range 1.2-29.7 mGy). Renal stones were associated with 27% higher radiation exposure compared to ureteral stones (8.3 vs. 6.7 mGy; p = 0.02). There was a positive correlation between stone diameter and radiation exposure (Spearman's correlation coefficient ρ = 0.28; p < 0.001). Stones with diameter greater than 10 mm were associated with 37% higher radiation exposure compared to smaller stones (9.1 vs. 6.6 mGy; p < 0.001). CONCLUSION: There is a direct correlation between stone burden, as well as location, and radiation exposure during URS + LL. Clinicians should consider strategies to reduce total radiation exposure in recurrent stone formers at risk of high radiation exposure by limiting screening time, using pulsed rather than continuous fluoroscopy, management with primary URS + LL, or using ultrasound guidance.

Case of acute severe postpartum urinary incontinence: an extravesical subsphincteric prolapsed ureterocoele.

A 32-year-old woman presents to outpatients 10 days postpartum, with symptoms of an intermittent vaginal lump and urinary incontinence. Vaginal examination revealed no demonstrable prolapse or stress incontinence. A swelling in the bladder was noted during an antenatal scan suggesting a ureterocoele. She was referred for pelvic floor physiotherapy in the first instance. Forty-eight hours later, she represented to casualty with discomforting vaginal lump symptoms and continuous urinary incontinence. At this stage on vaginal inspection, there was an evident dusky lump emerging from the urethra with continuous incontinence. An extravesical subsphincteric prolapsed ureterocoele was evident, 5 cm beyond the external urethral meatus. The diagnosis was confirmed with an MRI scan which demonstrated the prolapsed obstructing ureterocoele causing significant left-sided hydroureteronephrosis. The ureterocoele was managed with a cystoscopy and transurethral incision of the ureterocoele under anaesthesia, which facilitated drainage and resolution. At 3-month postoperatively, the patient remains continent and satisfied.

Urethral Sphincter Injection of Botulinum Toxin A: A Review of Its Application and Outcomes.

The first reported application of Botulinum toxin-A (BTX-A) into the urethral sphincter predates the first documented use in the bladder. The aim of this review is to describe the clinical indications of BTX-A injection into the urethral sphincter and its clinical efficacy. This review of the literature includes the larger more significant published studies that have reported on this use of BTX-A. Case reports and articles not published in English were excluded. There have been many published clinical studies describing the use of BTX-A in the urethral sphincter, four of which are randomized placebo controlled trials. These studies tend to include patients either in urinary retention or with obstructed voiding, both in the neuropathic and non-neuropathic populations. Studies tend to demonstrate improvements in urodynamic parameters and quality of life after injection. There have been many small clinical studies in this area, however larger placebo-controlled trials are needed to evaluate this treatment at higher levels of evidence.

Urolithiasis following urinary diversion.

Urolithiasis is a well-known occurrence after cystectomy and urinary diversion. With high incidence and recurrence rates of urolithiasis, complex anatomy and associated morbidities, these patients remain a management challenge for urologists. The purpose of this review is to examine the literature and consider the risk factors for stone formation in this group of patients and reflect on the reported outcomes with the range of available treatment options.

Open-label study evaluating outpatient urethral sphincter injections of onabotulinumtoxinA to treat women with urinary retention due to a primary disorder of sphincter relaxation (Fowler's syndrome).

OBJECTIVES: To assess the efficacy (defined as improvements in maximum urinary flow rate [Qmax ] of ≥50%, post-void residual urine volume [PVR] and scores on the International Prostate Symptom Score [IPSS] questionnaire) and safety of urethral sphincter injections of onabotulinumtoxinA in women with a primary disorder of urethral sphincter relaxation, characterised by an elevated urethral pressure profile (UPP) and specific findings at urethral sphincter electromyography (EMG), i.e. Fowler's syndrome. PATIENTS AND METHODS: In this open-label pilot Institutional Review Board-approved study, 10 women with a primary disorder of urethral sphincter relaxation (elevated UPP, sphincter volume, and abnormal EMG) presenting with obstructed voiding (five) or in complete urinary retention (five) were recruited from a single tertiary referral centre. Baseline symptoms were assessed using the IPSS, and Qmax and PVR were measured. After 2% lidocaine injection, 100 U of onabotulinumtoxinA was injected into the striated urethral sphincter, divided on either side, under EMG guidance. Patients were reviewed at 1, 4 and 10 weeks after injection, and assessed using the IPSS, Qmax and PVR measurements. The UPP was repeated at week 4. RESULTS: The mean (range) patient age was 40 (25-65) years, and the mean symptom scores on the IPSS improved from 25.6 to 14.1, and the mean 'bother' score reduced from 6.1 to 3.5 at week 10. As compared with a baseline mean Qmax of 8.12 mL/s in the women who could void, the Qmax improved to 15.8 mL/s at week 10. Four of the five women in complete retention could void spontaneously, with a mean Qmax of 14.3 mL/s at week 10. The mean PVR decreased from 260 to 89 mL and the mean static UPP improved from 113 cmH2 O at baseline to 90 cmH2 O. No serious side-effects were reported. Three women with a history of recurrent urinary tract infections developed a urinary tract infection. There were no reports of stress urinary incontinence. Seven of the 10 women opted to return for repeat injections. CONCLUSIONS: This pilot study shows an improvement in patient-reported lower urinary tract symptoms, and the objective parameters of Qmax , PVR and UPP, at 10 weeks after urethral sphincter injections of onabotulinumtoxinA. No serious side-effects were reported. This treatment could represent a safe outpatient treatment for young women in retention due to a primary disorder of urethral sphincter relaxation. However, a larger study is required to confirm the findings of this pilot study.