Mycotic Abdominal Aortic Aneurysm Secondary to BCG Therapy for Non-muscle Invasive Urothelial Carcinoma of the Bladder.

Bacillus Calmette-Guerin (BCG) therapy for treatment of bladder cancer is a rare cause of Mycobacterium bovis infected aortic aneurysm. Typical presentations have included general malaise, fever, and lower back pain. We present a case with lower back pain and constipation as presenting symptoms, leading to diagnosis of mycotic aneurysm presumed secondary to intravesical BCG therapy. Treatment included open surgical repair with femoral vein grafting and anti-tubercular therapy. This case highlights the importance of a high index of suspicion for less common infectious complications of BCG therapy.

The times they are a-changin': The evolution of prostate cancer screening practices and beliefs among primary care physicians in Victoria, British Columbia.

INTRODUCTION: Prostate cancer screening practices remain controversial among primary care practitioners (PCPs). Inconsistent guidelines and publication of large prostate cancer screening trials have failed to provide definitive guidance. This study investigates the evolution of prostate cancer screening practices and beliefs over 12 years, in Victoria, British Columbia. METHODS: Questionnaires were delivered to 119 randomly selected PCPs in 2019. Descriptive analysis together with exploratory graphs and Pearson Chi-squared test for independence was calculated. The 2008 data was compared by determining if their value fell within the 2019 data's 95% confidence interval. RESULTS: Response rate was 69.8% (83/119); 30.1% of PCPs reported regularly screening asymptomatic men with prostate-specific antigen (PSA) testing and 37.3% reported regularly performing digital rectal exam (DRE). The combination of PSA and DRE was the most used (48.2 %) screening modality. Most (73.5%) reported that guidelines influence their screening practices, with the most popular choice being those published by The Canadian Task Force on Preventive Health Care (CTF) (32.5%). CONCLUSIONS: The results demonstrate a movement away from prostate cancer screening among PCPs when compared to 2008. PCPs believe that DRE and PSA are less valuable as screening tools and that there is insufficient evidence to support their use. The most used initial screening modality was the combination of PSA/DRE, however, we found a decrease in their use between the two study periods. Clinical guidelines continue to influence PCPs screening practices, but the shift of more PCPs following the CTF guidelines since 2008 has likely led to the reciprocal decrease in prostate cancer screening.

Primary bladder amyloidosis as a cause of haematuria.

We report the case of a 46-year-old man who initially presented with macroscopic haematuria. Although initially concerning for a malignancy in the bladder, histology demonstrated a primary bladder amyloidosis that has remained stable for 6 years since the initial diagnosis. Primary bladder amyloidosis is an important clinical entity that can mimic bladder malignancy on clinical history, radiological investigation and cystoscopic evaluation. Although uncommon, it should not be neglected as a possible diagnosis in patients presenting with haematuria.

The "G-Spot" Is Not a Structure Evident on Macroscopic Anatomic Dissection of the Vaginal Wall.

BACKGROUND: Controversy exists in the literature regarding the presence or absence of an anatomic "G-spot." However, few studies have examined the detailed topographic or histologic anatomy of the putative G-spot location. AIM: To determine the anatomy of the anterior vaginal wall and present detailed, systematic, accessible findings from female cadaveric dissections to provide anatomic clarity with respect to this location. METHODS: Systematic anatomic dissections were performed on 13 female cadavers (32-97 years old, 8 fixed and 5 fresh) to characterize the gross anatomy of the anterior vaginal wall. Digital photography was used to document dissections. Dissection preserved the anterior vaginal wall, urethra, and clitoris. In 9 cadavers, the vaginal epithelial layer was reflected to expose the underlying urethral wall and associated tissues. In 4 cadavers, the vaginal wall was left intact before preservation. Once photographed, 8 specimens were transversely sectioned for macroscopic inspection and histologic examination. OUTCOMES: The presence or absence of a macroscopic anatomic structure at detailed cadaveric pelvis dissection that corresponds to the previously described G-spot and gross anatomic description of the anterior vaginal wall. RESULTS: Deep to the lining epithelium of the anterior vaginal wall is the urethra. There is no macroscopic structure other than the urethra and vaginal wall lining in the location of the putative G-spot. Specifically, there is no apparent erectile or "spongy" tissue in the anterior vaginal wall, except where the urethra abuts the clitoris distally. CLINICAL IMPLICATIONS: The absence of an anatomic structure corresponding to the putative G-spot helps clarify the controversy on this subject. STRENGTHS AND LIMITATIONS: Limitations to this study include limited access to specimens immediately after death and potential for observational bias. In addition, age, medical history, and cause of death are not publishable for privacy reasons. However, it is one of the most thorough and complete anatomic evaluations documenting the anatomic detail of the anterior vaginal wall. CONCLUSION: The G-spot, in its current description, is not identified as a discrete anatomic entity at macroscopic dissection of the urethra or vaginal wall. Further insights could be provided by histologic study. Hoag N, Keast JR, O'Connell HE. The "G-Spot" Is Not a Structure Evident on Macroscopic Anatomic Dissection of the Vaginal Wall. J Sex Med 2017;14:1524-1532.

Surgical management of female urethral strictures.

Female urethral stricture (FUS) represents a rare condition, yet one that can cause significant, bothersome lower urinary tract symptoms (LUTS). Historically, urethral dilation has been a preferred treatment choice for these patients. A variety of reconstructive surgical techniques have been described in recent years to provide more definitive management in this challenging group of patients. We present an overview of FUS and a summary of surgical management options.

Impact of bladder dysfunction in the management of post radical prostatectomy stress urinary incontinence-a review.

Bladder dysfunction is a relatively common urodynamic finding post radical prostatectomy (RP). It can be the sole cause of post prostatectomy incontinence (PPI) or may be found in association with stress urinary incontinence (SUI). The aim of this review is to provide a comprehensive review of the diagnosis and different treatments of post RP bladder dysfunction. A comprehensive literature review using medical search engines was performed. The search included a combination of the following terms, PPI, detrusor overactivity (DO), detrusor underactivity (DU), impaired compliance, anticholinergic, onabotulinumtoxinA (Botox®) and sacral neuromodulation (SNM). Definitions, general overview and management options were extracted from the relevant medical literature. DO, DU and impaired compliance are common and may occur alone or in combination with SUI. In some patients the conditions exist pre RP, in others they arise due to denervation and surgical changes. DO can be treated with anticholinergics, Botox® and SNM. DO may need to be treated before SUI surgery. DU may be a contraindication to male sling surgery as some patients may go into urinary retention. Severely impaired bladder compliance may be a contraindication to SUI surgery as the upper tracts may be at risk. Each individual dysfunction may affect the outcome of PPI treatments and clinicians should be alert to managing bladder dysfunction in PPI patients.

Urodynamic findings in Susac syndrome: first reported filling cystometrogram.

Susac syndrome is a rare neurological disease, with only 300 cases reported in the literature. Lower urinary symptoms are not an uncommon feature of the disease, yet there is no information on specific dysfunction typical urodynamic findings associated with the disease. We present what we believe to be the first reported filling cystometrogram study of Susac syndrome for the evaluation of voiding dysfunction.

Diabetes and elevated urea level predict for uretero-ileal stricture after radical cystectomy and ileal conduit formation.

INTRODUCTION: Benign uretero-ileal anastomotic stricture is a significant complication following radical cystectomy and ileal conduit urinary diversion after radical cystectomy. We examined risk factors for stricture formation to predict those at greatest stricture risk. METHODS: A retrospective chart review was conducted for patients undergoing radical cystectomy and ileal conduit diversion between 2002 and 2012. Demographic data and patient variables were analyzed to determine risk factors for uretero-ileal stricture using multivariate logistic regression. RESULTS: Over the study period, 133 patients underwent cystectomy and ileal conduit formation, with 14 (10.5%) developing uretero-ileal anastomotic stricture. Diabetes and elevated serum urea level (defined as >7.1 mmol/L) were associated with increased risk for development of uretero-ileal stricture (odds ratio 4.31 and 4.28, respectively; p<0.05 for each). CONCLUSIONS: In this patient cohort, diabetes and elevated serum urea level were predictive for the development of uretero-ileal anastomotic stricture. Further prospective study with larger patient samples is required.

Sacral neuromodulation for detrusor hyperactivity with impaired contractility.

INTRODUCTION: Detrusor hyperactivity with impaired contractility (DHIC) is a challenging condition to manage. Sacral neuromodulation (SNM) is a proven treatment modality for both the individual aspects of DHIC. To date, data reporting the outcome of SNM for DHIC are lacking. MATERIALS AND METHODS: Consecutive patients undergoing SNM for DHIC were followed prospectively, from April 2013 to October 2016. Patient demographics, bladder diaries, subjective response rates, ICIQ-OAB, and PGI-I scores were recorded. Success was defined as greater than 50% improvement in storage symptoms and a 50% improvement in voided volume or reduction of post-void residual volumes. RESULTS: Twenty patients underwent stage 1 trial of SNM for DHIC. Median age was 68.5, IQR (54.25-76.25). Thirteen (65%) patients were female. A total of 14/20 (70%) of patients had a significant treatment response, 9/20 had a response to both elements of DHIC, 4/20 patients had a response to the detrusor overactivity (DO) alone, and 1/20 had a response to the voiding component alone. A total of 12/20 (60%) patients proceeded to insertion of an IPG. At mean follow-up of 17 months, IQR (1.5-35), 11/12 (91.7%) of patients are still using the SNM for DHIC. Median PGI score is 2, IQR (2-4). SNM for DHIC resulted in statistically significant improvements in voided volume (P = 0.016), PVR (P = 0.0296), ICIQ-OAB score (P < 0.0001), and ICIQ-OAB bother score (P = 0.016) CONCLUSION: This is the first study we know of to report the results of SNM for DHIC. SNM is associated with satisfactory success rates, treating both the detrusor hyperactivity, and impaired contractility components of this condition.

Sacral neuromodulation for refractory overactive bladder after prior intravesical onabotulinumtoxinA treatment.

AIMS: Sacral neuromodulation (SNM) is a well-established treatment modality for refractory overactive bladder (OAB). There is a paucity of evidence examining the use of SNM in patients who have received prior intravesical onabotulinumtoxinA (BTXA) treatment. We aim to review those patients who underwent SNM for refractory OAB following treatment with BTXA. METHODS: A retrospective review was conducted to identify patients who had undergone prior intradetrusor BTXA for refractory OAB, then subsequent first-stage SNM. Patient demographics, number/dosage of BTXA, voiding diaries, and patient global impression of improvement (PGI-I) scores were recorded. Successful first-stage SNM was defined as subjective patient improvement of greater than 50%. Patient satisfaction and device use at last follow-up was noted. RESULTS: Eighty-three patients were identified having undergone SNM for OAB, of which 36 had prior BTXA treatment and were included in the series. 23/36 (63.9%) of patients had successful first-stage SNM, and underwent insertion of implantable pulse generator, compared to 33/47 (70.2%) in those who had never been treated with BTXA (P = 0.5). Mean PGI-I score was 2.6 (range 1-4). With a mean follow up of 29.1 months (range 12-53), 17/23 (73.9%) were satisfied, and using the device at last follow-up. CONCLUSION: SNM is a suitable treatment option in those patients who have had prior BTXA treatment for refractory OAB, even in those for whom BTXA proved ineffective. Success rates were within the published range, and comparable to our own results, for SNM in OAB patients without prior BTXA treatment.

An Indwelling Ureteral Stent Forgotten for Over 12 Years.

Ureteral stents are one of the most commonly used urologic devices with the purpose of establishing and maintaining ureteral patency. They are also associated with a number of complications including infection, migration, stent-related symptoms, and encrustation, leading to lithiasis. Prolonged stent dwell time is associated with a greater degree of these complications. We present the case of a 36-year-old man who presented with a severely encrusted ureteral stent that had been placed 12.5 years prior for an obstructive left-sided ureteral stone and was lost to follow-up. The patient underwent a combination of percutaneous nephrolithomy, cystolitholapaxy, and ureteroscopy to remove the stent and associated 1.7 cm renal pelvic stone and 4.1 cm bladder stone, necessitating two operative sittings to render him stone free.

Vaginal-sparing ventral buccal mucosal graft urethroplasty for female urethral stricture: A novel modification of surgical technique.

PURPOSE: To present a novel modification of surgical technique to treat female urethral stricture (FUS) by a vaginal-sparing ventral buccal mucosal urethroplasty. Recurrent FUS represents an uncommon, though difficult clinical scenario to manage definitively. A variety of surgical techniques have been described to date, yet a lack of consensus on the optimal procedure persists. MATERIALS AND METHODS: We present a 51-year-old female with urethral stricture involving the entire urethra. Suspected etiology was iatrogenic from cystoscopy 17 years prior. Since then, the patient had undergone at least 25 formal urethral dilations and periods of self-dilation. In lithotomy position, the urethra was dilated to accommodate forceps, and ventral urethrotomy carried out sharply, exposing a bed of periurethral tissue. Buccal mucosa was harvested, and a ventral inlay technique facilitated by a nasal speculum, was used to place the graft from the proximal urethra/bladder neck to urethral meatus without a vaginal incision. Graft was sutured into place, and urethral Foley catheter inserted. RESULTS: The vaginal-sparing ventral buccal mucosal graft urethroplasty was deemed successful as of last follow-up. Flexible cystoscopy demonstrated patency of the repair at 6 months. At 10 months of follow-up, the patient was voiding well, with no urinary incontinence. No further interventions have been required. CONCLUSIONS: This case describes a novel modification of surgical technique for performing buccal mucosal urethroplasty for FUS. By avoiding incision of the vaginal mucosa, benefits may include reduced: morbidity, urinary incontinence, and wound complications including urethro-vaginal fistula.

Intravesical OnabotulinumtoxinA Injection for Overactive Orthotopic Ileal Neobladder: Feasibility and Efficacy.

The efficacy of intravesical onabotulinumtoxinA (BTXA) in the treatment of overactive bladder (OAB) has been well documented. The use of BTXA injection in orthotopic neobladders is yet to be studied. We present 4 cases of patients injected with intravesical BTXA for overactive orthotopic ileal neobladder. We recorded patient demographics, presenting and follow-up symptoms, urodynamic profiles, and Patient Global Impression of Improvement (PGI-I) scores. The 4 patients reported varying degrees of subjective improvements in the symptoms, including urgency, urge incontinence, and pad usage. Mean follow-up duration was 8.3 months (range, 5-14 months). Average PGI-I score was 3 ("a little better") (range, 2-4). To our knowledge, the current study is the first case series examining BTXA injection for orthotopic neobladder overactivity. BTXA injection yielded varying degrees of objective and subjective improvements, without significant complications. Intravesical BTXA injection is feasible and may be considered as a potential treatment alternative for OAB in orthotopic neobladders, although further study is warranted.

Primary malignant melanoma of the urinary bladder and ureter.

Primary malignant melanoma of the urinary bladder is a rare lesion. We report the case of a 78-year-old male with no previous history of cutaneous melanoma who presented with hematuria. Further investigation with imaging and cystoscopy raised suspicion of a primary bladder and ureteric melanoma, which had subsequently metastasized. This was confirmed with histological assessment and a thorough search for alternative primary lesions. Unfortunately, our patient passed away prior to receiving any oncological treatment for his metastatic melanoma, underscoring both the high mortality of this lesion and the need for a consensus on definitive treatment.